Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic
Identifieur interne : 000380 ( Pmc/Corpus ); précédent : 000379; suivant : 000381Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic
Auteurs : Andrea T. Obi ; Geoff D. Barnes ; Thomas W. Wakefield ; Sandra Brown Rvt ; Jonathon L. Eliason ; Erika Arndt ; Peter K. HenkeSource :
- Journal of Vascular Surgery. Venous and Lymphatic Disorders [ 2213-333X ] ; 2020.
Abstract
A markedly increased demand for vascular ultrasound laboratory and other imaging studies in COVID-19 positive patients has occurred, due to most with markedly elevated D-dimer, and a presumed prothrombotic state in many of the very ill patients. This article summarizes a broad institutional consensus focusing on evaluation and recommended empirical therapy for COVID-19 positive patients. We recommend following the algorithms with the idea that as more data becomes available that this may well change.
Url:
DOI: 10.1016/j.jvsv.2020.04.009
PubMed: 32305585
PubMed Central: 7162794
Links to Exploration step
PMC:7162794Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic</title><author><name sortKey="Obi, Andrea T" sort="Obi, Andrea T" uniqKey="Obi A" first="Andrea T." last="Obi">Andrea T. Obi</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Barnes, Geoff D" sort="Barnes, Geoff D" uniqKey="Barnes G" first="Geoff D." last="Barnes">Geoff D. Barnes</name><affiliation><nlm:aff id="aff2">Section of Vascular Medicine, Department of Cardiology, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Wakefield, Thomas W" sort="Wakefield, Thomas W" uniqKey="Wakefield T" first="Thomas W." last="Wakefield">Thomas W. Wakefield</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Brown Rvt, Sandra" sort="Brown Rvt, Sandra" uniqKey="Brown Rvt S" first="Sandra" last="Brown Rvt">Sandra Brown Rvt</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Eliason, Jonathon L" sort="Eliason, Jonathon L" uniqKey="Eliason J" first="Jonathon L." last="Eliason">Jonathon L. Eliason</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Arndt, Erika" sort="Arndt, Erika" uniqKey="Arndt E" first="Erika" last="Arndt">Erika Arndt</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Henke, Peter K" sort="Henke, Peter K" uniqKey="Henke P" first="Peter K." last="Henke">Peter K. Henke</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32305585</idno><idno type="pmc">7162794</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162794</idno><idno type="RBID">PMC:7162794</idno><idno type="doi">10.1016/j.jvsv.2020.04.009</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000380</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000380</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic</title><author><name sortKey="Obi, Andrea T" sort="Obi, Andrea T" uniqKey="Obi A" first="Andrea T." last="Obi">Andrea T. Obi</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Barnes, Geoff D" sort="Barnes, Geoff D" uniqKey="Barnes G" first="Geoff D." last="Barnes">Geoff D. Barnes</name><affiliation><nlm:aff id="aff2">Section of Vascular Medicine, Department of Cardiology, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Wakefield, Thomas W" sort="Wakefield, Thomas W" uniqKey="Wakefield T" first="Thomas W." last="Wakefield">Thomas W. Wakefield</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Brown Rvt, Sandra" sort="Brown Rvt, Sandra" uniqKey="Brown Rvt S" first="Sandra" last="Brown Rvt">Sandra Brown Rvt</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Eliason, Jonathon L" sort="Eliason, Jonathon L" uniqKey="Eliason J" first="Jonathon L." last="Eliason">Jonathon L. Eliason</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Arndt, Erika" sort="Arndt, Erika" uniqKey="Arndt E" first="Erika" last="Arndt">Erika Arndt</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author><author><name sortKey="Henke, Peter K" sort="Henke, Peter K" uniqKey="Henke P" first="Peter K." last="Henke">Peter K. Henke</name><affiliation><nlm:aff id="aff1">Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Vascular Surgery. Venous and Lymphatic Disorders</title><idno type="ISSN">2213-333X</idno><idno type="eISSN">2213-3348</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>A markedly increased demand for vascular ultrasound laboratory and other imaging studies in COVID-19 positive patients has occurred, due to most with markedly elevated D-dimer, and a presumed prothrombotic state in many of the very ill patients. This article summarizes a broad institutional consensus focusing on evaluation and recommended empirical therapy for COVID-19 positive patients. We recommend following the algorithms with the idea that as more data becomes available that this may well change.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Kearon, C" uniqKey="Kearon C">C. Kearon</name></author><author><name sortKey="Akl, E A" uniqKey="Akl E">E.A. Akl</name></author><author><name sortKey="Comerota, A J" uniqKey="Comerota A">A.J. Comerota</name></author><author><name sortKey="Prandoni, P" uniqKey="Prandoni P">P. Prandoni</name></author><author><name sortKey="Bounameaux, H" uniqKey="Bounameaux H">H. Bounameaux</name></author><author><name sortKey="Goldhaber, S Z" uniqKey="Goldhaber S">S.Z. Goldhaber</name></author><author><name sortKey="Nelson, M E" uniqKey="Nelson M">M.E. Nelson</name></author><author><name sortKey="Wells, P S" uniqKey="Wells P">P.S. Wells</name></author><author><name sortKey="Gould, M K" uniqKey="Gould M">M.K. Gould</name></author><author><name sortKey="Dentali, F" uniqKey="Dentali F">F. Dentali</name></author><author><name sortKey="Crowther, M" uniqKey="Crowther M">M. Crowther</name></author><author><name sortKey="Kahn, S R" uniqKey="Kahn S">S.R. Kahn</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pannucci, C J" uniqKey="Pannucci C">C.J. Pannucci</name></author><author><name sortKey="Swistun, L" uniqKey="Swistun L">L. Swistun</name></author><author><name sortKey="Macdonald, J K" uniqKey="Macdonald J">J.K. MacDonald</name></author><author><name sortKey="Henke, P K" uniqKey="Henke P">P.K. Henke</name></author><author><name sortKey="Brooke, B S" uniqKey="Brooke B">B.S. Brooke</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tang, N" uniqKey="Tang N">N. Tang</name></author><author><name sortKey="Bai, H" uniqKey="Bai H">H. Bai</name></author><author><name sortKey="Chen, X" uniqKey="Chen X">X. Chen</name></author><author><name sortKey="Gong, J" uniqKey="Gong J">J. Gong</name></author><author><name sortKey="Li, D" uniqKey="Li D">D. Li</name></author><author><name sortKey="Sun, Z" uniqKey="Sun Z">Z. Sun</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Li, X Y" uniqKey="Li X">X.Y. Li</name></author><author><name sortKey="Du, B" uniqKey="Du B">B. Du</name></author><author><name sortKey="Wang, Y S" uniqKey="Wang Y">Y.S. Wang</name></author><author><name sortKey="Kang, H Y J" uniqKey="Kang H">H.Y.J. Kang</name></author><author><name sortKey="Wang, F" uniqKey="Wang F">F. Wang</name></author><author><name sortKey="Sun, B" uniqKey="Sun B">B. Sun</name></author><author><name sortKey="Qiu, H B" uniqKey="Qiu H">H.B. Qiu</name></author><author><name sortKey="Tong, Z H" uniqKey="Tong Z">Z.H. Tong</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Driggin, E" uniqKey="Driggin E">E. Driggin</name></author><author><name sortKey="Madhavan, M V" uniqKey="Madhavan M">M.V. Madhavan</name></author><author><name sortKey="Bikdeli, B" uniqKey="Bikdeli B">B. Bikdeli</name></author><author><name sortKey="Chuich, T" uniqKey="Chuich T">T. Chuich</name></author><author><name sortKey="Laracy, J" uniqKey="Laracy J">J. Laracy</name></author><author><name sortKey="Bondi Zoccai, G" uniqKey="Bondi Zoccai G">G. Bondi-Zoccai</name></author><author><name sortKey="Brown, T S" uniqKey="Brown T">T.S. Brown</name></author><author><name sortKey="Nigoghossian, C" uniqKey="Nigoghossian C">C. Nigoghossian</name></author><author><name sortKey="Zidar, D A" uniqKey="Zidar D">D.A. Zidar</name></author><author><name sortKey="Haythe, J" uniqKey="Haythe J">J. Haythe</name></author><author><name sortKey="Brodie, D" uniqKey="Brodie D">D. Brodie</name></author><author><name sortKey="Beckman, J A" uniqKey="Beckman J">J.A. Beckman</name></author><author><name sortKey="Kirtane, A J" uniqKey="Kirtane A">A.J. Kirtane</name></author><author><name sortKey="Stone, G W" uniqKey="Stone G">G.W. Stone</name></author><author><name sortKey="Krumholz, H M" uniqKey="Krumholz H">H.M. Krumholz</name></author><author><name sortKey="Parikh, S A" uniqKey="Parikh S">S.A. Parikh</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chen, J" uniqKey="Chen J">J. Chen</name></author><author><name sortKey="Wang, X" uniqKey="Wang X">X. Wang</name></author><author><name sortKey="Zhang, S" uniqKey="Zhang S">S. Zhang</name></author><author><name sortKey="Liu, B" uniqKey="Liu B">B. Liu</name></author><author><name sortKey="Wu, X" uniqKey="Wu X">X. Wu</name></author><author><name sortKey="Wang, Y" uniqKey="Wang Y">Y. Wang</name></author><author><name sortKey="Wang, X" uniqKey="Wang X">X. Wang</name></author><author><name sortKey="Yang, M" uniqKey="Yang M">M. Yang</name></author><author><name sortKey="Sun, J" uniqKey="Sun J">J. Sun</name></author><author><name sortKey="Xie, Y" uniqKey="Xie Y">Y. Xie</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bartlett, M A" uniqKey="Bartlett M">M.A. Bartlett</name></author><author><name sortKey="Mauck, K F" uniqKey="Mauck K">K.F. Mauck</name></author><author><name sortKey="Daniels, P R" uniqKey="Daniels P">P.R. Daniels</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bahia, A" uniqKey="Bahia A">A. Bahia</name></author><author><name sortKey="Albert, R K" uniqKey="Albert R">R.K. Albert</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Killewich, L A" uniqKey="Killewich L">L.A. Killewich</name></author><author><name sortKey="Nunnelee, J D" uniqKey="Nunnelee J">J.D. Nunnelee</name></author><author><name sortKey="Auer, A I" uniqKey="Auer A">A.I. Auer</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Zhou, F" uniqKey="Zhou F">F. Zhou</name></author><author><name sortKey="Yu, T" uniqKey="Yu T">T. Yu</name></author><author><name sortKey="Du, R" uniqKey="Du R">R. Du</name></author><author><name sortKey="Fan, G" uniqKey="Fan G">G. Fan</name></author><author><name sortKey="Liu, Y" uniqKey="Liu Y">Y. Liu</name></author><author><name sortKey="Liu, Z" uniqKey="Liu Z">Z. Liu</name></author><author><name sortKey="Xiang, J" uniqKey="Xiang J">J. Xiang</name></author><author><name sortKey="Wang, Y" uniqKey="Wang Y">Y. Wang</name></author><author><name sortKey="Song, B" uniqKey="Song B">B. Song</name></author><author><name sortKey="Gu, X" uniqKey="Gu X">X. Gu</name></author><author><name sortKey="Guan, L" uniqKey="Guan L">L. Guan</name></author><author><name sortKey="Wei, Y" uniqKey="Wei Y">Y. Wei</name></author><author><name sortKey="Li, H" uniqKey="Li H">H. Li</name></author><author><name sortKey="Wu, X" uniqKey="Wu X">X. Wu</name></author><author><name sortKey="Xu, J" uniqKey="Xu J">J. Xu</name></author><author><name sortKey="Tu, S" uniqKey="Tu S">S. Tu</name></author><author><name sortKey="Zhang, Y" uniqKey="Zhang Y">Y. Zhang</name></author><author><name sortKey="Chen, H" uniqKey="Chen H">H. Chen</name></author><author><name sortKey="Cao, B" uniqKey="Cao B">B. Cao</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Obi, A T" uniqKey="Obi A">A.T. Obi</name></author><author><name sortKey="Tignanelli, C J" uniqKey="Tignanelli C">C.J. Tignanelli</name></author><author><name sortKey="Jacobs, B N" uniqKey="Jacobs B">B.N. Jacobs</name></author><author><name sortKey="Arya, S" uniqKey="Arya S">S. Arya</name></author><author><name sortKey="Park, P K" uniqKey="Park P">P.K. Park</name></author><author><name sortKey="Wakefield, T W" uniqKey="Wakefield T">T.W. Wakefield</name></author><author><name sortKey="Henke, P K" uniqKey="Henke P">P.K. Henke</name></author><author><name sortKey="Napolitano, L M" uniqKey="Napolitano L">L.M. Napolitano</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wells, P S" uniqKey="Wells P">P.S. Wells</name></author><author><name sortKey="Anderson, D R" uniqKey="Anderson D">D.R. Anderson</name></author><author><name sortKey="Bormanis, J" uniqKey="Bormanis J">J. Bormanis</name></author><author><name sortKey="Guy, F" uniqKey="Guy F">F. Guy</name></author><author><name sortKey="Mitchell, M" uniqKey="Mitchell M">M. Mitchell</name></author><author><name sortKey="Gray, L" uniqKey="Gray L">L. Gray</name></author><author><name sortKey="Clement, C" uniqKey="Clement C">C. Clement</name></author><author><name sortKey="Robinson, K S" uniqKey="Robinson K">K.S. Robinson</name></author><author><name sortKey="Lewandowski, B" uniqKey="Lewandowski B">B. Lewandowski</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Silveira, P C" uniqKey="Silveira P">P.C. Silveira</name></author><author><name sortKey="Ip, I K" uniqKey="Ip I">I.K. Ip</name></author><author><name sortKey="Goldhaber, S Z" uniqKey="Goldhaber S">S.Z. Goldhaber</name></author><author><name sortKey="Piazza, G" uniqKey="Piazza G">G. Piazza</name></author><author><name sortKey="Benson, C B" uniqKey="Benson C">C.B. Benson</name></author><author><name sortKey="Khorasani, R" uniqKey="Khorasani R">R. Khorasani</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wells, P S" uniqKey="Wells P">P.S. Wells</name></author><author><name sortKey="Anderson, D R" uniqKey="Anderson D">D.R. Anderson</name></author><author><name sortKey="Rodger, M" uniqKey="Rodger M">M. Rodger</name></author><author><name sortKey="Forgie, M" uniqKey="Forgie M">M. Forgie</name></author><author><name sortKey="Kearon, C" uniqKey="Kearon C">C. Kearon</name></author><author><name sortKey="Dreyer, J" uniqKey="Dreyer J">J. Dreyer</name></author><author><name sortKey="Kovacs, G" uniqKey="Kovacs G">G. Kovacs</name></author><author><name sortKey="Mitchell, M" uniqKey="Mitchell M">M. Mitchell</name></author><author><name sortKey="Lewandowski, B" uniqKey="Lewandowski B">B. Lewandowski</name></author><author><name sortKey="Kovacs, M J" uniqKey="Kovacs M">M.J. Kovacs</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Underhill, J" uniqKey="Underhill J">J. Underhill</name></author><author><name sortKey="Sherman, M A" uniqKey="Sherman M">M.A. Sherman</name></author><author><name sortKey="Howard, R" uniqKey="Howard R">R. Howard</name></author><author><name sortKey="Hage, A" uniqKey="Hage A">A. Hage</name></author><author><name sortKey="Obi, A" uniqKey="Obi A">A. Obi</name></author><author><name sortKey="Napolitano, L" uniqKey="Napolitano L">L. Napolitano</name></author><author><name sortKey="Coleman, D M" uniqKey="Coleman D">D.M. Coleman</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="editorial"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Vasc Surg Venous Lymphat Disord</journal-id><journal-id journal-id-type="iso-abbrev">J Vasc Surg Venous Lymphat Disord</journal-id><journal-title-group><journal-title>Journal of Vascular Surgery. Venous and Lymphatic Disorders</journal-title></journal-title-group><issn pub-type="ppub">2213-333X</issn><issn pub-type="epub">2213-3348</issn><publisher><publisher-name>Published by Elsevier Inc. on behalf of the Society for Vascular Surgery.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32305585</article-id><article-id pub-id-type="pmc">7162794</article-id><article-id pub-id-type="publisher-id">S2213-333X(20)30221-3</article-id><article-id pub-id-type="doi">10.1016/j.jvsv.2020.04.009</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Obi</surname><given-names>Andrea T.</given-names></name><degrees>MD</degrees><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Barnes</surname><given-names>Geoff D.</given-names></name><degrees>MD</degrees><xref rid="aff2" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>Wakefield</surname><given-names>Thomas W.</given-names></name><degrees>MD</degrees><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au4"><name><surname>Brown RVT</surname><given-names>Sandra</given-names></name><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au5"><name><surname>Eliason</surname><given-names>Jonathon L.</given-names></name><degrees>MD</degrees><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au6"><name><surname>Arndt</surname><given-names>Erika</given-names></name><degrees>BA</degrees><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au7"><name><surname>Henke</surname><given-names>Peter K.</given-names></name><degrees>MD</degrees><email>henke@umich.edu</email><xref rid="aff1" ref-type="aff">a</xref><xref rid="cor1" ref-type="corresp">∗</xref></contrib></contrib-group><aff id="aff1"><label>a</label>Section of Vascular Surgery, Department of Surgery, University of Michigan Health System</aff><aff id="aff2"><label>b</label>Section of Vascular Medicine, Department of Cardiology, University of Michigan Health System</aff><author-notes><corresp id="cor1"><label>∗</label>Reprint requests to Peter K. Henke, MD, University of Michigan Health System (UMHS), 1500 E. Medical Center Drive, Cardiovascular Center - 5463, Ann Arbor, MI 48109-5867. Phone: (734) 763-0250, FAX: (734) 647-9867. <email>henke@umich.edu</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>17</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>17</day><month>4</month><year>2020</year></pub-date><history><date date-type="received"><day>2</day><month>4</month><year>2020</year></date><date date-type="accepted"><day>14</day><month>4</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Published by Elsevier Inc. on behalf of the Society for Vascular Surgery.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><p>A markedly increased demand for vascular ultrasound laboratory and other imaging studies in COVID-19 positive patients has occurred, due to most with markedly elevated D-dimer, and a presumed prothrombotic state in many of the very ill patients. This article summarizes a broad institutional consensus focusing on evaluation and recommended empirical therapy for COVID-19 positive patients. We recommend following the algorithms with the idea that as more data becomes available that this may well change.</p></abstract><kwd-group id="kwrds0010"><title>Keywords</title><kwd>anticoagulant</kwd><kwd>deep venous thrombosis</kwd><kwd>venous thromboembolism</kwd><kwd>pulmonary embolism</kwd><kwd>duplex ultrasound</kwd></kwd-group></article-meta></front><body><sec id="sec1"><title>Introduction</title><p id="p0010">The diagnosis of venous thromboembolism (VTE) traditionally relies upon assessment of the patient for history and physical exam findings consistent with the diagnosis, risk stratification, then imaging with duplex ultrasonography for deep venous thrombosis (DVT) or with computed tomography (CT-PE) for pulmonary embolism.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> This common diagnosis and its work up are a familiar thread in the fabric of all emergency departments, inpatient wards and intensive care units across the country and the world. The COVID-19 pandemic has caused a massive rent in this cloth as hospitals experience a surge of patients: CT PE is often delayed or not performed due to co-morbid renal failure precluding the use of intravenous contrast and cardiopulmonary instability leading to an unacceptable risk for transfer. Similarly, duplex ultrasonography (DUS) for the diagnosis of DVT is difficult to perform due to large number of patients, many of whom will be housed in field hospitals without diagnostic vascular unit labs (DVUs), a contracted registered vascular technician workforce, and length of time associated with and difficulty in completely disinfecting the machines in between patients.</p><p id="p0015">Beyond the obligation of “do no harm” to our patient population, a global pandemic also shines light on the moral obligations of and to ancillary healthcare staff. For instance, while it is hotly debated on a national stage whether the physician “duty to treat” moral standard should be upheld without proper personal protective equipment, it is even less clear to what obligation the registered vascular technician (RVTs) should be held to when their services only indirectly impact morbidity and mortality. It is arguably both within the realm of physician capability and obligation to minimize exposure to RVTs in our DVUs, while minimizing harm to patients. Furthermore, with a dedicated skill set requiring the use of expensive equipment, RVTs represent a scare resource during a pandemic, that if depleted, would inhibit our ability to detect other life and limb threatening conditions that require urgent/emergent treatment such as acute limb ischemia, pseudoaneurysms and carotid disease leading to stroke.</p><p id="p0020">Facing mounting requests for duplex ultrasonography (DVT scans) for VTE diagnosis during the exponential growth phase of the COVID-19 pandemic in our community, we formed an ad hoc committee of venous thrombosis experts, vascular surgeons, hospitalists and critical care physicians, vascular medicine physicians and RVTs. This committee is charged with rapidly reviewing evidence for VTE diagnosis and treatment and adapt clinical algorithms for use during a time when imaging resources, such as ultrasound machines and sonographers with experience and expertise, are expected to be scarce, recognizing both our moral obligation to our patients and to our vascular sonographers. Underlying these algorithms is the absolute commitment at the institutional level to ensure appropriate diagnostic imaging, long term therapy recommendations and follow up once the surge has passed. As a frame of reference, we are expected to experience a volume of >3,000 patients at our peak in Michigan, and to be several fold in excess of our hospital capacity, utilizing field hospitals for approximately 8 weeks.</p></sec><sec id="sec2"><title>Methods</title><p id="p0025">A committee comprised of vascular thrombosis experts, vascular surgeons, vascular medicine physicians, and vascular technologist was convened. We also sought, via multiple conference calls, input from intensivists, pulmonologists, and hematologists for critique and vetting of the algorithms that resulted. Existing published protocols for diagnosis and management of VTE by our faculty practice group were reviewed, alongside current ACCP and National Institution for Health and Care Excellence.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> Our institutional experience with VTE events and utility of empiric low dose anticoagulation with H1N1 viral pneumonia were reviewed, as well as emerging evidence regarding VTE risk in COVID-19 infections. Feedback from content experts in vascular surgery, hematology, pharmacology, internal medicine, cardiology, anesthesiology and critical care was solicited. Implementation was rapidly achieved via dissemination in care bundles, computerized physician order entry (CPOE) sets, and best practice alerts.</p></sec><sec id="sec3"><title>Results</title><p id="p0030">Consensus was achieved regarding 9 critical guiding principles (<xref rid="tbl1" ref-type="table">Table I</xref>) based upon best evidence, available resources and ethical obligations to patients and staff. High priority was placed on treating suspected VTE without definitive imaging in the context of acceptable bleeding risk, recognizing the potential to decrease morbidity and mortality. Extreme pragmatism was applied, recognizing the well-being and scarcity of RVTs was paramount over obtaining a diagnosis when clinical management would not be altered.<table-wrap position="float" id="tbl1"><label>Table I</label><caption><p>Critical Guiding Principles</p></caption><table frame="hsides" rules="groups"><tbody><tr><td>1. All patients with COVID-19 or suspected COVID-19 should be treated with thromboprophylaxis. This statement places value on avoiding the need to reassess VTE risk when a patient has a change in status, and accepts overall low bleeding risk associated with use of anticoagulants used at thromboprophylactic doses.</td></tr><tr><td>2. Elevated D-dimer is expected with severe COVID infection and should not be a determinant in the decision to obtain imaging. Negative D-dimer in combination with a low clinical risk score can still safely exclude VTE and may have limited utility for this purpose.</td></tr><tr><td>3. Current guidelines recommend empiric treatment of suspected PE if imaging is expected to take > 4 hours, or for DVT if imaging is expected to take > 24 hours. We expect that due to stress on the healthcare system that imaging may be delayed for up to a month or greater, but that patients may be safely empirically treated during this time by determining risk-benefit ratio.</td></tr><tr><td>4. Duplex ultrasonography should be utilized when the three following conditions are met simultaneously: (1) bleeding risk is high, (2) the results will change management (3) clinical suspicion of pulmonary embolism is high and CT PE is unobtainable <underline>or</underline> clinical suspicion of DVT is high (based upon modified Wells and Wells scoring systems).</td></tr><tr><td>5. Most patients with confirmed or suspected VTE who are not at high bleeding risk should receive therapeutic doses of anticoagulation.</td></tr><tr><td>6. In patients with ARDS, low dose non-nomogram heparin infusion may reduce risk of major bleeding while still protecting from thrombotic events. There is no data available for this treatment strategy in intubated patients without ARDS.</td></tr><tr><td>7. Patients treated with low dose anticoagulation protocols should be transitioned to full dose anticoagulation when no longer ICU status.</td></tr><tr><td>8. Referral for CT PE or duplex may be performed once patient has recovered as an inpatient, however, may need to be completed in the outpatient setting in a resource scarce setting. CVC venous clinics (or hematology, if a consulting service as inpatient) will provide continuity of care in reviewing these outpatient imaging tests and providing long term anticoagulation recommendations to the patient, thereby expediting discharges without the burden of additional testing and relieving inpatient providers of burden of follow up.</td></tr><tr><td>9. Upper extremity duplex ultrasonography should be limited to patients with unilateral limb symptoms and criteria as listed in #4 and should not be performed routinely.</td></tr></tbody></table></table-wrap></p><sec id="sec3.1"><title>VTE prophylaxis</title><p id="p0035">As an institutional standard, all patients are routinely risk assessed with the Caprini risk assessment model upon admission.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> The committee recognized that healthy patients with only a diagnosis may fall into a low risk category that would not warrant VTE prophylaxis. There is a paucity of data on VTE in COVID-19, however one study found a mortality benefit to thromboprophylaxis with subcutaneous unfractionated heparin or low molecular weight heparin amongst COVID-19 positive patients with highly elevated (>3x upper limit of normal) D-dimer and sepsis induced coagulopathy score.<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref> The true incidence of VTE is unknown, and likely variable across different patient populations, with the highest case reports of pulmonary embolism (PE) in up to 40% of patients with elevated D dimer undergoing CT PE.<xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref> These data suggest VTE or primary pulmonary thrombi may be an underlying etiology responsible for mortality in severe COVID-19 infections. In patients who initially present with less severe disease, the risk from failure to reassess and provide timely thromboprophylaxis in an over-capacity healthcare system is much more likely to outweigh the risk of major bleeding from appropriately dosed thromboprophylaxis (∼1%).<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> Further, while some may choose to use larger doses of thromboprophylaxis, there is no clear evidence basis for this, and we defer to the front line practicioner.<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref> The committee therefore recommends routine thromboprophylaxis of all hospitalized patients with COVID-19 regardless of risk score (<xref rid="tbl2" ref-type="table">Table II</xref>).<table-wrap position="float" id="tbl2"><label>Table II</label><caption><p>Anticoagulation strategies</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Thromboprophylaxis</th><th>• Low molecular weight heparin 40mg qday (or 30mg bid)<break></break>• Subcutaneous heparin 5000 units tid</th></tr></thead><tbody><tr><td>Full dose anticoagulation</td><td>• “Heparin Nomogram for DVT/PE”<break></break>• Low molecular weight heparin 1.5mg/kg qday (or 1mg/kg bid)<break></break>• Direct oral anticoagulant (standard dosing)</td></tr><tr><td>Low dose anticoagulation protocol</td><td>• Many patients can receive “Heparin Nomogram for DVT/PE” without bolus<break></break>• “Heparin Nomogram for ACS/AF” (Xa target 0.2-0.5)<break></break>• Non-nomogram Heparin at discretion of attending (Xa target 0.2-0.3)</td></tr></tbody></table></table-wrap></p></sec><sec id="sec3.2"><title>Suspected Diagnosis of Pulmonary Embolism</title><p id="p0040">The existing, published Michigan Medicine faculty practice guidelines recommend utilization of a modified Wells’ score (<xref rid="tbl3" ref-type="table">Table III</xref><bold>)</bold> to determine pretest probability of a PE.<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref><table-wrap position="float" id="tbl3"><label>Table III</label><caption><p>Modified Wells Score for Assessment of Clinical Likelihood for Pulmonary Embolism</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Criteria</th><th>Points</th></tr></thead><tbody><tr><td>Clinical signs and symptoms of DVT (objectively measured calf swelling and pain with palpation in the deep vein region)</td><td>3</td></tr><tr><td>An alternative diagnosis is less likely than PE</td><td>3</td></tr><tr><td>Heart rate > 100 beats per minute</td><td>1.5</td></tr><tr><td>Immobilization or surgery in the previous four weeks</td><td>1.5</td></tr><tr><td>Previous DVT or PE</td><td>1.5</td></tr><tr><td>Hemoptysis</td><td>1</td></tr><tr><td>Malignancy (on treatment, treated in the past six months, or palliative care)</td><td>1</td></tr></tbody></table><table-wrap-foot><fn><p>Note: Total score > 4 = PE-likely, ≤ 4 = PE-unlikely</p></fn></table-wrap-foot></table-wrap></p><p id="p0045"><bold>If the pre-test probability of the modified Wells’ PE score is low (score ≤4, mean probably of PE 1.7-2.2% if D-dimer negative; 5.1-7.8% overall, independent of the D-dimer):</bold> The current recommendation is thromboprophylaxis for the non-intubated, admitted patient and the intubated critically ill patient at high risk for bleeding (<xref rid="fig1" ref-type="fig">Figures 1</xref> and <xref rid="fig2" ref-type="fig">2</xref>). The intubated, critically ill patient who is low risk by the Wells’ score may qualify for empiric lower dose anticoagulation if their bleeding risk is low. Higher consideration should be given to empiric low dose anticoagulation if the Partial pressure of arterial oxygen/Fractional inspired oxygen (P/F) ratio is less than 200. We do not recommend that duplex ultrasonography be performed in patients to exclude the diagnosis of PE. The rationale for this is that the use of DVT imaging in the setting of suspected PE has a low accuracy, a sensitivity of 44%, a specificity of 86%, a positive predictive value 58% and a negative predictive value of 77%.<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> This data has been substantiated in other studies with reported sensitivities of 25-38% for the diagnosis of thrombosis when being used as a surrogate for PE. Thus, duplex imaging has significant limitations in the diagnosis of PE or in situ pulmonary thrombosis and is not a direct test for PE.<fig id="fig1"><label>Figure 1</label><caption><p>Algorithm for stable patient with suspected DVT. Note PE = pulmonary embolism; VTE = venous thromboembolism; AC = anticoagulation; LE = lower extremity; Pt = patient; Dx = diagnosis.</p></caption><graphic xlink:href="gr1_lrg"></graphic></fig><fig id="fig2"><label>Figure 2</label><caption><p>Algorithm for critically ill patient with suspected DVT. Note PE = pulmonary embolism; VTE = venous thromboembolism; AC = anticoagulation; ACS = acute coronary syndrome; LE = lower extremity; Pt = patient; Dx = diagnosis.</p></caption><graphic xlink:href="gr2_lrg"></graphic></fig></p><p id="p0050">A negative D dimer in combination with a low modified Wells’ score is generally sufficient to exclude PE as a diagnosis. However, in the setting of COVID-19 infection, which is associated with elevated D dimer, the clinical utility of D dimer is unknown.<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> A clinician may draw a D dimer at their discretion in the setting of a low modified Wells’ score if a negative result will reassure the patient. However, if positive, which is likely, it may distract from pursuing other, more likely diagnoses.</p><p id="p0055"><bold>If the pre-test probability is of the Wells’ PE score is high (score <underline>></underline>4):</bold> We recommend full dose anticoagulation for the high risk patient with a low risk for bleeding anticoagulation based on bleeding risk (VTE Bleed score <2, no other risk factors such as thrombocytopenia, cirrhosis, other thrombotic use). Lower dose empiric anticoagulation may be utilized as clinically appropriate in the intubated critically ill patients due to the bleeding risk associated with hemorrhagic pneumonitis with higher Xa levels. For the patient at <bold>high risk of bleeding (</bold><xref rid="tbl4" ref-type="table">Table IV</xref><bold>)</bold>, the clinician could consider obtaining a CT PE study<bold>, if this would alter management</bold>. If a CT PE is unable to be obtained, lower extremity duplex ultrasonography would be an alternative option, recognizing limitations in sensitivity and specificity. Prior to obtaining imaging, clinicians should screen each patient to ensure that testing will not be futile nor redundant (<xref rid="tbl5" ref-type="table">Table V</xref>).<table-wrap position="float" id="tbl4"><label>Table IV</label><caption><p>Under the following circumstances no further studies should be performed:</p></caption><table frame="hsides" rules="groups"><tbody><tr><td>1. Patient end of life/comfort care.</td></tr><tr><td>2. Patient has another indication for anticoagulation.</td></tr><tr><td>3. Patient has a previous CT PE or DVT scan this admission without a change in modified Wells risk stratification.</td></tr><tr><td>4. Patient would not consent to or be a candidate for anticoagulation or IVC filter if offered.</td></tr><tr><td>5. Patient has a diagnosis of VTE from OSH study.</td></tr></tbody></table></table-wrap><table-wrap position="float" id="tbl5"><label>Table V</label><caption><p>Wells Score for Likelihood Estimation of Lower Extremity Deep Venous Thrombosis</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Clinical Characteristic</th><th>Score</th></tr></thead><tbody><tr><td>Active cancer (patient receiving treatment for cancer within the previous 6 months or currently receiving palliative treatment)</td><td>1</td></tr><tr><td>Paralysis, paresis, or recent casting or immobilization of the lower extremities</td><td>1</td></tr><tr><td>Recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring general or regional anesthesia</td><td>1</td></tr><tr><td>Localized tenderness along the distribution of the deep venous system</td><td>1</td></tr><tr><td>Entire leg swollen</td><td>1</td></tr><tr><td>Calf swelling at least 3 cm larger than that on the asymptomatic side (measured 10 cm below the tibial tuberosity)</td><td>1</td></tr><tr><td>Pitting edema confined to the symptomatic leg</td><td>1</td></tr><tr><td>Previously documented DVT</td><td>1</td></tr><tr><td>Collateral non-varicose superficial veins</td><td>1</td></tr><tr><td>Alternative diagnosis at least as clinically likely as DVT</td><td>-2</td></tr></tbody></table><table-wrap-foot><fn><p>A score of < 2 is considered low likelihood for DVT. From Wells et al., N Eng J Med 2003;349:1227-1235; Wells et al, Lancet 1997; 350:1795-1798</p></fn></table-wrap-foot></table-wrap></p><p id="p0060">If the diagnostic study is negative, thromboprophylaxis is recommended. If the study is positive, consideration should be given to full dose anticoagulation in the non-intubated admitted patient and lower dose empiric anticoagulation (either clinician run non-nomogram; or using the ACS nomogram without bolus, <xref rid="fig1" ref-type="fig">Figures 1</xref> and <xref rid="fig2" ref-type="fig">2</xref>) in the intubated critically ill patients due to the bleeding risk, or full dose anticoagulation if felt to be appropriate by the intensivist.</p><p id="p0065">Rationale for using anticoagulation at lower than full dose but higher than prophylactic dose in those patients with severe ARDS:</p><p id="p0070">Viral pneumonia associated venous thrombotic events resulting in significant mortality were witnessed during the H1N1 2009 pandemic. Patients meeting the following criteria during this time were treated with an empiric low dose anticoagulation protocol: P/F ratio < 200; viral pneumonia suspected or confirmed; no absolute contraindications to anticoagulation. In patients meeting these criteria, the following protocol reduced the risk of VTE and primary pulmonary thrombi without increasing bleeding complications: initiation of non-nomogram heparin infusion with a goal Xa between 0.2-0.3; no bolus dose administered. The lower Xa is necessary given the risk of bleeding with hemorrhagic pneumonitis. Of note, this goal Xa does not match with an existing heparin nomogram at our institution, and requires manual titration by the inpatient team.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> It therefore may be a reasonable, although untested, strategy to utilize the ACS nomogram with lower Xa ranges (0.2-0.5) to reduce clinician workload if bleeding risk is acceptable (<xref rid="tbl2" ref-type="table">Table II</xref>). In intubated patients without ARDS, there is a paucity of data regarding risk-benefit ratio of empiric anticoagulation strategies. Patients with thrombocytopenia (platelets < 30) should not be anticoagulated due to attendant bleeding risk, based on expert consensus.</p></sec><sec id="sec3.3"><title>Suspected Diagnosis of DVT</title><p id="p0075">The existing Michigan Medicine faculty practice guidelines recommend utilization of Wells’ score to determine pretest probability of a DVT (<xref rid="tbl6" ref-type="table">Table VI</xref>).<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> We recommend use of this score during the COVID-19 pandemic, recognizing that sensitivity and specificity diminishes in the inpatient setting and performance in the setting of pandemic pneumonia is untested, yet no reasonable alternative exists.<xref rid="bib12" ref-type="bibr">12</xref>, <xref rid="bib13" ref-type="bibr">13</xref>, <xref rid="bib14" ref-type="bibr">14</xref><table-wrap position="float" id="tbl6"><label>Table VI</label><caption><p>Under the following circumstances no further studies should be performed:</p></caption><table frame="hsides" rules="groups"><tbody><tr><td>1. Patient end of life/comfort care.</td></tr><tr><td>2. Patient has another indication for anticoagulation.</td></tr><tr><td>3. Patient has a previous CT PE or DVT scan this admission without a change in modified Wells risk stratification.</td></tr><tr><td>4. Patient would not consent to or be a candidate for anticoagulation or IVC filter if offered.</td></tr><tr><td>5. Patient has a diagnosis of VTE from OSH study.</td></tr></tbody></table></table-wrap><table-wrap position="float" id="tbl7"><label>Table 6</label><caption><p>VTE-BLEED Score</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Factor</th><th>Score</th></tr></thead><tbody><tr><td>Active cancer<sup>a</sup></td><td>2</td></tr><tr><td>Male with uncontrolled arterial hypertension<sup>b</sup></td><td>1</td></tr><tr><td>Anemia<sup>c</sup></td><td>1</td></tr><tr><td>History of bleeding<sup>d</sup></td><td>1</td></tr><tr><td>Age ≥ 60 years old</td><td>1</td></tr><tr><td>Renal dysfunction<sup>e</sup></td><td>1</td></tr><tr><td colspan="2"><bold>Classification of patients with the VTE-BLEED score</bold></td></tr><tr><td>Low bleeding risk</td><td>Total score <2</td></tr><tr><td>High bleeding risk</td><td>Total score ≥2</td></tr><tr><td colspan="2"><bold>Other factors that contribute to bleeding:</bold><break></break>• Thrombocytopenia<break></break>• Cirrhosis<break></break>• Other anti-thrombotic use</td></tr></tbody></table><table-wrap-foot><fn id="tspara0055"><p><sup>a</sup>Cancer diagnosed within 6 mos. before VTE (excluding BCC or SCC of the skin), recently recurrent or progressive cancer or any cancer that required anti-cancer Tx within 6 mos. before VTE was diagnosed</p></fn><fn id="tspara0060"><p><sup>b</sup>Males w/ SBP ≥ 140 mmHg at baseline</p></fn><fn id="tspara0065"><p><sup>c</sup>Hgb <13 g/dl in men or <12 g/dl in women</p></fn><fn id="tspara0070"><p><sup>d</sup>Including prior major or non-major clinically relevant bleeding event, rectal bleeding, frequent nose bleeding, or hematuria</p></fn><fn id="tspara0075"><p>eGFR <60 ml/min</p></fn><fn id="tspara0080"><p>Adapted from From Klok FA, etal. Thrombosis Haemost 2017;117:1164</p></fn></table-wrap-foot></table-wrap></p><p id="p0080"><bold>If the pre-test probability of the modified Wells’ DVT score is low (score <2, mean probably of DVT 3%):</bold> The current recommendation is thromboprophylaxis in the non-intubated admitted patient. The intubated, critically ill patient who is low risk by the Wells’ score may qualify for empiric lower dose anticoagulation if their bleeding risk is low (<xref rid="fig3" ref-type="fig">Figures 3</xref> and <xref rid="fig4" ref-type="fig">4</xref>). Higher consideration should be given to empiric low dose anticoagulation if the P/F ratio is less than 200. The use of duplex ultrasound testing with a risk of only 3% DVT does not warrant the risk to the technologists of performing the tests in COVID-19 positive patients or those PUI. Anticoagulation would not be used unless the Wells’ scores changes. D dimer can be used only to rule out the presence of DVT; however, is expected to be elevated in COVID-19 and should not provide impetus to obtain imaging in the absence of any other clinical manifestation of DVT.<fig id="fig3"><label>Figure 3</label><caption><p>Algorithm for stable patient with suspected PE. Note PE = pulmonary embolism; VTE = venous thromboembolism; AC = anticoagulation; LE = lower extremity; Pt = patient; Dx = diagnosis.</p></caption><graphic xlink:href="gr3_lrg"></graphic></fig><fig id="fig4"><label>Figure 4</label><caption><p>Algorithm for critically ill patient with suspected PE. Note PE = pulmonary embolism; VTE = venous thromboembolism; AC = anticoagulation; ACS = acute coronary syndrome; LE = lower extremity; Pt = patient; Dx = diagnosis.</p></caption><graphic xlink:href="gr4_lrg"></graphic></fig></p><p id="p0085"><bold>If the pre-test probability of the Wells’ DVT score is high(score >2, mean probability of DVT 16.6%-74.6%):</bold> With the higher likelihood of DVT in this group, we would recommend anticoagulation based on bleeding risk (VTE-BLEED score). In the low bleeding risk patient (VTE-BLEED score <2), we suggest empiric full dose therapeutic anticoagulation for the non-intubated admitted patient. In the intubated critically ill patient, we recommend empiric lower dose anticoagulation, due to the expected elevated bleeding risk with common comorbid conditions such as renal failure, DIC and hemorrhagic pneumonitis (<xref rid="fig3" ref-type="fig">Figures 3</xref> and <xref rid="fig4" ref-type="fig">4</xref>). In the high bleeding risk patient (VTE-BLEED score >2), a lower extremity DVT scan may be indicated if the patients meets criteria (<xref rid="tbl5" ref-type="table">Table V</xref>). We note that the VTE-BLEED score (<xref rid="tbl4" ref-type="table">Table IV</xref>) is validated in the outpatient population, and that no similar score exists for use in the acutely hospitalized nor critically ill population. This specific patient cohort may have additional risk factors that increase bleeding risk such as thrombocytopenia, cirrhosis and other anti-thrombotic use that should be taken into consideration by the clinician at the bedside. Furthermore, the VTE-BLEED scan is validated for bleeding risk over a longer time period than expected in most patients treated with this algorithm, therefore physicians may be comfortable with full dose anticoagulation if a patient has multiple risk factors, recognizing the less absolute number of days subjected to risk. If the DVT scan is negative, then thromboprophylaxis is recommended. If the study is positive, consideration should be given to full dose anticoagulation, or an IVC filter. For patients treated with lower dose empiric anticoagulation in the ICU setting, standard full dose anticoagulation should be initiated once they become floor status.</p></sec><sec id="sec3.4"><title>Upper extremity DVT</title><p id="p0090">Given the low morbidity of upper extremity line associated DVT in our critically ill population,<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref> we do not recommend routine upper extremity duplex ultrasound. If a patient has unilateral symptoms and a high risk for bleeding, the need for upper extremity imaging can be considered on a case by case basis. If low bleeding risk, and high likelihood of DVT, the patient should be empirically treated.</p></sec><sec id="sec3.5"><title>Consideration for long term therapy</title><p id="p0095">In patients who are treated with anticoagulants and are unable to get diagnostic imaging during the COVID-19 surge, we recommend that they be discharged with a one to two-month supply of direct oral anticoagulants (or vitamin K antagonists), until they are able to undergo diagnostic imaging. For patients deemed moderate to high risk for PE, a CT PE protocol within 1 month should be ordered once they are considered negative for COVID-19. For patients deemed high risk for DVT, a lower extremity duplex ultrasound should be ordered again once they are considered negative for COVID-19. All patients should be followed and provided recommendations for long term duration of therapy. Current efforts are aimed at developing protocols for high through-put imaging post pandemic and diligent follow up via newly expanded video and or telephone visits.</p></sec></sec><sec id="sec4"><title>Discussion</title><p id="p0100">It is said that necessity is the mother of innovation. Just a few short months ago, it was inconceivable that hospitals across the United States and the globe would be stretched far beyond capacity, that essential resources would be rationed, and that even the most mundane, everyday clinical diagnosis and treatment algorithms would be altered. This is the current status as only a small aliquot of hours stand between us and the overwhelming tide of patients throughout the nation and in many parts of the world. Proactive use of an algorithmic approach to care in this setting has the following advantages: (1) decreases variability in care across the healthcare system; (2) relieves stress on the individual provider on determining optimal treatment without appropriate and usual diagnostic tests; (3) harnesses existing healthcare infrastructure to ensure conscientious follow up for patients and restore confidence in the system; (4) protects scare resources; and (5) fulfills our moral obligation to our patients and staff.</p><p id="p0105">As we move forward through the inevitable crush of patients, conserving clinicians’ mental energy for critical decisions should be of the highest priority given the expected emotional and mental exhaustion in the pandemic setting. As vascular specialists, using our knowledge of clinical scoring systems and risk-benefit ratio, we can extrapolate the current knowledge and standard of care to provide practical and pragmatic straightforward rules for treatment that alleviates the bedside clinician mired in the purgatory of diagnostic uncertainty. In this treatment paradigm, we emphasize preventing VTE related morbidity and mortality at the expense of bleeding complications over a short term while imaging is delayed, and also utilizing therapy that has shown benefit for other severe viral states (H1N1). While direct oral anticoagulants are now more readily available, and have improved bleeding profile, we expect that with such a large influx of patients, bleeding complications are a statistical certainty. With such an approach, the commitment to providing follow up – the DVT scan that would normally be obtained in 24 hours, now will be obtained in 2-4 weeks – must be absolute, meticulous and unwavering.</p><p id="p0110">The lack of hospital system beds across the country alongside the press reports of temporary morgues and ventilator rationing may very well serve to undermine the confidence of Americans in the existing healthcare infrastructure. Using content experts and protocolizing treatment plans is one method that can allow us to maintain consistency in care delivery and restore faith in the local hospital system. Undoubtedly, there are areas beyond VTE where vascular surgeons can and are developing protocols that can help to streamline the care of patients during a time of crisis. During the time of crisis, we can further respond by collating data in an organized fashion, adapting protocols as more is learned and disseminating information rapidly. Vascular surgeons are often the quarterback in crisis; but in the current challenge of the COVID-19 pandemic our role is to use our expertise and tools to protect and aid those serving on the frontlines.</p></sec></body><back><ref-list id="cebib0010"><title>References</title><ref id="bib1"><label>1</label><element-citation publication-type="journal" id="sref1"><person-group person-group-type="author"><name><surname>Kearon</surname><given-names>C.</given-names></name><name><surname>Akl</surname><given-names>E.A.</given-names></name><name><surname>Comerota</surname><given-names>A.J.</given-names></name><name><surname>Prandoni</surname><given-names>P.</given-names></name><name><surname>Bounameaux</surname><given-names>H.</given-names></name><name><surname>Goldhaber</surname><given-names>S.Z.</given-names></name><name><surname>Nelson</surname><given-names>M.E.</given-names></name><name><surname>Wells</surname><given-names>P.S.</given-names></name><name><surname>Gould</surname><given-names>M.K.</given-names></name><name><surname>Dentali</surname><given-names>F.</given-names></name><name><surname>Crowther</surname><given-names>M.</given-names></name><name><surname>Kahn</surname><given-names>S.R.</given-names></name></person-group><article-title>Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines</article-title><source>Chest</source><volume>141</volume><year>2012</year><fpage>e419S</fpage><lpage>e496S</lpage><pub-id pub-id-type="pmid">22315268</pub-id></element-citation></ref><ref id="bib2"><label>2</label><element-citation publication-type="journal" id="sref2"><person-group person-group-type="author"><name><surname>Pannucci</surname><given-names>C.J.</given-names></name><name><surname>Swistun</surname><given-names>L.</given-names></name><name><surname>MacDonald</surname><given-names>J.K.</given-names></name><name><surname>Henke</surname><given-names>P.K.</given-names></name><name><surname>Brooke</surname><given-names>B.S.</given-names></name></person-group><article-title>Individualized Venous Thromboembolism Risk Stratification Using the 2005 Caprini Score to Identify the Benefits and Harms of Chemoprophylaxis in Surgical Patients: A Meta-analysis</article-title><source>Ann Surg</source><volume>265</volume><year>2017</year><fpage>1094</fpage><lpage>1103</lpage><pub-id pub-id-type="pmid">28106607</pub-id></element-citation></ref><ref id="bib3"><label>3</label><element-citation publication-type="journal" id="sref3"><person-group person-group-type="author"><name><surname>Tang</surname><given-names>N.</given-names></name><name><surname>Bai</surname><given-names>H.</given-names></name><name><surname>Chen</surname><given-names>X.</given-names></name><name><surname>Gong</surname><given-names>J.</given-names></name><name><surname>Li</surname><given-names>D.</given-names></name><name><surname>Sun</surname><given-names>Z.</given-names></name></person-group><article-title>Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy</article-title><source>J Thromb Haemost</source><year>2020</year></element-citation></ref><ref id="bib4"><label>4</label><element-citation publication-type="journal" id="sref4"><person-group person-group-type="author"><name><surname>Li</surname><given-names>X.Y.</given-names></name><name><surname>Du</surname><given-names>B.</given-names></name><name><surname>Wang</surname><given-names>Y.S.</given-names></name><name><surname>Kang</surname><given-names>H.Y.J.</given-names></name><name><surname>Wang</surname><given-names>F.</given-names></name><name><surname>Sun</surname><given-names>B.</given-names></name><name><surname>Qiu</surname><given-names>H.B.</given-names></name><name><surname>Tong</surname><given-names>Z.H.</given-names></name></person-group><article-title>[The keypoints in treatment of the critical coronavirus disease 2019 patient]</article-title><source>Zhonghua Jie He He Hu Xi Za Zhi</source><volume>43</volume><year>2020</year><fpage>E026</fpage><pub-id pub-id-type="pmid">32111113</pub-id></element-citation></ref><ref id="bib5"><label>5</label><element-citation publication-type="journal" id="sref5"><person-group person-group-type="author"><name><surname>Driggin</surname><given-names>E.</given-names></name><name><surname>Madhavan</surname><given-names>M.V.</given-names></name><name><surname>Bikdeli</surname><given-names>B.</given-names></name><name><surname>Chuich</surname><given-names>T.</given-names></name><name><surname>Laracy</surname><given-names>J.</given-names></name><name><surname>Bondi-Zoccai</surname><given-names>G.</given-names></name><name><surname>Brown</surname><given-names>T.S.</given-names></name><name><surname>Nigoghossian</surname><given-names>C.</given-names></name><name><surname>Zidar</surname><given-names>D.A.</given-names></name><name><surname>Haythe</surname><given-names>J.</given-names></name><name><surname>Brodie</surname><given-names>D.</given-names></name><name><surname>Beckman</surname><given-names>J.A.</given-names></name><name><surname>Kirtane</surname><given-names>A.J.</given-names></name><name><surname>Stone</surname><given-names>G.W.</given-names></name><name><surname>Krumholz</surname><given-names>H.M.</given-names></name><name><surname>Parikh</surname><given-names>S.A.</given-names></name></person-group><article-title>Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic</article-title><source>J Am Coll Cardiol</source><year>2020</year></element-citation></ref><ref id="bib6"><label>6</label><element-citation publication-type="journal" id="sref6"><person-group person-group-type="author"><name><surname>Chen</surname><given-names>J.</given-names></name><name><surname>Wang</surname><given-names>X.</given-names></name><name><surname>Zhang</surname><given-names>S.</given-names></name><name><surname>Liu</surname><given-names>B.</given-names></name><name><surname>Wu</surname><given-names>X.</given-names></name><name><surname>Wang</surname><given-names>Y.</given-names></name><name><surname>Wang</surname><given-names>X.</given-names></name><name><surname>Yang</surname><given-names>M.</given-names></name><name><surname>Sun</surname><given-names>J.</given-names></name><name><surname>Xie</surname><given-names>Y.</given-names></name></person-group><article-title>Findings of Acute Pulmonary Embolism in COVID-19 Patients</article-title><source>Lancet</source><year>2020</year></element-citation></ref><ref id="bib7"><label>7</label><element-citation publication-type="journal" id="sref7"><person-group person-group-type="author"><name><surname>Bartlett</surname><given-names>M.A.</given-names></name><name><surname>Mauck</surname><given-names>K.F.</given-names></name><name><surname>Daniels</surname><given-names>P.R.</given-names></name></person-group><article-title>Prevention of venous thromboembolism in patients undergoing bariatric surgery</article-title><source>Vasc Health Risk Manag</source><volume>11</volume><year>2015</year><fpage>461</fpage><lpage>477</lpage><pub-id pub-id-type="pmid">26316771</pub-id></element-citation></ref><ref id="bib8"><label>8</label><element-citation publication-type="journal" id="sref8"><person-group person-group-type="author"><name><surname>Bahia</surname><given-names>A.</given-names></name><name><surname>Albert</surname><given-names>R.K.</given-names></name></person-group><article-title>The modified Wells score accurately excludes pulmonary embolus in hospitalized patients receiving heparin prophylaxis</article-title><source>J Hosp Med</source><volume>6</volume><year>2011</year><fpage>190</fpage><lpage>194</lpage><pub-id pub-id-type="pmid">21480489</pub-id></element-citation></ref><ref id="bib9"><label>9</label><element-citation publication-type="journal" id="sref9"><person-group person-group-type="author"><name><surname>Killewich</surname><given-names>L.A.</given-names></name><name><surname>Nunnelee</surname><given-names>J.D.</given-names></name><name><surname>Auer</surname><given-names>A.I.</given-names></name></person-group><article-title>Value of lower extremity venous duplex examination in the diagnosis of pulmonary embolism</article-title><source>J Vasc Surg</source><volume>17</volume><year>1993</year><fpage>934</fpage><lpage>938</lpage><comment>; discussion 938-9</comment><pub-id pub-id-type="pmid">8487362</pub-id></element-citation></ref><ref id="bib10"><label>10</label><element-citation publication-type="journal" id="sref10"><person-group person-group-type="author"><name><surname>Zhou</surname><given-names>F.</given-names></name><name><surname>Yu</surname><given-names>T.</given-names></name><name><surname>Du</surname><given-names>R.</given-names></name><name><surname>Fan</surname><given-names>G.</given-names></name><name><surname>Liu</surname><given-names>Y.</given-names></name><name><surname>Liu</surname><given-names>Z.</given-names></name><name><surname>Xiang</surname><given-names>J.</given-names></name><name><surname>Wang</surname><given-names>Y.</given-names></name><name><surname>Song</surname><given-names>B.</given-names></name><name><surname>Gu</surname><given-names>X.</given-names></name><name><surname>Guan</surname><given-names>L.</given-names></name><name><surname>Wei</surname><given-names>Y.</given-names></name><name><surname>Li</surname><given-names>H.</given-names></name><name><surname>Wu</surname><given-names>X.</given-names></name><name><surname>Xu</surname><given-names>J.</given-names></name><name><surname>Tu</surname><given-names>S.</given-names></name><name><surname>Zhang</surname><given-names>Y.</given-names></name><name><surname>Chen</surname><given-names>H.</given-names></name><name><surname>Cao</surname><given-names>B.</given-names></name></person-group><article-title>Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study</article-title><source>Lancet</source><volume>395</volume><year>2020</year><fpage>1054</fpage><lpage>1062</lpage><pub-id pub-id-type="pmid">32171076</pub-id></element-citation></ref><ref id="bib11"><label>11</label><element-citation publication-type="journal" id="sref11"><person-group person-group-type="author"><name><surname>Obi</surname><given-names>A.T.</given-names></name><name><surname>Tignanelli</surname><given-names>C.J.</given-names></name><name><surname>Jacobs</surname><given-names>B.N.</given-names></name><name><surname>Arya</surname><given-names>S.</given-names></name><name><surname>Park</surname><given-names>P.K.</given-names></name><name><surname>Wakefield</surname><given-names>T.W.</given-names></name><name><surname>Henke</surname><given-names>P.K.</given-names></name><name><surname>Napolitano</surname><given-names>L.M.</given-names></name></person-group><article-title>Empirical systemic anticoagulation is associated with decreased venous thromboembolism in critically ill influenza A H1N1 acute respiratory distress syndrome patients</article-title><source>J Vasc Surg Venous Lymphat Disord</source><volume>7</volume><year>2019</year><fpage>317</fpage><lpage>324</lpage><pub-id pub-id-type="pmid">30477976</pub-id></element-citation></ref><ref id="bib12"><label>12</label><element-citation publication-type="journal" id="sref12"><person-group person-group-type="author"><name><surname>Wells</surname><given-names>P.S.</given-names></name><name><surname>Anderson</surname><given-names>D.R.</given-names></name><name><surname>Bormanis</surname><given-names>J.</given-names></name><name><surname>Guy</surname><given-names>F.</given-names></name><name><surname>Mitchell</surname><given-names>M.</given-names></name><name><surname>Gray</surname><given-names>L.</given-names></name><name><surname>Clement</surname><given-names>C.</given-names></name><name><surname>Robinson</surname><given-names>K.S.</given-names></name><name><surname>Lewandowski</surname><given-names>B.</given-names></name></person-group><article-title>Value of assessment of pretest probability of deep-vein thrombosis in clinical management</article-title><source>Lancet</source><volume>350</volume><year>1997</year><fpage>1795</fpage><lpage>1798</lpage><pub-id pub-id-type="pmid">9428249</pub-id></element-citation></ref><ref id="bib13"><label>13</label><element-citation publication-type="journal" id="sref13"><person-group person-group-type="author"><name><surname>Silveira</surname><given-names>P.C.</given-names></name><name><surname>Ip</surname><given-names>I.K.</given-names></name><name><surname>Goldhaber</surname><given-names>S.Z.</given-names></name><name><surname>Piazza</surname><given-names>G.</given-names></name><name><surname>Benson</surname><given-names>C.B.</given-names></name><name><surname>Khorasani</surname><given-names>R.</given-names></name></person-group><article-title>Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting</article-title><source>JAMA Intern Med</source><volume>175</volume><year>2015</year><fpage>1112</fpage><lpage>1117</lpage><pub-id pub-id-type="pmid">25985219</pub-id></element-citation></ref><ref id="bib14"><label>14</label><element-citation publication-type="journal" id="sref14"><person-group person-group-type="author"><name><surname>Wells</surname><given-names>P.S.</given-names></name><name><surname>Anderson</surname><given-names>D.R.</given-names></name><name><surname>Rodger</surname><given-names>M.</given-names></name><name><surname>Forgie</surname><given-names>M.</given-names></name><name><surname>Kearon</surname><given-names>C.</given-names></name><name><surname>Dreyer</surname><given-names>J.</given-names></name><name><surname>Kovacs</surname><given-names>G.</given-names></name><name><surname>Mitchell</surname><given-names>M.</given-names></name><name><surname>Lewandowski</surname><given-names>B.</given-names></name><name><surname>Kovacs</surname><given-names>M.J.</given-names></name></person-group><article-title>Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis</article-title><source>N Engl J Med</source><volume>349</volume><year>2003</year><fpage>1227</fpage><lpage>1235</lpage><pub-id pub-id-type="pmid">14507948</pub-id></element-citation></ref><ref id="bib15"><label>15</label><element-citation publication-type="journal" id="sref15"><person-group person-group-type="author"><name><surname>Underhill</surname><given-names>J.</given-names></name><name><surname>Sherman</surname><given-names>M.A.</given-names></name><name><surname>Howard</surname><given-names>R.</given-names></name><name><surname>Hage</surname><given-names>A.</given-names></name><name><surname>Obi</surname><given-names>A.</given-names></name><name><surname>Napolitano</surname><given-names>L.</given-names></name><name><surname>Coleman</surname><given-names>D.M.</given-names></name></person-group><article-title>The natural history and outcomes of line-associated upper extremity deep venous thromboses in critically ill patients</article-title><source>J Vasc Surg Venous Lymphat Disord</source><volume>5</volume><year>2017</year><fpage>630</fpage><lpage>637</lpage><pub-id pub-id-type="pmid">28818213</pub-id></element-citation></ref></ref-list><fn-group><fn id="d32e762"><p id="ntpara0010">Conflicts of Interest and Source of Funding: None of the authors report conflicts of interest. Vascular Cures Wiley Foundation Grant (AO)</p></fn><fn id="d32e765"><p id="ntpara0015">Article Highlights</p></fn><fn id="d32e768"><p id="ntpara0020"><bold>Type of Research</bold>: Evidence based algorithm designed for use in times of extreme scarcity.</p></fn><fn id="d32e772"><p id="ntpara0025"><bold>Key Findings:</bold> Standard imaging techniques such as duplex ultrasonography and CT may not be available for VTE diagnosis due to sheer volume of patients, difficulty in disinfecting equipment, and inadequate number of qualified imaging personnel. Empiric treatment of suspected VTE may be warranted based upon risk stratification and risk-benefit ratio calculation until imaging is available.</p></fn><fn id="d32e776"><p id="ntpara0030"><bold>Take Home Message:</bold> During the COVID-19 pandemic and other times of extreme scarcity, empiric treatment of VTE without confirmatory imaging may need to be undertaken, balancing risk-benefit ratios.</p></fn><fn id="d32e780"><p id="ntpara0035">Table of Contents Summary</p></fn><fn id="d32e783"><p id="ntpara0040">Based on evidence review, patients with low pretest probability of DVT or PE by clinical scoring system should be treated with thromboprophylaxis; those at high risk should be treated empirically until imaging is available. The authors advocate for imaging only on a limited basis for patients at high risk of both thrombosis and bleeding, when the results will change management.</p></fn></fn-group></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Sante/explor/StressCovidV1/Data/Pmc/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 000380 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd -nk 000380 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien
|wiki= Sante
|area= StressCovidV1
|flux= Pmc
|étape= Corpus
|type= RBID
|clé= PMC:7162794
|texte= Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 Pandemic
}}
Pour générer des pages wiki
HfdIndexSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/RBID.i -Sk "pubmed:32305585" \
| HfdSelect -Kh $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd \
| NlmPubMed2Wicri -a StressCovidV1
| This area was generated with Dilib version V0.6.33. |  |