Increased incidence of massive hemorrhage at uncommon sites after initiation of systemic anticoagulation in critically ill patients with coronavirus disease 2019 (COVID-19) infection

Background The management of the Coronavirus disease 2019 (COVID-19) infected patients continues to be challenging. Critically ill COVID patients are at increased risk of serious thrombotic events and hence increased mortality. On the other side, COVID-19 patients are also showing major life-threatening bleeds, especially when systemic anticoagulation is used. Pro-coagulant propensity in critically ill COVID-19 patients have been published, but very few have described the incidence of major bleeding and its characteristics. Methods In this study, we retrospectively observed the incidence of major bleed in 25 critically ill COVID-19 patients admitted to the Intensive Care Unit at the American University of Beirut Medical Center. Six cases were identified and described together with their outcome. Results Major bleeding occurred in six of the 25 studied patients. Four patients were on therapeutic anticoagulation at the onset of the bleed, two required embolization for bleeding control and one died from hemorrhagic shock. Half of the described cases had unusual sites of bleeding including gluteal and abdominal wall muscles. Conclusions A high rate of major bleeding was witnessed in our sample of critically ill patients with COVID-19 infection, with the majority being on therapeutic anticoagulation. This rate may be higher than previously reported, necessitating additional attention from the treating physician when considering empiric therapeutic anticoagulation. Moreover, the uncommon sites of bleeding shed the light on the need for additional studies in our population to identify the predisposing risk factors and mechanisms behind it.

Automated summary

The management of critically ill COVID-19 patients presents challenges due to the increased risk of serious thrombotic events and major life-threatening bleeds. This study observed a high rate of major bleeding in 25 critically ill patients, with six cases experiencing major bleeds, including unusual sites like gluteal and abdominal wall muscles. Further studies are needed to identify predisposing risk factors and mechanisms behind major bleeding in this population.