The study cohort included 1228 COVID-19 patients in 40 hospitals (347 in ICU vs. 881 in non-ICU settings), of which 261 (21.3%) received at least one vascular access device of interest. Patients that underwent device placement more often had comorbidities such as hypertension, diabetes, moderate or severe kidney disease and cardiovascular disease compared to patients that did not undergo device insertion. Additionally, patients that received vascular access devices were more frequently transferred from another hospital, more often admitted directly to an ICU setting, and more often placed on mechanical ventilation on the first day of hospitalization (Table 1).
Among the 261 patients that underwent vascular access device insertion, 65 (24.9%) had more than one vascular access device placed during hospitalization. The most common combination of device use was non-tunneled CVC and an HD catheter. The majority of patients (68.6%) had a vascular access device inserted in an ICU setting, whereas 40.6% underwent device placement in non-ICU settings. Catheter placement both inside and outside of an ICU setting occurred in 24 (9.2%) patients. Among 365 included devices, the prevalence of acute, non-tunneled CVCs was 42.2%, acute HD catheters 18.4%, midline catheters 15.6%, PICCs 15.6%, tunneled CVCs 6.8%, and implanted ports 1.4%. Non-tunneled CVCs accounted for more than half of all devices placed in the ICU (55.5%), whereas midlines accounted for over a third of devices placed outside the ICU (35.8%).
Device insertion site and characteristics
Device characteristics, including vein of insertion, number of lumens, and mean dwell time, are shown in Table 2. While various anatomical sites were utilized for insertion, trends for vein of insertion were generally similar between the ICU and non-ICU placements. For example, most CVCs in ICU and non-ICU settings were placed in the internal jugular vein (73.5% vs. 90.9%, p = 0.200 respectively). Across all devices, the patient’s right side was more commonly accessed than the left (41.3% vs. 23.1%, p < 0.001). Multi-lumen catheter use was frequent but differed between ICU and non-ICU settings, with greater multi-lumen catheter placement in the ICU (98.2% ICU vs. 80.6% non-ICU, respectively, p < 0.001). Overall, single lumen catheters were used infrequently in hospitalized patients with COVID-19 (1.8% ICU vs. 19.4% non-ICU, p < 0.001).
Differences in mean catheter dwell time were observed between ICU and non-ICU devices. Mean dwell times were significantly greater in patients with vascular devices placed in the ICU compared to non-ICU settings (9 vs. 5 days, p = 0.025).
The overall prevalence of VTE in the study cohort was 6.0%. However, among patients with vascular access devices in place, 10.0% experienced either a confirmed or suspected VTE event (absolute risk difference = 4.0%). VTE events included 6 upper extremity DVT, 9 lower extremity DVT, and 16 PE (Table 3). All six upper extremity DVT events were catheter-related and occurred in patients with non-tunneled CVCs (and among those with a combination with PICCs or HD catheters [n = 5] or midline catheters [n = 1]). As well, six patients experienced both an upper-extremity DVT with concomitant PE. Of the 26 patients, 17 (65.4%) had image-confirmed thrombosis whereas 9 (34.6%) were suspected. Notably, all but seven VTE events occurred in patients who were critically ill in an ICU during their stay. Patients who underwent placement of multiple types of catheters experienced significantly more VTE events compared to those with one type of catheter (21.5% vs. 6.1%, p < 0.001). The frequency of VTE across catheter types ranged from 2.9% for midlines to 6.6% for non-tunneled catheters and 6.7% for PICCs. Patients with ports and tunneled catheters had the highest frequency of VTE events (20.0% and 13.3%, respectively). Importantly, among the 26 patients with suspected or confirmed VTE, only 8 (30.8%) survived to discharge or hospital transfer.
After controlling for available patient characteristics and risk factors associated with VTE as defined by the Caprini risk score, patients that had a vascular access device placed were significantly more likely to experience thrombosis compared to those that did not (OR 4.17, 95% CI: 2.33–7.46). The increased risk of VTE in patients with vascular access device held true for both patients who had devices placed in the ICU and non-ICU settings.
Data regarding VTE prophylaxis and thrombosis management were available for all 26 patients with a confirmed or suspected thrombotic event after device placement. Within this group, 20 (76.9%) patients received VTE prophylaxis in the form of LMWH or subcutaneous unfractionated heparin prior to diagnosis of thrombosis; six (23.1%) patients did not receive pharmacologic VTE prophylaxis for unknown reasons. Intravenous unfractionated heparin was the predominant choice for initial management of patients with thrombosis with LMWH utilized in the remainder of cases. Notably, no direct oral anticoagulants were used as initial therapy. Among the eight patients that survived to hospital discharge, 5 (62.5%) were discharged on therapeutic doses of anticoagulation (2 on direct oral anticoagulants, 1 on warfarin, 2 on LMWH).