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class=3DForte1>RELATIONSHIP BETWEEN THROMBOTIC EVENTS AND SARS-COV-2 INFECTION: A
LITERATURE REVIEW
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class=3DStrong>RELAÇÃO ENTRE EVENTOS TROMBÓTICOS E INFECÇÃO PELA SARS-COV-2: UMA
REVISÃO DE LITERATURA
Tahissa Frota Cavalcante[1] * Cris= tefânia Meirú de Lima[2] * José Erivelton de Souza Maciel Ferreira[3] * Osmar Rodrigues Paixão Ne= to[4] * Rafaella Pessoa Moreira= span>[5] * Viviane Nóbrega * Goularte Azevedo[6]
ABSTRACT
Objective: to present the knowledge produced about
thrombotic events and their relationship with SARS-CoV-2 infection. Method:=
an
integrative literature review study, carried out in May and June 2020, in f=
our
databases/virtual libraries/portals and academic search engines, with the
following keywords: coronavirus, SARS and thrombus (Pubmed, Cochrane and
Science Direct) and SARS Virus and Blood Coagulation Disorders (Virtual Hea=
lth
Library). After the search, 263 studies were found and with the use of
inclusion and exclusion criteria, 59 works remained. Results: the studies
showed that the chances of occurrence of thrombotic events increase in older
people with comorbidities. In addition, the most prevalent thrombotic event=
s in
patients affected by the disease were microvascular pulmonary thrombosis, l=
ower
limb venous thromboembolism, acute coronary syndrome and stroke. The assess=
ment
and follow-up of patients, especially those hospitalized in the Intensive C=
are
Unit, regarding their inflammatory state and their hypercoagulability marke=
rs
are important for early detection and decision-making for the administratio=
n of
anticoagulant therapies. Nursing is essential for the follow-up and monitor=
ing
of these patients. Final considerations: although the incidence of thrombot=
ic
events in people with COVID-19 worldwide is already better described in the
literature, it is still necessary to produce more clinical and epidemiologi=
cal
studies to better explain this relationship; it is also important to determ=
ine
whether this disease can actually be classified as belonging to the group of
vascular diseases.
Keywords: SARS-CoV-2; Coronavirus Infections; Thrombosis; Nursing; Critical Care Nursing=
.
RESUMO
Objetivo:
apresentar o conhecimento produzido sobre eventos trombóticos e sua relação=
com
a infecção pela SARS-CoV-2. Método: estudo do tipo revisão integrativa da
literatura, realizado nos meses de maio e junho de 2020, em quatro bases de
dados/bibliotecas virtuais/portais e buscadores acadêmicos, com as seguintes
palavras-chave: coronavírus, SARS and throm=
bus
(Pubmed, Cochrane and Science Direct) e Vírus da SARS
and Transtornos da Coagulação Sanguínea (Biblioteca Virtual da Saúde). Após=
a
busca, foram encontrados 263 estudos e com o emprego dos critérios de inclu=
são
e exclusão restaram 59 trabalhos. Resultados: os trabalhos mostraram que=
as
chances de ocorrência de eventos trombóticos aumentam em pessoas mais idosa=
s e
com comorbidades. Além disso, os eventos trombóticos mais prevalentes nos
pacientes acometidos pela doença foram trombose pulmonar microvascular,
tromboembolismo venoso de membros inferiores, síndrome coronariana aguda e
acidente vascular cerebral. A avaliação e acompanhamento de pacientes,
principalmente os internados em Unidade de Terapia Intensiva, no tocante ao=
seu
estado inflamatório e os seus marcadores de hipercoagulabilidade são
importantes para a detecção precoce e tomada de decisão para a administraçã=
o de
terapias anticoagulantes. A enfermagem é primordial para o acompanhamento e
monitoramento desses pacientes. Considerações finais: embora a incidência d=
os
eventos trombóticos em pessoas com COVID-19 em âmbito mundial já esteja mel=
hor
descrita na literatura, ainda é necessário que se produzam mais estudos
clínicos e epidemiológicos para melhor explicar essa relação; é importante
ainda para que se possa determinar se de fato essa doença pode ser classifi=
cada
como pertencente ao grupo de doenças vasculares.
Palav=
ras-chave:
SARS-CoV-2;
Infecções por Coronavirus; Trombo; Enfermagem; Enfermagem de Cuidados Críti=
cos.
INTRODUCTION
Organizations and researchers around the world are
concerned about the spread of this new coronavirus called SARS-CoV-2, the v=
irus
responsible for the outbreak of the new coronavirus 2019 disease (COVID-19),
detected on December 31, 2019 in Wuhan, China(1).
Although the clinical manifestations caused by
SARS-CoV-2 are similar to those caused by the common flu and a large percen=
tage
of people manifest mild symptoms, attention should be paid to the elderly a=
nd
people with comorbidities (such as cardiovascular diseases, diabetes mellit=
us,
asthma, and chronic obstructive pulmonary disease), pregnant women, and wom=
en
up to 45 days postpartum, because these conditions increase the chances for=
the
most serious forms of the disease. The main complications of SARS-CoV-2
infection are pneumonia, severe acute respiratory syndrome (SARS), renal
failure, sepsis, cardiomyopathies, and increased clotting activity, which
favors the occurrence of thrombotic events(2).
Patients hospitalized in the intensive care unit (=
ICU)
are particularly in risk to develop pulmonary thromboembolism, so it is
essential to take into account the associated fa=
ctors,
such as prolonged rest, the base illness, age, and comorbidities, in order =
to
perform anticoagulant prophylaxis(3). In addition, in February 2=
020,
it was consistently demonstrated that SARS-CoV-2 causes a cytokines storm,
which lead to the activation of the coagulation cascade that generate
thrombotic complications(4-5).
Disseminated intravascular coagulation (DIC) is a
secondary complication of serious infections, classically related to bacter=
ial
infections, malaria, hemorrhagic fevers associated with Dengue and Ebola
viruses, and is now also related to SARS-CoV-2. One study detected ischemia
(acro-ischemia) concomitant with the onset of dyspnea(6). This
observation led researchers to consider the hypothesis of respiratory failu=
re,
due to the extensive pulmonary capillary obstruction by thrombi, and that t=
he
DIC may be playing an important role in hypoxemia, as well as in the morbid=
ity
and mortality results of ICU patients with COVID-19(6).
Because the disease is currently a pandemic, sever=
al
research questions are emerging as the disease progresses and manifests its=
elf
in different parts of the world. Research has been carried out and has alre=
ady
helped to clarify some themes such as the genome of the virus, the main for=
ms
of virus transmission and disease prevention, the search for effective and =
safe
drugs to treat the infection, and the formulation and testing of vaccines.
However, much research is still needed to deepen the issues listed above.
In this context, the following questions arose: a)
What is the incidence of thrombotic events in patients with SARS-CoV-2
worldwide? b) What are the most common thrombotic events in patients with
SARS-CoV-2? c) Is there a difference in the incidence of these thrombotic
events with respect to sex, age group and previous presence of comorbiditie=
s?
d) What are the most common clinical and laboratory manifestations of
thrombotic events in patients with SARS-CoV-2? e) Is there a decrease in
morbidity and mortality in patients with SARS-CoV-2 treated with anticoagul=
ant
and/or cardiovascular protector agents?
In view of the aforementioned facts, this study's =
main
objective is to present the current knowledge about thrombotic events relat=
ed
with SARS-CoV-2 infection. The relevance of this study lies in the fact that
SARS-CoV-2 is a novel virus that can be easily spread and cause a significa=
nt
number of deaths in the world population, as well as important and serious
complications such as thrombotic events. Thus, studies are needed to elucid=
ate
the issues related to thrombotic events in patients with COVID-19. Its
relevance is also given because it presents a synthesis of many works that =
have
been published on the topic COVID-19, providing relevant information to
professional nurses and others that make up the interdisciplinary health te=
ams.
METHO=
DS
=
To accomplish this study, the literature review was
chosen as the objective was to synthesize research results on a limited top=
ic,
in a systematic and organized manner, contributing to the deepening of
knowledge(7). The steps of the literature review were:
identification of the research questions, literature search, data evaluatio=
n,
data analysis, and presentation(8).
Identification of the research questions
The search was carried out on the topic of interes=
t:
coagulopathies and thrombotic events related to SARS-CoV-2 infection. To ga=
ther
knowledge about this theme, an integrative literature review was conducted =
with
the following purpose: To present the current knowledge about thrombotic ev=
ents
related with SARS-CoV-2 infection.
As already mentioned, the research questions were:=
a)
What is the incidence of thrombotic events in patients with SARS-CoV-2
worldwide? b) What are the most common thrombotic events in patients with
SARS-CoV-2? c) Is there a difference in the incidence of these thrombotic
events with respect to sex, age group and previous presence of comorbiditie=
s?
d) What are the most common clinical and laboratory manifestations of
thrombotic events in patients with SARS-CoV-2? e) Is there a decrease in
morbidity and mortality in patients with SARS-CoV-2 treated with anticoagul=
ant
and/or cardiovascular protector agents?
Literature search
The following databases were searched: Virtual Hea=
lth
Library (which contains the LILACS, BDENF, WHO-IRIS, PAHO-IRIS, and SCIELO =
databases),
Pubmed (wich contains the Medical Literature An=
alysis
and Retrieval System Online database), Cochrane and Science Direct (one of =
the
largest sources of health research databases accessed through the Elsevier
portal).
The decision to use these diverse databases, porta=
ls,
and libraries, was intended to expand the scope of the research and thus
minimize possible bias. The search strategy employed a combination of speci=
fic
descriptors of each database.
The MeSH terms "coronavirus",
"SARS", and "thrombus" were used in Pubmed, Science Dir=
ect,
and Cochrane databases. The DeCS structured and trilingual vocabulary
descriptors in the health sciences "SARS Virus" and "Blood
Coagulation Disorders" in Portuguese and their respective synonyms in
English and Spanish were used in the Virtual Health Library.
We highlight that initially the search was perform=
ed
using controlled descriptors in each database. However, due to the small nu=
mber
of studies, the descriptors were used as keywords, expanding the scope of t=
he
research. The inclusion criteria established for the studies were: a) full-=
text
articles investigating the theme of coagulopathies and thrombotic events
related to SARS-CoV-2 infection; and b) studies that answer at least one of=
the
research questions.
The literature search was conducted in May 2020 and
updated in June 28, 2020. Each database was accessed in a single day, with a
recording of the search pages. The selection of studies was carried out in =
the
following days, through reading of the titles and abstracts. When necessary,
the full text was read to check whether it met the inclusion and exclusion
criteria.
Figure 1
displays a flowchart describing the selection process of the evaluated stud=
ies.
Figure 1<=
span
lang=3DEN-US style=3D'font-size:12.0pt;font-family:"Times New Roman",serif;
mso-fareast-font-family:"Times New Roman";mso-ansi-language:EN-US;mso-farea=
st-language:
PT-BR'> - Flowchart of selection of works selected from the databases selec=
ted
for this integrative review.
Source: The authors (2020).
Data evaluation - methodological quality
The methodological quality of the studies was evaluated in June 2020
based on their levels of evidence(9).
Data analysis – data reduction, display, comparison, and presentatio=
n
The last steps of the <=
span
class=3DSpellE>literarure review are similar, they are presented in a
single section. All selected studies were synthesized according to the
following characteristics: identification, methodological description, resu=
lts,
and level of evidence. Data were presented in a qualitative way using major
themes for categorization, as follows: relationship between thrombotic events and sociodemographic and clinical
factors in patients with SARS-CoV-2; most common thrombotic events in patie=
nts
with SARS-CoV-2 with some clinical and laboratory findings; and results of
treatments for this clinical situation.
Ethical aspects
Regarding ethical aspects, there was no need to send the project to =
the
Research Ethics Committee of the University of International Integration of=
Lusofonia Afro-Brazilian, in accordance with Resoluti=
on
466/2012(10), as it is an integrative review study.
RESUL=
TS
The results fr=
om
the methodological quality assessment of the studies based on their levels =
of
evidence(9) is shown in Table 1.
Table 1
– Description of the methodological quality assessment of the articles incl=
uded
in this integrative review.
Levels of Evidence |
Absolute frequency of
studies |
Relative frequency of=
studies |
1 |
1(41) |
2.0% |
2 |
0 |
0.0% |
3 |
0 |
0,0% |
4 |
6(19,28,32,36,37,62) |
11.1% |
5 |
20(11,13,22,23,25,27,29,30,33-35,43-46,49,52,55,=
68,70) |
37.0% |
6 |
17(15,20,21,24,26,40,42,47,48,53,54,56-58,61,63)=
|
31.4% |
7 |
10(14,16,17,31,38,51,60,64,65,69) |
18.5% |
Source:
The authors (2020).
Table
1 shows that most studies included in this review are literature reviews,
descriptive studies, and case reports. However, it is opportune to consider
that the COVID-19 pandemic is a major health emergency in global public hea=
lth,
therefore, health information is relevant even from studies with a low leve=
l of
evidence. The exchange of information between health workers and the consta=
nt
update of knowledge about the novel coronavirus raise research questions and
stimulate the development of case reports, descriptive studies, and literat=
ure
reviews. Such studies can serve as a basis for the development of research =
with
more robust methods and can enhance the clinical practice through
evidence-based decision making.
The results are
presented according to the following thematic categories: relationship betw=
een
thrombotic events and sociodemographic and clinical factors in patients with
SARS-CoV-2; most common thrombotic events in patients with SARS-CoV-2 with =
some
clinical and laboratory findings; and results of treatments for this clinic=
al
situation.
Relationship
between thrombotic events and sociodemographic and clinical factors in pati=
ents
with SARS-CoV-2
Evidence of abnormal coagulation parameters associ=
ated
with COVID-19 appeared at the beginning of reports from China(=
11).
A study developed with the first 99 hospitalized patients in Wuhan(=
12) found that in 36% of the patients had high D-dimer,
increased inflammatory biomarkers such as inteleukin-6, high erythrocyte
sedimentation volume, and high C-reactive protein. Thrombocytopenia was pre=
sent
in only 12% of patients and four died of septic shock
A number of authors(13-17) referenced the
study by Tang et al.(18) on coagulopathies and COVID-19. Such research=
(18) evaluated 183
patients with SARS-CoV-2, among which 21 patients (11.5%) died. From the 21
patients who died 71% met the criteria of the International Society for
Thrombosis and Homeostasis for disseminated intravascular coagulation compa=
red
with 0.6% of the surviving patients.
Worldwide, the=
re
are no population-based or multicenter studies on the prevalence of thrombo=
tic
events in people with SARS-CoV-2.
Several studie=
s(13,19-35)
point out that most of the thrombotic events related to SARS-CoV-2 occur in
elderly people, male, and patients with pre-existing=
span>
chronic diseases such as cardiovascular, cerebrovascular, lung, cancer, liv=
er
diseases, nephropathies, obesity, and diabetes mellitus. A st=
udy(36)
about venous thromboembolism in patients with COVID-19 based on autopsy
findings found that the presence of neurodegenerative diseases is a risk fa=
ctor
for thrombotic complications in patients with SARS-CoV-2. An Italian cohort
study(37) observed that fibrinogen values appeared=
to
be higher in women affected by COVID-19 compared to the control group. A nonsignificant trend towards
increased fibrinogen levels has been demonstrated in male patients. Patients
with SARS and COVID-19 tend to have significant levels of fibrinogen compar=
ed
to those without SARS, and D-dimer levels showed an insignificant upward tr=
end. Researchers A point of
interest in the COVID-19 pandemic has been differences in the pattern of
mortality in young people. Some of these patients have a worse prognosis, b=
ut
without predisposing risk factors. In Italy, high mortality rates have been
observed in young patients(40). One explanation for this finding=
may
be mutations in the coagulation cascade or complement inhibitory factors, s=
uch
as complement factor H, which appears to exist in 1% of the Italian populat=
ion(40). However, a
systematic review study(41) with meta-analysis of the impact of
cerebrovascular and cardiovascular diseases on the severity and mortality o=
f COVID-19
found that such diseases were associated with increased mortality, but gend=
er,
age, arterial hypertension, diabetes mellitus, and respiratory conditions d=
id
not influenced this association. Most common thrombotic events in patients
with SARS-CoV-2 with some clinical and laboratory findings Thromboembolism
related to the SARS-CoV-2 virus can be seen in the pulmonary vessels in
addition to cases of acute fibrinous and organizing pneumonia. Pulmonary le=
sion
of small blood vessels is a common manifestation in patients dying from COV=
ID
19, with microvascular thrombosis in the lungs and thromboembolism with
hemorrhagic infarction in larger vessels. In COVID-19, microvascular thromb=
osis
is largely observed(21,24,25,28,30-34,36,42-46). Several researchers(11,12,17,25-28,33,34,37,45,47-53)Guidelines on the prevention and treatment of thromboembolism(38)=
sup> recommend the assessment of the risk for venous thromboembolism based =
on different clinical conditions, such as: age over 40, three days in bed, =
laboratory confirmation of COVID-19 combined with one of following risk fac=
tors: presence of sepsis, presence of severe acute respiratory disease, hea=
rt failure, obesity, history of venous thromboembolism, acute exacerbation =
of obstructive pulmonary disease, acute stroke, acute coronary syndrome, va=
ricose veins in the lower limbs, cancer, inflammatory bowel disease, and ch=
ronic kidney failure.
Other studies(19,28,54) reported that small vessel thrombosis led to intestinal ischemia,
cholestasis and distention of the gallbladder and acute infarction of organs
such as spleen, liver and kidneys in people with COVID-19. A research(36) also described, based on autopsy results, that
pulmonary emboli are due to deep venous thrombosis of the lower limbs and t=
hat
complications such as thrombosis in the prostate venous plexus are also pre=
sent
in people with SARS-CoV-2 infection.
Rega=
rding
cardiovascular complications related to COVID-19, these involve heart failu=
re,
myocarditis, pericarditis, vasculitis, and cardiac arrhythmias. The presence of microangiop=
athy
and microthrombi can also predispose the patient to microinfarctions in
multiple organs, such as liver, heart or kidney, further exacerbating the s=
tate
of injury and multiple organ failure(29,50-51,55)<=
/span>.
Two s=
tudies
described thrombotic events in the skin capillaries, which generate the
necrotizing capillary lesion, manifesting through slightly purplish reticul=
ated
eruptions on the chest, legs and arms, consistent with livedo reticularis(56-57). The
explanation for this manifestation is that as endothelial cells also
express the ACE2 gene, SARS-CoV-2 may cause direct endothelial dysfunction
after binding to ACE2, leading to subsequent thrombosis(15).
Other research(40) developed on the anal=
ysis
of the deposition of the SARS-CoV-2 virus in five placentas reported that t=
here
was thrombosis in larger vessels of the fetal circulation, frank thrombosis=
in
three cases, while in the other two cases, vascular thrombosis confined to =
the
villi of the trunk was confirmed, generating poor fetal perfusion due to
thrombosis in placental vessels.
The
clinical and laboratory manifestations of thrombotic events in people with
SARS-CoV-2 are correlated with the specific signs and symptoms of central
venous thrombosis(26,48), stroke(41,47,49,53), acute
myocardial infarction(13,21,29,41), pulmonary thrombosis(28=
,31,33,45,58),
deep peripheral venous thrombosis(20), disseminated intravascular
coagulation(14,45,58), and acute renal failure(53,59-60).
Rese=
arch on
intestinal abnormalities(19) found abnormalities in the intestinal wall of ICU patien=
ts
affected by SARS-CoV-2 =
using
CT scans. The researche=
rs
found gastrointestinal symptoms such as nausea, vomiting, diarrhea, abdomin=
al
pain, and thickening of the intestinal wall, associated with pneumatosis and
portal venous gas due to mesenteric ischemia.
Regar=
ding
laboratory tests, several studies(11,16,17,24,30,46,49,61) cited
high D-dimer values as a predisposing factor for the occurren=
ce
of thrombotic events in patients with COVID-19.
Results of treatments for this clinical situation
Current reports demonst=
rate
benefits of heparins in the prophylaxis of thrombotic events in patients wi=
th
COVID-19. Treatments with low molecular weight heparin (enoxaparin) or
unfractionated heparin have been adopted and the success of the treatment
depends on age and D-dimer values. When the value of this marker exceeds six
times the normal upper limit, mortality becomes lower with the treatment(22,55).
ICU patients with COVID=
-19
should use higher doses of low molecular weight heparin, as it has been sho=
wn
that they develop pulmonary thromboembolism even with prophylactic treatmen=
t.
Thus, both ICU and regular ward patients, even receiving low molecular weig=
ht
heparin, are developing deep venous thrombosis or pulmonary embolism, which
reinforces that heparin doses must be doubled in this clinical context(11,16,18,20,22-23,25,27,30,33,38,43,45,62-63).
Another study on pulmon=
ary
embolism in patients with COVID-19 added that there was an improvement in t=
he
antithrombotic effect when there was a change from enoxaparin to rivaroxaba=
n(24). Researchers(25) add that for patients =
with
stroke and COVID-19 it seems reasonable to treat with =
tPA.
In addition, AT1 receptor blockers, such as losartan, may have a protective
effect in stroke patients.
Researchers=
(16,18,34,64) report the results on the use of intravenous immunoglobulin (IVIG) and
anticoagulant therapy with low molecular weight heparin as early as possibl=
e,
especially when the number of circulating T and B lymphocytes decreases and
inflammatory cytokines and D-Dimer increases drastically. Although intraven=
ous
immunoglobulin has been shown to be effective in treating patients with
influenza and SARS, more clinical data is needed to determine immunoglobulin
efficacy in patients with COVID-19.
It should be noted that preclinical studies(6=
6-67)
document the anti-thrombotic effects of vitamin D supplementation. Research=
ers
also point out that most intervention studies do not clearly show the
protective effects of vitamin D supplementation in preventing cardiovascular
events. However, most studies have not evaluated people with severe vitamin=
D
deficiency(67-68). Vitamin D deficiency is a prevalent problem
worldwide – 7% of the world population has severe deficiency and about 40% =
have
borderline levels of vitamin D in the body(66).
Regar=
ding
cardiovascular protection, two studies(29,51) describe that pati=
ents
with COVID-19 and cardiac injury must be closely monitored for the increase=
in
cardiac enzymes – the markers of cardiac stress, and that the administratio=
n of
cardioprotective agents is necessary.
DISCU=
SSION
Among the explanations about the formation of micr=
othrombi
with lesions in several target organs, we find that the SARS-CoV-2 virus ha=
s an
extensive tissue distribution causing the release of a high number of
pro-inflammatory cytokines (cytokine storm), promoting a systemic inflammat=
ory
response syndrome with an important impact on the hematopoietic system and
hemostasis, leading to infarction of organs such as lungs, heart, liver, and
kidneys(14,50,68).
It is=
worth
mentioning that specific changes in hemostasis are already present in the
initial stage of the SARS-CoV-2 infection(11,18,37).
COVID-19-associated coagulopathy due to acute systemic inflammatory respons=
e is
characterized by an elevation of several coagulation markers, such as D-dim=
er
(a fibrin or fibrinogen degradation product), concomitant increase in
inflammatory markers (including C-reactive protein), and mild thrombocytope=
nia(49,61).
Some hypotheses
that justify the increased incidence of thrombotic events in older people a=
nd
with pre-existing chronic diseases are: a) the
tendency of these people to have a higher D-dimer value(16,18,34);
b) the use of antihypertensive drugs, such as ACE inhibitors and angiotensi=
n II
receptor blockers, which increase the expression of the ECA2 gene, and favor
the replication of the SARS-CoV-2 virus(30); and c) alteration of
the renin-angiotensin-aldosterone system that is intrinsically linked to the
coagulation cascade and can aggravate the immunothromb=
osis
process, further stimulating the formation of microthrombi in COVID-19=
(69).
There is strong evidence that occlusion and format=
ion
of microthrombi in small pulmonary vessels exists in critically ill patients
with COVID-19 and that, therefore, the early application of anticoagulant
therapy in these patients is important to improve the prognosis(18).
Every patient at risk of deep venous thrombosis admitted to the ICU should
receive some preventive treatment (pharmacological, mechanical, or both), as
prevention is essential, as long as it is safe and effective. The nursing t=
eam
is essential in this process, from the administration of prescribed drugs to
the performance of non-pharmacological measures that contribute as part of =
this
preventive treatment described.
Nurses and other professionals should also be awar=
e of
the signs and symptoms of thrombotic events manifested by patients with
COVID-19, because it is proven to be a disease that can generate such
complications, which require timely effective clinical decision-making. Such
complications affect the morbidity and mortality profile, as described. This
responsibility applies even more to the nursing team, as they are the
professionals who most provide direct care to clients.
The
recommendation for nurses and other health professionals who provide nursing
care to critical or semi-critical patients in referral hospitals for COVID-=
19
is to closely monitor sick patients. It is noteworthy to pay attention to t=
he
signs and symptoms of thrombotic events, the inflammatory markers and the
hypercoagulable state they present. In addition, they can early recognize t=
he
high risk of thrombosis in these patients, especially in the elderly with
comorbidities, especially cardiovascular, pulmonary, endocrine - diabetes
mellitus - and metabolic - obesity, for the early and effective implementat=
ion
of anticoagulant therapy.
Some =
research
questions were not answered, such as the incidence of thrombotic events in
people with SARS-CoV-2 worldwide and the effects of cardiovascular protecti=
ve
drugs on the reduction of morbidity and mortality. It is important that
researchers from the most diverse areas of health can seek to answer them o=
ver
time so that their findings are promptly published.
This
literature review has the following implications: a) it brings an in-depth =
and
updated synthesis of the knowledge produced by researchers from different
countries about serious complications arising from the SARS-CoV-2 virus, su=
ch
as thrombotic events; b) it can assist decision-making by doctors and nurse=
s to
monitor and treat COVID-19 patients; c) it describes knowledge gaps and
research questions that need to be investigated further to contribute to the
advancement of knowledge in the field; and d) in the context of this pandem=
ic,
studies involving the topic of infection by SARS-CoV-2 and COVID 19 are very
important, regardless of the approaches, as this is a new disease and the
knowledge that has been produced and disseminated has contributed to reduci=
ng
the severe impacts caused by the SARS-CoV-2 virus.
Many =
issues
highlighted in this integrative review need to be further investigated for
further clarification, such as problems of thrombotic events related to
SARS-CoV-2 virus infection in different continents; and whether there are
proven effective protective factors (clinical, laboratory, pharmacological)
that would decrease the chances of developing thrombotic events in people
infected with SARS-CoV-2; and what are the effective tools used by the nurs=
ing
team to reduce the incidence of this problem in this population.
Other
issues also raised, which also need to be investigated, were whether vitami=
n D
supplementation is effective in preventing thrombotic events in people with
COVID-19; the comparison between non-pharmacological and pharmacological
methods of preventing venous thrombosis in people with COVID 19; and follow=
-up
studies of people who have had COVID-19 to determine the incidence of
thrombotic events at a later stage or to investigate the recurrence of new
events among those who manifested some thrombotic disease at an early stage=
of
SARS infection. CoV-2.
FINAL CONSIDERATIONS=
b>
The s=
tudies
included in this review indicate that there is a relationship between the
pathophysiology of SARS-CoV-2 infection and thrombotic events, through cyto=
kine
storm and disseminated intravascular coagulation. The literature also showed
that the chances of occurrence of thrombotic events in COVID-19 increase in=
the
elderly and associated comorbidities. It also suggested that the most
appropriate thrombotic events in this clinical setting were microvascular
pulmonary thrombosis, lower limb venous thromboembolism, acute coronary
syndrome, and stroke.
The
assessment and follow-up of patients, especially those admitted to the ICU,
regarding their inflammatory status and their hypercoagulability markers, s=
uch
as D-dimer, were considered important for early detection and decision-maki=
ng
regarding the administration of anticoagulants. Nursing is essential for the
follow-up and monitoring of these patients, as well as for quick and effect=
ive
decision-making for the stability of the clinical picture of patients in cr=
itical
care until the arrival of other professionals who make up the intensive care
team.
Discr=
imination
of thrombotic events in people with COVID-19 worldwide is already available=
in
the literature, but further clinical and epidemiological studies are still =
needed
to better explain this relationship. It is also important to determine whet=
her
this disease can really be classified as belonging to the group of vascular
diseases. The results of this study can support research in this thematic l=
ine.
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Autor
correspondente
José Erivelton de S=
ouza
Maciel Ferreira. Rua Antônia Vicente, Baturité-CE 62.760-000, +558599811657=
8, eriveltonsmf@gmail.com.
=
Submission=
: 2021-05-14
Approval=
: 2021-06-12
[1] Enfermeira. D=
outora
em Enfermagem. Professora do curso de Enfermagem e do Programa de Pós-Gradu=
ação
em Enfermagem da Universidade da Integração Internacional da Lusofonia
Afro-Brasileira (UNILAB), Redenção-Ceará, Brasil. Orci=
d:
https://orcid.org/0000-0002-=
7758-4273
[2] Acadêmica do curso de graduação em Enfermagem =
span>da Universida=
de da
Integração Internacional da Lusofonia Afro-Brasileira (UNILAB), Redenção-CE,
Brasil. Orcid: https://orcid.org/0000-0001-=
8919-4988
[3] Enfermeiro. Especialista em Enfermagem Cirúrgica.
Pós-graduando lato sensu em Enfermagem do Trabalho. Mestrando em Enfermagem=
da Universidad=
e da
Integração Internacional da Lusofonia Afro-Brasileira (UNILAB), Redenção-Ce=
ará,
Brasil. Orcid: https://orcid.org/0000-0003-=
2668-7587
[4] Acadêmico do curso de graduação em Enfermagem =
span>da Universida=
de da
Integração Internacional da Lusofonia Afro-Brasileira (UNILAB), Redenção-Ce=
ará,
Brasil. Orcid: https://orcid.org/0000-0003-4183-6018
[5] Enfermeira. D=
outora
em Enfermagem. Professora do curso de Enfermagem e do Programa de Pós-Gradu=
ação
em Enfermagem da Universidade da Integração Internacional da Lusofonia
Afro-Brasileira (UNILAB), Redenção-Ceará, Brasil. Orci=
d:
https://orcid.org/0000-0003-=
2341-7936
[6] Enfermeira. Especialista em Enfermagem em Nefrol= ogia. Mestranda em Enfermagem da Universidade da Integração Internacional da Lusofonia Afro-Brasileira (UNILAB), Redenção-Ceará, Brasil. Orci= d: https://orcid.org/0000-0002-0134-0694<= o:p>
=