Are BLOOD CLOTS the reason why COVID patients are dying? | Blood thinners to save lives?

welcome back to another covid 19 video  in this video i want to talk about   why so many covid 19 patients in the  hospital are developing blood clots   and should we empirically give high doses of blood  thinners to these patients who are in the hospital   so that's what we're going to tackle in this  video but before i dive right in let's look at   a very interesting report that was published based  on a study of patients who had severe covid disease   with ards this study was done based on patients in  italy by the famous dr gatanoni who i think of as   the godfather of ards i mean this guy was  publishing research articles about ards   while i was still in diapers let's start off by  taking a quick look at what a normal ct scan of   the chest looks like black represents air and bone  is white if the patient receives iv contrasts the   blood vessels will look white but the important  thing to notice here is that the lungs are normal   now let's take a look at dr gatenoni's study  what he found in his study of covid patients with   severe ards is that there seems to be two types  of ards first take a look at the po2 and fio2   ratios of the patients in the study where it says  95 millimeters mercury and 84 millimeters mercury   these are extremely low levels of oxygen these  numbers are telling us that these lungs in these   patients are having a very difficult time getting  oxygen into their blood in half the patients in   the study the patients had the typical ards  that we all know and hate which causes tons   of inflammation with fluid and debris filling the  alveoli where the chest x-ray and the ct skin of   the lungs looks horrible this is depicted in  the bottom ct scan let's take a closer look   look at all that grayish crap filling up the lungs  that's not supposed to be there this type of ards   is what's known as the h-type h refers to high  elastance meaning lots of stiffness in the lungs   these lungs are very stiff which does not bode  well for lung function but then there's this   other type of ards which the other half of the  patients in this study had these patients longs   have some of that grayish crap meaning there's  some inflammation going on there but it's not as   much as you would expect given the degree of their  hypoxemia in other words the oxygen levels are   far below what you would expect given the degree  of inflammation that you're seeing in the lungs   this type of ards is known as the l-type meaning  these patients have low elastance meaning their   lungs aren't very stiff so with this l phenotype  there's something else besides inflammation that   is contributing towards their very low oxygen  levels and it can only be one of two things or   a combination of these two things and that is  one constriction of the arteries that deliver   blood to the lungs in other words pulmonary  vasoconstriction and this is essentially pulmonary   hypertension meaning the pressure in these  arteries is high this means that there's less   blood being sent to the lungs to pick up oxygen  and this by itself can can cause low oxygen levels   the second thing is the development of clots  within these arteries and capillaries and this   also impairs the ability of the lungs to get  oxygen into the blood so what exactly are blood   clots and why are they so dangerous blood clots  don't normally form in the body unless we have   bleeding for example if we cut our finger that's  how we heal right the clot stops further bleeding   but sometimes some people form clots when  they're not supposed to our blood besides being   mostly water is made up of a bunch of different  proteins with different carbohydrates and fats   and these different chemicals interact with each  other and all it takes is one piece of the puzzle   to be missing or abnormal to totally throw off  the balance of either clotting too much or not   clotting enough for example hemophilia b these  patients are missing a protein called factor ix   and that's why they bleed more than they should  if it bleeds we can kill it no arnold that's   that's not what we're going for here but some  people could have the opposite problem where they   clot too easily and they form unwanted blood  clots which is what happens with for example   anti-phospholipid antibody syndrome and that's  why these patients need to be on a blood thinner   so anti-phospholipid antibody syndrome is not only  a mouthful but it's a pain in the ass because it   has a tendency to cause clots in both veins and  arteries but guess what it's not the only cause of   abnormal clotting as there are hundreds of other  medical conditions that can do the same thing such   as factor v liden and prothrombin gene mutation or  antithrombin deficiency or protein c and protein   s deficiency regardless of the cause when blood  clots do form they're most commonly in the deep   veins of our legs and sometimes our arms although  they can form anywhere in our blood vessels when   blood clots form in our deep veins it's called  deep vein thrombosis and the most common symptoms   are swelling and pain so deep vein thrombosis or  dvt these are dangerous because they can break off   and travel to the heart and to the lungs and this  is called pulmonary embolism which can be fatal   and there are plenty of people who die every year  from pulmonary emboli sometimes the clot is so big   that it causes death within minutes thankfully  not everyone who gets a blood clot in their lung   dies the most common symptoms of pulmonary emboli  are shortness of breath chest pain and sometimes   cough they can also have lightheadedness and  dizziness or even temporarily lose consciousness   and some people don't have any symptoms at  all it usually depends on the size of the clot   sometimes clots can form in the arteries and  cause a stroke or they can lodge in the coronary   arteries and cause a myocardial infarction  meaning a heart attack or they can cut off   blood flow to a leg which is what happened to  this doctor remember it's an aneurysm that clotted   leading to an infarction but this also happened to  someone with covid 19 broadway star nick cordero   who unlike dr house had to have his leg amputated  as a result and there are more reports of patients   presenting to the hospital not with typical  covid 19 symptoms but symptoms of pulmonary emboli   this is this patient's ct scan of the chest they  used iv contrast to do what's called an angiogram   so this is called a ct a of the chest or ct angio  of the chest this is in the coronal plane meaning   in this view it's like you're facing the patient  the contrast given makes the blood vessels light   up in bright white and when we see a dark  spot where it's supposed to be bright white   that's how we identify the pulmonary embolism this  patient also had bilateral ground glass opacities   or infiltrates if you will which is representative  of fluid and or inflammation this patient was   admitted to the hospital was treated with a blood  thinner and was eventually discharged from the   hospital so our blood clots at least part of the  reason why some people with covid 19 are dying   I can tell you that the number of clotting problems  my colleagues are seeing in icu across the country   all related to covid 19 is unprecedented but this  isn't just a bunch of doctors and nurses that i   know who are reporting this there's actually a  recent dutch study that found that 184 patients   in the icu with covid 19 pneumonia 20% of those  patients were having clotting issues there is   also a similar study in wuhan where 25 percent of  hospitalized covid patients had clots why and how   it starts coronavirus ii which invades the cells  of the lungs specifically the type 2 alveoli how   is that causing blood clots to form in the body  when someone has a severe case of covid 19 it's   causing a ton of inflammation within the lungs  this inflammation is what's triggering the blood   clots to develop we knew this happens with ards  even before covid 19 came around so if you saw   my video on how covid kills you may recall how  i was talking about how with ards these patients   usually develop microthrombi meaning tiny clots  that form in the tiny blood vessels in the lungs   and these microthrombi can combine to form  bigger thrombi meaning bigger clots this   happens at least partly because of the cytokine  storm that develops as a result of the infection   blood clots are also a concern with seriously  ill people in general regardless of what illness   they have because these patients aren't moving  much if at all and the lack of movement further   predisposes one to have in clots and that's the  exact reason why when patients are admitted to   the intensive care unit we usually give them  blood thinners unless there's a reason not to   for example if they have bleeding we don't  want to give those patients blood thinners   but when we give these blood thinners we're giving  them in prophylactic doses meaning the intention   is to reduce their risk of developing a clot in  the first place but these prophylactic doses are   considered low dose and the chances of someone  having severe bleeding from these small doses   is very small but the blood clots with covid 19  these are just a whole nother beast so how and why   is covid 19 causing more blood clots than usual  like everything else in life it's complicated and   we still don't have it figured out check out this  diagram actually don't it's really complicated   i'll summarize it for you long story short  here the virus enters the alveolar cells   in the lungs using the ac2 receptor and once  it does that it causes the cell to have less   h2 receptor on its surface this increases  the amount of three things within the lungs   one inflammation two formation of clots and three  constriction of blood vessels going to the lungs   meaning pulmonary vasoconstriction and guess what  each and every one of these things by itself can   lead to low oxygen levels so you can imagine what  that means when you have all three of these things   going on at the same time the way that oxygen  gets into our blood from the alveoli it has to   diffuse from the alveoli to our capillaries but  in those capillaries that encapsulate the alveoli   there's destruction there as well the inflammation  in the cytokine storm is going on there in the   capillaries not just the alveoli the lining  of these capillaries is called the endothelium   perhaps you remember this drawing from yours truly  pay attention to the wall of the capillary this   lining is called the endothelium the cytokine  storm causes destruction of the alveolus   and the endothelium and this this my friends is a  trigger for clotting we knew this happens in ards   even before covid but guess what the virus that  causes covid can actually invade the cells here   in the endothelium because these cells have  ace2 receptors as well and that can cause   even more inflammation and more clotting and this  study which looked at autopsies of two patients   found blood clots in the lungs and just beneath  the surface of the skin the autopsy results showed   that within the lung there's lots of destruction  of the capillaries that surround the alveoli   exactly what i was just talking about they also  found blood clots beneath the skin's surface   on three living patients and in another published  report in the new england journal medicine   there were three patients in the icu who had covid  19 and these three patients developed blood clots   that were significant enough to cause major  blockages in blood vessels these three patients   were positive for anti-phospholipid antibodies  more on that in a bit let's take a look at the   first case here it's a 69 year old male with  a history of hypertension diabetes stroke who   comes in with fever cough shortness of breath  and diarrhea also had a headache he developed   lower and lower oxygen levels to the point where  he required intubation with mechanical ventilation   he also developed ischemia in both legs and  in some of his fingers ischemia means he's not   getting enough blood flow to a certain part of his  body and in his case it was to his fingers and to   his legs and when they did a ct skin of his head  they found that he had multiple areas of strokes   when they did blood work on him he had low levels  of platelets he had elevated prothrombin time and   elevated partial thromboplastin time he also had  elevated levels of fibrinogen and d-dimer as it   turns out he was positive for anti-cardiolipin-iga  antibodies as well as anti-beta-2 glycoprotein iga   and igg antibodies so what's the diagnosis  that's right anti-phospholipid antibody syndrome   the other two patients in these case reports  basically had the same story in the same diagnosis   these antibodies that i just mentioned are not  in the blood for the vast majority of people   these antiphospholipid antibodies are bad because  they attack the phospholipid proteins in our body   and if it's severe enough they can cause  major clots to form in our blood vessels   so anti-phospholipid antibody syndrome it's a  condition that depends on someone's genetics   but these antibodies can also arise transiently  in patients with critical illness and various   infections so do all patients with covid 19 who  have blood clots do they all have this transient   anti-phospholipid antibody syndrome we don't know  yet so here's what we know so far even though   there are lots of gaps in our knowledge with this  disease there's all the stuff that happens in the   lungs that we just talked about but also there's a  cytokine storm that is triggered in the lungs that   can affect other organs in the body such as the  heart the brain and the kidneys and as if that's   not bad enough just about all the other organs in  the body have ace2 receptors such as the heart the   brain and the kidneys so inside the body covid  is causing a category 10 hurricane in some people   about three to four percent of people who get the  virus so besides looking at drugs that treat the   infection we also have to consider giving big  doses of blood thinners to patients with severe   disease even if we're not able to diagnose them  as having clots now some might say well doc why   can't you just diagnose them with clots easier  said than done even during normal times but it's   especially harder to do this during a pandemic  every test we do whether it's an ultrasound of   the legs looking for clots there whether it's  getting a ct scan of the lungs looking for a clot   or ct the brain looking for a clot that's causing  stroke there all of these things require more ppe   more potential exposure to the healthcare staff  and sometimes doing these things have more risk to   the patient during certain tests for example like  doing cta the chest where we give iv contrast   all these things have risks but even if we do all  these tests and they come back negative there's   still the possibility of a false negative because  no test has 100 sensitivity and 100 specificity   in other words no test is 100 accurate so  there's going to be times where you have a   very sick patient with covid 19 in the icu  and you don't know if they have blood clots   the question becomes should you give them a high  dose blood thinner meaning should you treat them   as if they have blood clots not an easy question  to answer because the risk of life-threatening   bleeding increases when you give them  that high-dose blood thinner and based   on the studies i mentioned before it looks like  about 25% of covid patients who are in the icu   do have clots so one clue that might make us more  inclined to give high doses of blood thinners   would be to check their d dimer level in the blood  because very high d-dimer levels are associated   with more severe covid disease the problem  with that is just because someone has very high   d-dimer levels doesn't necessarily mean that they  have clots because it's a very non-specific test   we know that there are a thousand causes of high  d-dimer levels because inflammation in general is   a very well-known cause i mentioned before that  even before covid 19 we knew that ards causes   these microthrombin and that's why in the past  there have been studies that looked at giving   these patients different forms of blood thinners  these patients didn't benefit from the blood   thinners as they actually had more bleeding and  ultimately had worse outcomes but these studies   don't apply necessarily to covid 19 ards because  this ards is a whole nother animal also the blood   thinners in these studies were not the typical  blood thinners that we use today so that's another   reason unfortunately because this disease is  so mysterious and so new with relatively few   high quality studies doctors don't have much to  go on when it comes to treating these patients   we're going to have to make difficult decisions  especially when it comes to giving a high dose   of a blood thinner in the icu if we see that the  patient has a blood clot then the answer is easy   give them a blood thinner as long as they don't  have bleeding issues but if we don't see blood   clots it's a difficult decision that will have to  be made on a case-by-case basis also something a   lot of people want to know is there something that  you can do to reduce your risk of developing blood   clots the biggest thing that people in general  can do is to stay active meaning minimize your   time sitting in a chair that's one factor that  makes people more prone to developing clots   so exercise is great but even if you can't  exercise even just walking around the room   or doing some stretching exercises or  even jumping jacks if you can other than   that you're going to want to take your  doctor's advice on how to optimize your   health so that's all for this video hope you  enjoyed it and i'll see you in the next one

Channel: Doctor Mike Hansen

Views: 427,885

Keywords: blood clots, blood clotting, covid blood clots, covid strokes, covid patients, why covid patients are dying, blood clots and covid, reason why covid patients are dying, blood thinners, covid pneumonia, covid and blood clots, blood clot, blood clot in lung, blood clots in lungs, blood thinners for covid, blood clots covid, covid strokes blood clots, blood clot in lung covid, covid 19 blood clots, covid 19 and blood clots, blood clots in covid 19 patients, aspirin for covid

Id: qoJ4VDaGSfY

Length: 17min 25sec (1045 seconds)

Published: Wed Apr 29 2020