In response to Cromartie and Prin letter, the authors would like to mention that:
In the setting of Covid‐19 patients on ECMO, monitoring of anticoagulation therapy was performed using ACT with a reference range between 180 and 220 s.
The alteplase dose was chosen according to a systematic review and meta‐analysis by Zhang et al. [1] that compared the use of low‐dose rt‐PA (0.6 mg/kg, maximum 50 mg or 50 mg infused over 2 h) with standard dose (100 mg infused over 2 h) for the treatment of pulmonary embolism (PE) and concluded that low‐dose rt‐PA had similar efficacy but was safer than standard dose of rt‐PA. Also, the ESC guidelines [2] of treatment of PE approved the low‐dose protocol with rapid infusion in case of rapid hemodynamic deterioration.
The most serious side effect of lysis therapy is bleeding, which can be life threatening with an ominous prognosis [3]. Major bleeding was defined as fatal bleeding or overt bleeding with a drop in hemoglobin level of at least 20 g/L or requiring transfusion of at least two units packed blood cells, or hemorrhage into a critical anatomical site (such as intracranial, intraspinal, intraocular, retroperitoneal, or pericardial) [4, 5]. Minor bleeding was defined as any acute or subacute clinically overt bleeding that did not satisfy the criteria for major bleeding. ADEs, especially ICH, were assessed clinically during daily sedation interruptions. There was no detectable acute hemoglobin drop, and PAUS was used for follow‐up.
The main recommendations of our report [6] are the following: (i) bedside echocardiography can be a beneficial tool in the urgent assessment of the right ventricle‐to‐pulmonary vascular coupling in mechanically ventilated Covid‐19 patients and (ii) a low‐dose protocol of lysis therapy may be beneficial in mechanically ventilated, hemodynamically unstable Covid‐19 patients who show echocardiographic criteria of right ventricular strain. The decision of implementing lysis therapy should weigh the current mortality rate of this patient subset in the absence of a specific antiviral treatment, besides the proposed benefits of clinical improvement against the possible bleeding complication of such intervention.
Contributor Information
Eslam Abbas, Email: islam.omr@med.au.edu.eg.
Huda Al‐Foudri, Email: h_alfoudri@hotmail.com.
REFERENCES
- 1. Zhang Z, Zhai Z, Liang L, Liu F, Yang Y, Wang C. Lower dosage of recombinant tissue‐type plasminogen activator (rt‐PA) in the treatment of acute pulmonary embolism: a systematic review and meta‐analysis. Thromb Res. 2014;133(3):357–63. [DOI] [PubMed] [Google Scholar]
- 2. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing G‐J, Harjola V‐P, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Heart J. 2020;41(4):543–603. [DOI] [PubMed] [Google Scholar]
- 3. Tisdale JE, Colucci RD, Ujhelyi MR, Kluger J, Fieldman A, Chow MSS. Evaluation and comparison of the adverse effects of streptokinase and alteplase. Pharmacother J Hum Pharmacol Drug Ther. 1992;12(6):440–4. [PubMed] [Google Scholar]
- 4. Schulman S, Kearon C, Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non‐surgical patients. J Thromb Haemost. 2005;3(4):692–4. [DOI] [PubMed] [Google Scholar]
- 5. Roskell NS, Samuel M, Noack H, Monz BU. Major bleeding in patients with atrial fibrillation receiving vitamin K antagonists: a systematic review of randomized and observational studies. Europace 2013;15(6):787–97. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Mahdy A, Abbas E, Tarek R, Jabbour N, Al‐Foudri H. Using lysis therapy to treat five critically ill COVID‐19 patients who show echocardiographic criteria of right ventricular strain. EJHaem. 2021;2(4):799–804. [DOI] [PMC free article] [PubMed] [Google Scholar]