COVID -19 (SARS-CoV-2 ) virus emerged in Wuhan in December 2019 and the pandemic arrived in March 2020. In the first wave, we learnt that it mainly affects the respiratory tract, from mild symptoms to acute respiratory distress syndrome, leading to distress and death. With the ongoing second wave and many more new strains, it is evident that COVID-19 infection is a global inflammatory response and damages blood vessels, predisposing to coagulation (blood clotting) disorders that can lead to severe clotting events in the body. Blood clotting in the legs or hands, if not recognised in time can lead to a permanent disability.

Background:

43 yr old Ashraf (name changed), who is the sole breadwinner for his family and a father of four daughters was recovering from the Covid infection in a hospital, suddenly started complaining of severe pain in both his legs. The condition worsened when he lost power in the limbs and it started to turn pale and blue. He was then referred to an advanced centre for possible limb salvage.

There was no blood supply to both his legs which were gangrenous, up to his upper thighs. His condition deteriorated and went into septicemic shock. The only treatment left to save his life was to amputate both his legs from his upper thighs; Ashraf was saved from COVID -19 but at the huge cost of losing both his legs and making him permanently disabled.

Discussion:

Especially in the second wave of COVID-19 with the rise in the changing strains, the incidence of blood clotting has been multifarious. Blood clotting is a part of the body’s immune mechanism, but on the contrary this gets precipitated during the Covid infection, causing severe and widespread inflammation triggering a hyperimmune reaction, resulting in blood clotting across the organs which are under attack by the virus.

Blood clots are a serious condition and are capable of causing vast impairment. 

1. The virus can attack blood vessels in the body, most commonly the lungs which cause thrombosis or micro blood clots across the lungs causing sudden death. Blood clots can occur in both the veins as well as the arteries. 
2. A clot in the vein also known as deep vein thrombosis can be fatal for the patient in a moment’s notice if the clot migrates to the lungs, a condition that is known as pulmonary thromboembolism. 
3. A clot in the artery disrupts the flow of blood to the organ causing the death of the organ if not treated immediately. 
4. A stroke is a disruption of the blood supply to the brain while a heart attack is a disruption of blood supply to the heart. 
5. A clot in the limbs can lead to amputation. 
6. Patients with comorbidities like diabetes, kidney failure and hypertension as well as patients with lifestyle habits like smokers, alcoholics, drug addicts and obese are at a higher risk of blood clots.

Given that the medical community is aware of the risks of blood clots in Covid patients, it is of utmost importance that patients be constantly monitored for the occurrence of blood clots. Patients complaining of sudden pain, numbness, coolness, swelling or noticing a change in the colour of the limbs must raise the alarm of an underlying blood clot. Simple blood investigations like D-dimer, platelets and fibrinogen can indicate if the patient needs active intervention to manage blood clots through the administration of anticoagulants (blood thinners) like Heparin and low molecular heparin.

Early recognition and timely intervention can save lives and limbs. If detected early these clots can be managed with a simpler procedure like embolectomy (removal of clots), which can be done under local anaesthesia, and sometimes as a bedside procedure for very sick patients. Percutaneous procedures and thrombolysis is also an option for some of them.

Research has been conducted globally on the clinical protocols for COVID-19 patients to decrease the risk of death and debilitating organ damage due to blood clots. While we wait for the conclusion of these studies, it is recommended to prescribe anticoagulants(blood thinners) for moderate to severe COVID-19 patients at the time of hospital discharge.

Conclusion:

Apart from death and distress, it has been noted during the second wave that changing strains of the viruses are becoming more virulent leading to a significant rise in blood clotting issues which is now the most emergent cause for these disabilities. With the third wave expected anytime, we must remain vigilant for complications that can arise from blood clotting, and with early detection catastrophic incidences of limb loss and permanent disabilities can be avoided.

About Author –

Dr. Devender Singh, Consultant Vascular & Endovascular Surgeon, Yashoda Hospital
MS,DNB(Vascular)

Dr. Devender Singh

MS, DNB (Vascular Surgery)

Sr. Consultant Vascular & Endo Vascular Surgeon Clinical Director

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