Since the new crown, the number of amputations in many countries has increased significantly
Written by | Yan Xiaoliu
Source | "Medical Community" public account
"Positive." Candice Davis, who is in quarantine at home, called his mother and brother to talk about his COVID-19 test results.
She comforted her family: "I am in good health, I have not caught a cold all year round, and I will recover quickly." ”
A few days later, 30-year-old Candice was rushed to the hospital. Doctors believe that the condition is very bad and life-threatening.
Candace was then transferred to intensive care and fell into a medically induced coma.
After 3 weeks, the doctor removes the medication. Candice woke up to find her mother, Paige Davis, standing by the hospital bed, her eyes flushed: "Baby, you need to decide right away." The doctor said that if you want to save you, you have to have your leg amputated. ”
Candice agreed. When she woke up again, her forearms, half of her right foot, and the part below her left leg and knee were all removed.
Candice Davis (left) after amputation with family on November 30, 2021. /The Philadelphia Inquirer
According to the American Union of Amputees, there are about 185,000 amputations in the country each year, most of which are caused by diabetes, trauma and cancer. However, after the COVID-19 pandemic, amputations have suddenly increased.
A July 2020 study showed that COVID-19 infection increased the risk of amputation by 25%. This is more common in patients with pulmonary or systemic complications due to infection, as well as in patients with heart disease and diabetes.
"But why me?" Candice said.
In the summer of 2021, Candice and his brother Starr Davis traveled abroad. After returning home, both felt unwell and both tested positive for COVID-19.
By then, Starr had completed two doses of vaccination with mild symptoms. Three or four days would be fine.
Candice had been "planning to get a vaccine" but had been slow to act. Only 2 days after her diagnosis, she developed high fever, palpitations, and panic.
Candice Davis was in a coma for several weeks in the intensive care unit of the Presbyterian Hospital at the University of Pennsylvania. Infographic. Courtesy of /Paige Davis
On August 17, 2021, Candice was admitted to the hospital. Her blood pressure dropped to 70/50mmHg and her heart almost stopped beating. She was then diagnosed with myocarditis. Nayelah Sultan, a receiving physician at the Presbyterian Hospital at the University of Pennsylvania in the United States, said that there are a large number of cases where people infected with the new crown virus may have symptoms of myocarditis.
Subsequently, Candis developed a severe arrhythmia and extremely poor cardiac function. Hospitals are concerned that a heart transplant may be done.
Then, she used upper extracorporeal membrane oxygenation (ECMO) and a variety of drugs, including anticoagulation.
In order to prevent abnormal blood flow in the legs and lead to compartment syndrome, doctors also performed leg fasciectomy.
Candice Davis pre-infection infographic. Courtesy of /Starr Davis
After 3 weeks of coma, Candice woke up. She was startled by herself.
"My arms and legs were black. It was horrible. ”
Vascular surgeon Julia Glaser was involved in the amputation. She said Candice's limbs were severely circulatory and clotted. This may be related to COVID-19 infection.
"There is literature showing that the new crown virus needs to bind to the ACE2 receptor in order to enter the cell. The cardiovascular system also has ACE2 receptors. Therefore, the new crown virus can infect vascular endothelial cells. Julia Glaser explained that once the vascular endothelial dysfunction and coagulation process are affected, arteries and veins can be affected, resulting in a range of complications, including acute limb arterial ischemia (ALI), heart attack, deep vein thrombosis, pulmonary embolism, stroke and multi-organ dysfunction.
A Dutch study of 184 severe covid-19 patients found a 31% incidence of thrombotic comorbidities. Italian studies show that during the 2020 outbreak, the incidence of ALI was 16.3%, a significant increase (1.8%) compared to 2019. In a small study of 21 people, thrombosis severity was not related to COVID-19, with most patients having only mild (38%) or moderate (47%) COVID-19.
Shari Brosnahan, a critical care physician at New York University Langone Medical Center, said: "We have a lot of 40-year-old patients in our intensive care unit with blood clots on their extremities. It looks like they need amputation. They have no other problems than COVID-19 infections. ”
On November 30, 2021, Candice Davis eats with the help of his family. /The Philadelphia Inquirer
Behnood Bikdeli of The New York-Presbyterian Hospital in the United States offers another point. He wrote in THE JACC that patients with severe new coronary pneumonia usually have underlying diseases such as heart disease and chronic lung disease, which are themselves associated with a higher risk of blood clotting.
Covid-19 patients transferred to intensive care will lie still for a long time and are prone to blood clots.
"I'm an athlete who has won the title of 'master' in martial arts competitions and doesn't have any underlying ailments. But I was very sick. In April 2020, Mark Torregosa, 65, contracted COVID-19. After two months in the hospital, his limbs were swollen and blackened due to poor circulation.
On June 23 of that year, doctors amputated the lower part of his left knee and the sole of his right foot. About 1 week later, the doctor performed the operation again, amputating both hands.
After rehabilitation, Mark Torregosa rehabilitated at home. /The Philadelphia Inquirer
There are also studies that suggest this may be related to abnormal immune responses such as "cytokine storms." Peking Union Medical College Hospital Zhang Shuyang and others published an article in the New England Journal of Medicine, taking the lead in pointing out that new crown patients will have a variety of high-titer antiphospholipid antibodies clinical phenomenon.
The presence of antiphospholipid antibodies, suggesting an immune disorder in the patient, is part of an immune storm. This can worsen coagulation abnormalities and even catastrophic antiphospholipid antibody syndrome. It is clinically characterized by recurrent venous or arterial thrombosis.
Zhang Shuyang and others pointed out that clinical attention should be paid to anticoagulation treatment for patients with new crown, and if necessary, anticoagulation should be strengthened or even combined with antiplatelet therapy to reduce the risk of thrombosis.
But in young patients like Candice, the anticoagulation seems to be "ineffective."
Wes Ely, a professor of lung and critical care therapy at Vanderbilt University Medical Center in the United States, recalls that some patients have too many blood microclots in their bodies. "I draw blood from a COVID-19 patient with pulmonary embolism. The anticoagulant had been used to the maximum dose, but his blood was like 'frozen'. I've never seen anything like this in my life. ”
Candice Davis poses with brother Starr Davis and mother. Courtesy of /Starr Davis
On May 19, 2020, Circulation published a Chinese study online, saying that patients with COVID-19 with deep vein thrombosis had a significantly higher mortality rate than those without deep vein thrombosis.
At the same time, Greek studies showed that the new crown combined with ALI, the mortality rate is about 30%. If ali alone, the mortality rate is 5%-9%.
Two months after the release of "The Loop," 41-year-old American Broadway and TV actor Nick Cordero died of COVID-19. He was hospitalized for more than 3 months, during which time he underwent a left leg amputation for ALI.
"Compared to non-COVID-19 patients, most of the COVID-19 patients with ALI are very young and have no underlying peripheral artery disease." Peter Faries, director of vascular surgery at Icahn School of Medicine at Mount Sinai in New York, said that without COVID-19, so many people under the age of 50 had their limbs amputated as a result of ALI.
Pathological study of endothelial cell dysfunction in patients infected with the new coronavirus. /The Lancet
The World Health Organization has recommended that in severely ill patients admitted to hospital due to covid-19, prophylactic doses of anticoagulants should be used. If acromembial ischemia occurs, one of the treatment priorities is limb preservation.
But a small study recently published in the Annals of Vascular Surgery said that after the COVID-19 pandemic, the amputation rate of vascular surgery patients quadrupled. "Amputation is about saving lives." The study said.
In December 2021, Candice was finally discharged from the hospital.
Compared to rehabilitation, she is more concerned about when she will be vaccinated against COVID-19. "Look at me, that's why it's about getting vaccinated: my brother just lost his sense of taste and smell. And I lost my limbs. ”
Candice said that he gave interviews to the media and told his experiences to remind those who had a fluke mentality. "COVID-19 is not a big flu. While we have many ways to defeat the disease, don't choose the one that costs the most. ”
Source:
1.Some COVID Patients Need Amputations to Survive. Scientific American
2.COVID-19 is making amputations more common. Two Philly-area survivors tell their stories. The Philadelphia Inquirer
3.Attention should be paid to venous thromboembolism prophylaxis in the management of COVID-19. Lancet Haematol. doi: 10.1016/S2352-3026(20)30109-5. Epub 2020 Apr 9.
4.COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up: JACC State-of-the-Art Review. J Am Coll Cardiol. doi: 10.1016/j.jacc.2020.04.031.
5.Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med. DOI: 10.1056/NEJMc2007575
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