The FDA has posted their recommendations for treatment and imaging for COVID 19 patients 2/24/2022

https://www.covid19treatmentguidelines.nih.gov/therapies/antithrombotic-therapy/

Let me quote a few  lines -

About D-Dimer and other markers without symptoms. US not necessary.
"There is currently insufficient evidence to recommend either for or against routine screening for deep vein thrombosis in patients with COVID-19 who do not have signs or symptoms of venous thromboembolism (VTE), regardless of the status of their coagulation markers."

With symptoms
"For hospitalized patients with COVID-19 who experience rapid deterioration of pulmonary, cardiac, or neurological function or sudden, localized loss of peripheral perfusion, the Panel recommends evaluating the patients for thromboembolic disease (AIII)."

For me that means without leg symptoms, evaluate for PE with CT or V/Q, don't look at legs first.


"Anticoagulant Treatment for Thrombosis
The Panel recommends that when diagnostic imaging is not possible, patients with COVID-19 who experience an incident thromboembolic event or who are highly suspected to have thromboembolic disease be managed with therapeutic anticoagulation (AIII).
The Panel recommends that patients with COVID-19 who require extracorporeal membrane oxygenation or continuous renal replacement therapy or who have thrombosis related to catheters or extracorporeal filters be treated with antithrombotic therapy as per the standard institutional protocols for those without COVID-19 (AIII).

Antithrombotic Therapy for Hospitalized, Nonpregnant Adults Without Evidence of Venous Thromboembolism
The Panel recommends against the use of aspirin to prevent mortality or the need for organ support (AI).
The Panel recommends that anticoagulant or antiplatelet therapy not be used to prevent arterial thrombosis outside of the usual standard of care for patients without COVID-19 (AIII).
In hospitalized patients, low molecular weight heparin (LMWH) or unfractionated heparin (UFH) is preferred over oral anticoagulants, because these 2 types of heparin have shorter half-lives and the effect can be reversed quickly, can be administered intravenously or subcutaneously, and have fewer drug-drug interactions (AIII).
When heparin is used, LMWH is preferred over UFH.
For adults who require low-flow oxygen and do not require intensive care unit (ICU)-level care:
The Panel recommends the use of a therapeutic dose of heparin for patients with D-dimer levels above the upper limit of normal, who require low-flow oxygen, and who do not have an increased bleeding risk (CIIa).
Contraindications for the use of therapeutic anticoagulation in patients with COVID-19 are a platelet count <50 x 109/L, hemoglobin <8 g/dL, the need for dual antiplatelet therapy, bleeding within the past 30 days that required an emergency department visit or hospitalization, history of a bleeding disorder, or an inherited or active acquired bleeding disorder. This list is based on the exclusion criteria from clinical trials; patients with these conditions have an increased risk of bleeding."


Take Home message: Many of the scans you are probably doing do not need to be done. 

 As you can see, many of the patients being scanned already need to be on anticoagulation, full anticoagulation. 

As for calf evaluation. I understand the feeling that a limited study is not adequate. That is a debate for another time.

But for now, please for your safety, make sure the patients are treated correctly first, then if they still need US, do it. If they are getting AC, I don't believe they need US. 

Of course we scan patients who need the US.

Our numbers in Philly are really coming down now. Hope we see this nationwide and world wide.

Larry Needleman MD

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