Risk factors influence the arterial line patency in ICU-bound patients during COVID-19 pandemic: An observational cohort study

Figures & data

Table 1. Patients’ characteristics of the two study groups: Systemic anticoagulation (therapeutic), group-1 and non-systemic anticoagulation (prophylactic), group-2 anticoagulation dose.

Item	Systemic anticoagulation (Therapeutic) n = 197	Non-systemic anticoagulation (Prophylactic) n = 48	p value
Male gender n (%)	156 (79.2)	41 (85.4)	0.33
Age/year median (IQR)	50.0 (42.0, 55.5)	48.0 (42.0, 58.0)	0.696
BMI/kg/m^2 median (IQR)	30.0 (27.0, 34.0)	28.0 (25.8, 33.2)	0.189
Basal Laboratory Data
Platelets (K/uL) median (IQR)	239.0 (179.0, 315.0)	266.5 (171.3, 374.8)	0.195
INR median (IQR)	1.1 (1.0, 1.2)	1.1 (1.0, 1.2)	0.190
PT (seconds) median (IQR)	12.9 (11.8, 13.7)	12.9 (12.2, 14.3)	0.215
APTT (seconds) median (IQR)	29.3 (27.2, 32.5)	28.6 (25.4, 32.7)	0.402
D-Dimer (ng/mL) median (IQR)	0.9 (0.5, 3.2)	1.5 (0.5, 3.3)	0.671
Fibrinogen (mg/dL) median (IQR)	4.9 (3.8, 6.3)	4.0 (2.5, 4.2)	<0.0001
Ferritin (mcg/L) median (IQR)	991.5 (580.8, 1602)	1224 (417, 1716)	0.990
Anti-Xa level (IU/mL) median (IQR)	0.5 (0.4, 0.9)	1.1 (0.4, 1.1)	0.246
Associated morbidity and therapy
Co morbidities n (%)	103 (52.3)	24 (50.0)	0.776
Malignancy n (%)	3 (1.5)	2 (4.2)	0.245
Diabetes Mellitus n (%)	99 (50.3)	23 (47.9)	0.772
Previous history of CNS stroke n (%)	3 (1.5)	2 (4.2)	0.245
Cardiovascular diseases n (%)	12 (6.1)	6 (12.5)	0.127
Hypertension n (%)	76 (38.6)	24 (50.0)	0.149
Pulmonary diseases n (%)	16 (8.1)	4 (8.3)	0.962
Recent hospitalization (<30 days) n (%)	25 (12.7)	6 (12.5)	0.972
Recent surgery (<30 days) n (%)	3 (1.5)	1 (2.1)	0.783
Sedated Mechanical ventilated n (%)	71 (36.0%)	19 (39.6)	0.648
Procedure Data
Procedure duration/min median (IQR)	20.0 (15.0, 25.0)	20 (16.3, 30.0)	0.042
Physician ‘s Working Shift Time Morning Afternoon Evening	97 (49.2) 55 (27.9) 45 (22.8)	35 (72.9) 4 (8.3) 9 (18.8)	0.005
ASA scoring n (%) ASA1 ASA2 ASA3	30 (15.2) 137 (69.5) 30 (15.2)	9 (18.8) 27 (56.2) 12 (25.0)	0.176
Arterial Catheter insertion Ultra Sound – assisted n (%)	30 (15.2)	7 (14.6)	0.911
Vasopressor agents n (%)	61 (31.0)	9 (18.8)	0.093
Arterial line failure n (%)	51 (25.9)	22 (45.8)	0.007
Mortality n (%)	23 (11.7)	6 (12.5)	0.874
Duration of index A-line patency/day median (IQR)	5.0 (4.0, 9.0)	4.0 (3.0, 8.8)	0.184
Length of ICU stay/day median (IQR)	7.0 (4.0, 14.5)	9.0 (6.0, 16.5)	0.067
Length of Hospital stay/day median (IQR)	15.5 (7.3, 24.8)	16.0 (10.0, 28.0)	0.042

Abbreviations: Non-SA = Non Systemic anticoagulation (Prophylactic); SA = Systemic anticoagulation (Therapeutic); BMI = body mass index; INR = international normalized ratio; PT= prothrombin time; APTT; activated partial thromboplastin time; anti-Xa level = anti factor 10-a coagulation factor; ICU = intensive care unit; a-line = arterial line; ASA = American Society of Anaesthesia; IQR = inter quartile ratio. Statistically significant values at p < 0.05.

Table 2. Patients’ characteristics of the both failed and patent arterial lines.

Item	Failed arterial line n = 73	Patent arterial line n = 172	p value
Male gender n (%)	54 (74.0)	143 (83.1)	0.098
Age/year median (IQR)	51.0 (43.0, 55.0)	48.5 (42.0, 56.0)	0.201
Therapeutic measures Systemic anticoagulant Non-Systemic anticoagulant	51 (69.9) 22 (30.1)	146 (84.9) 26 (15.1)	0.007
BMI/kg/m^2 median (IQR)	29.0 (26.3, 34.0)	30.0 (27.0, 34.0)	0.581
ASA scoring n (%) ASA1 ASA 2 ASA 3	15 (20.5) 47 (64.4) 11 (15.1)	24 (14.0) 117 (68.0) 31 (18.0)	0.414
Basal Laboratory Data
Platelets (K/uL) median (IQR)	252 (191, 381)	239 (175, 312.8)	0.074
INR median (IQR)	1.1 (1.0, 1.2)	1.1 (1.0, 1.2)	0.420
PT (seconds) median (IQR)	12.9 (12.2, 13.5)	12.9 (11.8, 14.1)	0.521
APTT (seconds) median (IQR)	28.1 (25.5, 32.1)	29.7 (27.4, 32.5)	0.080
D-Dimer (ng/mL) median (IQR)	1.7 (0.7, 3.8)	0.8 (0.5, 3.1)	0.002
Fibrinogen (mg/dL) median (IQR)	4.9 (3.6, 6.6)	4.1 (3.2, 5.3)	0.017
Ferritin (mcg/L) median (IQR)	816 (512, 1278)	1088 (591, 1688)	0.085
Anti-Xa level (IU/mL) median (IQR)	0.4 (0.4, 0.92)	0.56 (0.36, 1.08)	0.646
Associated morbidity and therapy
Co-morbidities n (%)	49 (67.1)	78 (45.3)	0.002
Previous history of thrombosis n (%)	4 (5.5)	9 (5.2)	0.937
Renal Failure n (%)	5 (6.8)	8 (4.7)	0.483
Malignancy n (%)	0	5 (2.9)	0.141
Diabetes Mellitus n (%)	49 (67.1)	73 (42.4)	<0.0001
Previous history of CNS stroke n (%)	3 (4.1)	2 (1.2)	0.136
Cardiovascular diseases n (%)	7 (9.6)	11 (6.4)	0.381
Hypertension n (%)	31 (42.5)	69 (40.1)	0.732
Pulmonary diseases n (%)	3 (4.1)	17 (9.9)	0.131
Anticoagulation therapy n (%)	8 (11.0)	9 (5.2)	0.107
Aspirin therapy n (%)	20 (27.4)	12 (7.0)	<0.0001
Bleeding n (%)	6 (8.2)	5 (2.9)	0.066
Mortality n (%)	36 (49.3)	9 (5.2)	<0.0001
Recent hospitalization (<30 days) n(%)	10 (13.7)	21 (12.2)	0.748
Recent surgery (<30 days) n (%)	2 (2.7)	2 (1.2)	0.373
Procedure Data
Procedure duration/min median (IQR)	20.0 (16.0, 28.0)	20.0 (15.0, 25.0)	0.046
Physician ‘s Working Shift Time Failure number n (%) Morning Afternoon Evening	43 (58.9) 20 (27.4) 10 (13.7)	89 (51.7) 39 (22.7) 44 (25.6)	0.12
ICU Prone Position n (%)	35 (47.9)	36 (20.9)	<0.0001
Arterial Catheter US assisted n (%)	7 (9.6)	30 (17.4)	0.116
Vasopressor agents n (%)	33 (45.2)	37 (21.5)	<0.0001
Sedated Mechanical ventilated n (%)	42 (57.5)	48 (27.9)	<0.0001
Arterial Catheter Size n (%) Gauge −18 gauge Gauge −20 gauge Gauge −22 gauge	2 (2.7) 69 (94.5) 2 (2.7)	0 163 (94.8) 9 (5.2)	0.066
No of arterial blood gas (ABG)/day n (%) One time/day Two times/day Three times/day Four times/day Five times/day	7 (9.6) 24 (32.9) 24 (32.9) 18 (24.7) 0	63 (36.6) 55 (32.0) 32 (18.6) 21 (12.2) 1 (0.6)	<0.0001
Duration of index A-line patency/day median (IQR)	4.0 (3.0, 9.0)	5.0 (4.0, 9.0)	0.079
Length of ICU stay/day median (IQR)	15.0 (4.0, 27.5)	7.0 (6.0, 12.0)	0.001
Length of Hospital stay/day median (IQR)	15.0 (4.0, 27.5)	7.0 (6.0, 12.0)	0.042

Abbreviations: Non- SA = Non-Systemic anticoagulation (Prophylactic); SA = Systemic anticoagulation (Therapeutic); BMI = body mass index; INR = international normalized ratio; PT= prothrombin time; APTT; activated partial thromboplastin time; anti-Xa level = anti factor 10-a coagulation factor; ICU = intensive care unit; a-line = arterial line; ASA = American Society of Anaesthesia; IQR = inter-quartile ratio. Statistically significant values at p < 0.05.

Figure 1. The cumulative incidence of index arterial line failure in the systemic anticoagulation (therapeutic), group-1 and non-systemic anticoagulation (prophylactic), group-2 anticoagulation dose, (log-rank test statistic 6.95, P = 0.008).

Figure 2. The median duration of index a-line patency in the systemic anticoagulation (therapeutic), group-1 and non-systemic anticoagulation (prophylactic), group-2 anticoagulation dose, with Kaplan–Meier survival estimated, (log-rank P=0.008).

Table 3. Potential predictors of index arterial line failure: Univariate Cox-proportional hazard regression method.

	Univariate analysis
Predictors	Unadjusted Hazard ratio (HR) (95% Confidence Interval)	p value
Age (years)	0.98 (0.98–1.02)	0.78
Gender Male Female	1.0 (reference) 1.51 (0.89–2.57)	0.12
Anticoagulant Systemic anticoagulant Non-Systemic anticoagulant	1.0 (reference) 1.9 (1.5–3.14)	0.01
Co-morbidities (versus none)	1.58 (0.97–2.58)	0.07
DM (versus none)	1.72 (1.05–2.81)	0.03
CVS disease (versus none)	0.63 (0.28–1.43)	0.27
HTN (versus none)	0.81 (0.51–1.29)	0.38
Pulmonary Disease (versus none)	0.54 (0.17–1.72)	0.30
Insulin Therapy (versus none)	0.85 (0.53–1.36)	0.49
Renal Disease (versus none)	0.72 (0.29–1.81)	0.49
Smoking (versus none)	0.29 (0.04–2.09)	0.22
Thrombosis History (versus none)	0.62 (0.23–1.71)	0.36
CNS Stroke (versus none)	2.0 (0.61–6.24)	0.26
Malignancy (versus none)	0.05 (0–22.5)	0.33
BMI>30 BMI≤30	1.0 (reference) 0.68 (0.42–1.10)	0.10
Aspirin Therapy (versus none)	1.89 (1.12–3.18)	0.02
INR	1.20 (0.58–2.49)	0.62
PT	1.01 (0.95–1.08)	0.67
APTT	0.99 (0.94–1.03)	0.52
D-dimer	1.0 (0.98–1.03)	0.80
Platelets level	1.00 (1.00–1.01)	<0.0001
Fibrinogen level	0.83 (0.72–0.96)	0.01
Ferritin	1.00 (1.00–1.00)	0.55
Anti-Xa level	0.67 (1.7–2.65)	0.57
Procedure Duration (min)	1.01 (0.99–1.04)	0.33
Physician Working Shift Time Morning Afternoon Evening	1.0 (reference) 1.06 (0.62–1.80) 0.69 (0.35–1.39)	0.84 0.30
Performing Physician Seniority Group 1 Group 2 Group 3	1.0 (reference) 0.73(0.35–1.53) 1.91 (0.98–3.73)	0.40 0.06
Cannula insertion: ultrasound use versus Blind technique	4.06 (1.67–9.85)	0.002
Number ABG/day Number ABG/day (1) Number ABG/day (2) Number ABG/day (3) Number ABG/day (4) Number ABG/day (5)	1.0 (reference) 1.92 (0.82–4.49) 3.09 (1.31–7.29) 2.04 (0.83–5.04) –	0.133 0.01 0.122 –
ICU Position Prone Position Supine position	1.0 (reference) 2.36 (1.48–3.75)	<0.0001
Sedated Mechanical ventilation Awake	1.0 (reference) 1.17 (0.71–1.94)	0.54

Abbreviations: Non-SA = Non-Systemic anticoagulation (Prophylactic); SA = Systemic anticoagulation (Therapeutic); ASA = American Society of Anaesthesiologists; DM = diabetes mellitus; CVS = cardiovascular system disease; HTN = hypertension; CNS = central nervous system; BMI = body mass index; INR = international normalized ratio; PT= prothrombin time; APTT; activated partial thromboplastin time; ABG= arterial blood gas.

Performing Physician Seniority was divided into three groups according to years of working experience Group 1: Resident (1–4 Y experience), Group 2: Specialist (5–7 Y experience) and Group 3: Consultant (10+ Y experience)

Statistically significant at p < 0.05.

At protocol start for Systemic anticoagulation and at index arterial line failure.

Table 4. Potential predictors of index arterial line failure: multivariate Cox-proportional hazard regression method.

Predictors	Adjusted Hazard ratio (HR) (95% Confidence Interval)	p value
Platelets (per 100.000 increase)	1.40 (1.12–1.74)	0.003
Arterial Catheter Insertion Ultrasound Blind technique	1.0 (reference) 4.12 (1.60–10.67)	0.003
ICU Position Supine position Prone Position	1.0 (reference) 2.07 (1.18–3.63)	0.011

Normal platelets count 150.000–450.000 × 10⁹/L

Table 5. Deaths within the first 45 days after arterial line insertion and its cause according to systemic anticoagulation (therapeutic) and non-systemic anticoagulation (prophylactic).

Item	Systemic anticoagulation (Therapeutic) n = 23	Non-Systemic anticoagulation (Prophylactic) n = 6	p value
Sepsis/Septic shock n (%)	10 (43.5)	3 (50.0)	0.775
Cerebral lesion n (%)	1 (4.3)	0	0.603
COVID pneumonia n (%)	22 (95.7)	6 (100.0)	0.041
ARDS/respiratory failure n (%)	11 (47.8)	2 (33.3)	0.525
PCA ischemic infarction n (%)	2 (8.7)	0	0.454
DKA n (%)	1 (4.3)	0	0.603
Multiorgan failure n (%)	11 (47.8)	5 (83.3)	0.119
Renal failure n (%)	7 (30.4)	5 (83.3)	0.019
Coagulopathy n (%)	1 (4.3)	0	0.603
Heart failure n (%)	2 (8.7)	5 (83.3)	<0.0001

Table 6. Deaths within the first 45 days after arterial line insertion and its reasons according to the failure of arterial line.

Item	Failed arterial line N = 20	Patent arterial line N = 9	p value
Sepsis/Septic shock n (%)	7 (35.0)	6 (66.7)	0.113
Cerebral lesion n (%)	0	1 (11.1)	0.129
COVID pneumonia n (%)	20 (100)	8 (88.9)	0.129
ARDS/respiratory failure n (%)	6 (30.0)	7 (77.8)	0.017
PCA ischemic infarction n (%)	1 (11.1)	1 (5.0)	0.548
DKA n (%)	0	0 (5.0)	0.495
Multiorgan failuren (%)	10 (50.0)	6 (66.7)	0.404
Renal failure n (%)	7 (35.0)	5 (55.6)	0.298
Coagulopathy n (%)	1 (5.0)	0	0.495
Heart failure n (%)	5 (25.0)	2 (22.2)	0.872

Abbreviations: COVID = Coronavirus Disease; ARDS = adult respiratory distress syndrome; PCA = Posterior cerebral artery; DKA = diabetic ketoacidosis.