Utility of lower extremity ultrasound prior to application of serial compression device in patients with COVID-19: "choosing wisely" initiative at a major referral center in the Middle East.

Objective: The link between venous thromboembolism (VTE) and coronavirus disease 2019 (COVID-19) infection has been consolidated by many studies in the literature. The increased risk of VTE among COVID-19 patients, on the one hand, and the morbidity that can be associated with the ICU course, on the other hand, promote quality care among this patient population. "Choosing wisely" is a quality improvement initiative that emphasizes the importance of assessing the utility of diagnostic tests. Our study was a "Choosing Wisely" single-center initiative aimed at assessing the utility of LEUS among COVID-19 patients who are treated at AUBMC, a major referral center in the Middle East.

Methods: Data from hospitalized COVID-19 patients who underwent LEUS during the pandemic between 2019 and 2021 at our institution were retrospectively analyzed. LEUS was ordered to screen for preexisting DVT prior to the application of mechanical DVT prophylaxis via a serial compression device (SCD) or to rule out suspected DVT. Data on patients' demographics, comorbidities, and mortality were also retrieved.

Results: A total of 179 patients were included in this study. The mean age of the patients was 66.09 ± 16.587 years, and 108 (60.3%) of our patients were men. Ninety-four (52.5%) patients underwent LEUS for asymptomatic DVT screening prior to SCD placement, and 84 (46.9%) patients underwent LEUS to rule out suspected DVT in the context of other causes, namely, prolonged hospital stay, immobilization, and other hypercoagulable risk factors. Among the 94 patients who underwent LEUS screening, 12 (12.76%) patients were found to have DVT, and SCD placement was consequently aborted. Half of these patients had an IVC filter placed afterward. A previous history of DVT or pulmonary embolism (PE) was strongly associated with DVT occurrence in ICU and non-ICU patients. The mortality rate was 88 (49.2%) among the studied population, which was the highest among the ICU patients (88 (69.8%) with p < 0.001).

Conclusion: Compared with the available literature, we report a greater incidence of asymptomatic DVT among COVID-19 patients, including those screened prior to SCD. We suggest that the clinical utility of LEUS for this patient population outweighs its cost and presumed low benefit. Prospective studies with larger sample sizes are needed to further assess the utility of LEUS and promote the "Choosing Wisely" initiative.