Thrombolysis in severe COVID-19 pneumonia with massive pulmonary embolism

Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia. University of South Carolina, School of Medicine, Columbia, SC, USA. Electronic address: mike@blaivas.org. Research and Innovation Centre, King Saud Medical City, Riyadh, Saudi Arabia. Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia; University of South Carolina, School of Medicine, Columbia, SC, USA. Electronic address: karakitsosdimitrios@gmail.com.

The American Journal of Emergency Medicine. 2021;41:261.e1-261.e3
Abstract
OBJECTIVE No guidelines exist for the management of massive pulmonary embolism (PE) in COVID-19. We present a COVID-19 patient with refractory acute respiratory syndrome (ARDS), and life-threatening PE who underwent successful thrombolysis. CASE PRESENTATION A previously healthy 47 year old male was admitted to our hospital due to severe COVID-19 pneumonia [confirmed by Real-Time-Polymerase-Chain-Reaction (RT-PCR)]. He had rapidly evolving ARDS [partial arterial pressure of oxygen to fractional inspired concentration of oxygen ratio: 175], and sepsis. Laboratory results showed lymphocytopenia, and increased D-dimer levels (7.7 μg/ml; normal: 0-0.5 μg/ml). The patient was treated in the intensive care unit. On day-1, ARDS-net/prone positioning ventilation, and empiric anti-COVID treatment integrating prophylactic anticoagulation was administered. On hospital day-2, the patient developed shock with worsening oxygenation. Point-of-care-ultrasound depicted a large thrombus migrating from the right atrium to the pulmonary circulation. Intravenous alteplase (100 mg over 2 h) was administered as rescue therapy. The patient made an uneventful recovery, and was discharged to home isolation (day-20) on oral rivaroxaban. CONCLUSION Thrombolysis may have a critical therapeutic role for massive PE in COVID-19; however the risk of potential bleeding should not be underestimated. Point-of-care ultrasound has a pivotal role in the management of refractory ARDS in COVID-19.
Study details
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine