Thrombolysis in severe COVID-19 pneumonia with massive pulmonary embolism

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.

Case series of intravenous thrombolysis for acute ischemic stroke in confirmed COVID-19 patients: single-centre experience

“…No specific guidelines exist for the management of massive PE in COVID-19. Thrombolysis could be an effective and safe therapy for massive PE in mechanically ventilated COVID-19 patients [13]. A reported case of one COVID-19 patient with pneumonia and acute PE, infused a total of 30 mg of rtPA over 15 h, and the patient's clinical condition improved rapidly [12].…”

Pharmacotherapy consideration of thrombolytic medications in COVID-19-associated ARDS

“…In a severe COVID-19 patient with highly developing ARDS, sepsis and massive pulmonary embolism, alteplase was administered at the dose 100 mg slow IV infusion as rescue therapy. It seems that thrombolytic medications is a potential critical care practice for life-threatening pulmonary embolism in COVID-19 Pneumonia [ 114 ].…”

Trombólise de embolia pulmonar aguda tardia pós-covid-19

“…Foi utilizada alteplase 100 mg intravenosa em duas horas sem intercorrências. Após 20 dias de internação recebeu alta com rivaroxabana oral 10 . Em outro caso, um paciente masculino jovem com COVID-19 confirmado, desenvolveu EP de alto risco mesmo utilizando profilaxia para TEV.…”

“…Nos casos em que há EP com instabilidade ou risco elevado, a terapia fibrinolítica com os ativadores de plasminogênio (t-pA), principalmente a alteplase, está indicada, além de doses terapêuticas de heparinas 9 . Entretanto, há escassez de publicações em relação à trombólise nos eventos relacionados à COVID-19 2,10 . Neste relato, apresentamos o caso de uma paciente feminina adulta diagnosticada com COVID-19 leve que no 18º dia após o início dos sintomas evoluiu com EP associada à instabilidade de ventrículo direito (VD) e foi submetida a trombólise com alteplase intravenosa com sucesso.…”