Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia.
University of South Carolina, School of Medicine, Columbia, SC, USA.
Am J Emerg Med. 2021 Mar;41:261.e1-261.e3. doi: 10.1016/j.ajem.2020.07.068. Epub 2020 Jul 30.
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.
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.
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.
目前针对 COVID-19 合并大块肺栓塞（PE）并无相关管理指南。我们报告了 1 例 COVID-19 合并难治性急性呼吸窘迫综合征（ARDS）和危及生命的 PE 患者，该患者接受溶栓治疗后获得成功。
一位 47 岁既往健康男性，因严重 COVID-19 肺炎（经实时聚合酶链反应（RT-PCR）确诊）收入我院。患者迅速发展为 ARDS [动脉血氧分压与吸入氧浓度比值：175]，伴脓毒症。实验室结果显示淋巴细胞减少和 D-二聚体水平升高（7.7 μg/ml；正常值：0-0.5 μg/ml）。患者入住重症监护病房。入院第 1 天，给予 ARDS-net/俯卧位通气，以及经验性抗 COVID 治疗，包括预防性抗凝。入院第 2 天，患者发生休克，氧合恶化。床旁超声提示大块血栓从右心房移行至肺循环。给予静脉注射阿替普酶（100mg 持续 2 小时）作为挽救性治疗。患者恢复顺利，在口服利伐沙班后于第 20 天出院进行居家隔离。
溶栓治疗可能在 COVID-19 合并大块 PE 中具有关键的治疗作用；然而，不应低估潜在出血的风险。床旁超声在 COVID-19 合并难治性 ARDS 的管理中具有重要作用。
