Case Series of TpA Use in COVID-19 Patients with Venous Thromboembolism at a Community Hospital- Benefits and Outcomes

Abstract

Introduction: In December 2019, the WHO was notified of a novel Coronavirus otherwise known as COVID-19. The disease rapidly spread across multiple borders with a significant toll on loss of human life and a high degree of burden on medical systems across the world. As clinical data, laboratory studies and autopsy reports emerged, the underlying pathophysiological hypotheses evolved to include the eliciting of a hypercoagulable state as being amongst the key factor for the disease progression. In COVID-19 pneumonia, worsening hypoxemia despite maximal ventilator support should prompt evaluation for Pulmonary Embolism (PE) and thrombolytics (tPA) may be a life saver. Here we report 5 cases of severe COVID-19 Pneumonia with presumed pulmonary embolism and worsening hypoxemia successfully treated with thrombolytics with favorable response. Case report 1: 37-year-old Hispanic male with no known medical history presented with 3 days history of symptoms suggestive of COVID-19 Pneumonia including worsening shortness of breath. On admission he was in moderate respiratory distress, saturating at 78 % on room air (RA), which increased to low 90s on 15L oxygen (O2) on non-rebreather mask and subsequently intubated. COVID 19 PCR swab resulted positive and CXR showed characteristics of typical COVID 19 pneumonia with bilateral patchy reticular interstitial opacities. Patient was managed in the for Acute Severe Hypoxemic Respiratory Failure secondary to COVID 19 Pneumonia. Point-of-Care-Ultrasound (POCUS) (Image 1) showing moderately decreased LVEF and signs of RV volume and pressure overload with thrombus-in-situ. Patient developed clinically refractory hypoxia and newly developing shock for which he received a 100mg IV infusion of alteplase along with commencement of nitric oxide to enhance pulmonary vasodilation for better oxygenation with continued lung protective ventilatory support. After the systemic thrombolysis, the patient's oxygen requirement reduced markedly with subsequent POCUS showing return of the normal RV function and absent cardiac thrombus. Case report 2-5: Age range 43-75 years, all admitted with COVID-19 pneumonia and refractory hypoxemia with evidence if VTE. Thrombolytics was given to all the patients with good response and eventually discharge from the hospital. Discussion: Although most patients with COVID-19 predominantly have a respiratory tract infection, a proportion of patients progress to a more severe and systemic disease including but not limited to widespread coagulopathies. Despite covering for anticoagulation, there has been report of incidence of thromboembolic events in such patients. Therefore, it is very important to recognize increasing oxygen requirement and acute deterioration in this patients.