Fatal intracranial hemorrhage associated with thrombolytic therapy in severe COVID-19 disease

INTRODUCTION: The association between COVID-19 and coagulopathy has been established. The mechanism is likely to be multifactorial including direct endothelial damage by viral infection contributing to microvascular thrombosis;cytokine storm;and critical illness increase significantly the risk of developing thrombi. METHODS: 54 years old male, who presented to the ED after testing positive for COVID 19 due to generalized malaise and fever. On admission, he was hypoxic to 80% on room air, and requiring 4L oxygen (O2). Chest X-ray showed multifocal pneumonia. Inflammatory markers were elevated. Within 24 hours, O2 requirement escalated and patient was transferred to the ICU for intubation. He received convalescent plasma and Tocilizumab, Azithromycin. His medical course was complicated with sudden elevation of D-dimer from 1.4 to >20 ug/ml. Pulmonary embolism (PE) was suspected;echocardiogram revealed right ventricle (RV) strain, and heparin drip was started. His renal function worsened, requiring hemodialysis, and unable to receive Remdesivir. On day 10, patient started spiking high-grade fevers as 107F, blood cultures were negative, echocardiogram was negative for vegetation, but showed increasing of RV size, severe tricuspid regurgitation and markedly elevated pulmonary pressures consistent with worsening PE despite being on heparin drip. The decision was made to use 100mg Alteplase (TPA). The next day, neurological exam showed dilated pupils with no light reflex, and CT head was consistent with large intraparenchymal, intraventricular, and subarachnoid hemorrhage. Neuro-surgery was consulted but patient's condition was critical with poor prognosis to undergo surgery. 24 hours later, patient had a cardiac arrest and expired. RESULTS: Some studies showed the incidence of pulmonary embolism in COVID19 patients is 15.3%. This is associated with higher mortality of 45% compared with general cases with mortality of 4%. TPA is used for treatment of PE, with uncommon risk of intracranial hemorrhage in the general population of 5%. It is unknown, the incidence of intracranial bleeding associated with TPA, increases in severe COVID19 patients. Further studies are necessary to create thrombosis prevention and management protocols in patients with severe COVID19 infection, reducing mortality.

REPEATED PRONATION IN A MORBIDLY OBESE PATIENT OVERCOME BY A SEVERE COVID-19 INFECTION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: It is described in the literature, prone positioning showed improvement of gas exchange by ameliorating the ventral-dorsal transpulmonary pressure difference, reducing dorsal lung compression and improving lung perfusion and oxygenation. Prone positioning has a reduction in 28-day mortality in patients with severe acute respiratory syndrome on mechanical ventilation. The duration per session was 17±3 hours, with the average number of session of 4±4 per patient. CASE PRESENTATION: A 60-year-old female with a significant past medical history of morbid obesity (BMI: 51), stroke, atrial fibrillation, hypertension, and pacemaker placement who presented to the ED with nausea, vomiting, and diarrhea for the last 2 days. She also reported 2 weeks of general weakness, moderate dyspnea on exertion, fever, and chills. The patient was admitted due to respiratory distress requiring oxygen supplementation. Her chest x-ray showed bilateral opacities and COVID-19 test was positive. On the second day of admission, patient's respiratory status deteriorated requiring intubation and transfer to the ICU. Her course was complicated by septic shock requiring vasopressor, superimposed MRSA pneumonia which was treated with 8 days of vancomycin, mild acute kidney injury, and mild transaminitis. Inflammatory markers were remarkable for D-Dimer 2.63, ferritin 931, lactate dehydrogenase 894. Initially, the patient was placed on pressure-control ventilation then switched to volume control but continued to have high oxygen requirements and PEEP. Proning protocol was initiated and she was placed on 16 hours prone position, followed with 8 hours supine. Due to her refractory hypoxemia, it was decided to proceed with multiple prone positioning, total of 6 times to be weaned off the ventilator. She was successfully extubated after 18 days, and discharged home without any complications. DISCUSSION: We present a case of a patient with multiple comorbidities as hypertension, atrial fibrillation, morbid obesity with BMI 51, and age ≥60 years, associated to severe COVID-19 infection and high mortality, who underwent to multiple prone positions, with successful extubation. A recent study assessed prone positioning outcome in mechanically ventilated patients with COVID19 showing improvement in oxygenation and lung compliance with a median of two sessions (range, 1–3), and 18 hours per session. Also, a recent study showed earlier prone positioning was feasible and effective in improving oxygenation in non-intubated, awake and spontaneously breathing COVID19 patients with oxygen supplementation. CONCLUSIONS: Prone positioning in mechanical ventilated COVID19 patients improve oxygenation. The optimal number of sessions of prone positioning is unknown, and it needs further studies to create a prone protocol for severe COVID-19 disease, with the potential outcome of decreasing mortality. Reference #1: Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al.;PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159–2168. Reference #2: Ziehr D, Alladina J, Petri C, et al. Respiratory pathophysiology of mechanically ventilated patient with COVID-19: A cohort study. American journal of respiratory and critical care medicine. 2020, 201(12). Reference #3: Coppo A, Bellani G, Winterton D, Di Pietro M, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respiratory Medicine 2020. ) DISCLOSURES: No relevant relationships by Karim Anis, source=Web Response No relevant relationships by Anastasia Maltseva, source=Web Response No relevant relationships by Lady Sanchez Fernandez, source=Web Response

SEVERE HYPERBILIRUBINEMIA ASSOCIATED WITH NOVEL CORONAVIRUS INFECTION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: It has been reported in the literature, the incidence of liver injury in patients with severe COVID-19 infection, from 14.8% to 53%, mainly presented as mild to moderate elevations of ALT, AST, with slightly elevated bilirubin levels. In death COVID-19 cases, incidence increased to 58% and 78%. CASE PRESENTATION: 43 year-old male with PMH of gastrointestinal bleeding, proctitis who presented to the ER with the chief complaint of increasing shortness of breath. For the last 3 weeks, patient reported flu-like symptoms, and abdominal pain, mild diarrhea for 5 days, poor appetite, and anosmia. Social history were significant for patient's wife COVID-19 infection. At the ED, he was found febrile (T:102F), tachypneic (RR:25), oxygen saturation 93% with 2-3L of nasal cannula, and chest Xray showed multifocal bilateral infiltrates, and COVID-19 positive. Later, patient is admitted to the ICU due acute hypoxic respiratory failure, requiring intubation for 9 days. During his ICU hospitalization, patient had multiple complications as septic shock, persistent leukocytosis with the highest WBC of 35.9, elevated inflammatory markers as ferritin:7086, LDH:1925, total creatinine kinase:4856, DDimer: 13.23, liver function test was significant for total bilirubin elevation 9.2, with direct bilirubin predominance of 7.6, AST: 242 ALT: 141, ALP 124, negative viral hepatitis panel, unremarkable abdominal ultrasound. Since admission, patient received treatment with Ceftriaxone, Azythromycin, Plaquenil and Atorvastatin, but these medications were interrupted due to suspicion of side effect medication. In the last ICU days, his severity disease markers significant decreased, and liver function test improved but remaining in the upper limit, and he was discharge home. DISCUSSION: Different COVID19-related liver injury mechanisms have been postulated. First, immune mediated damage as a result of the severe inflammation. Second, direct cytotoxicity by binding the viral particle to ACE2 receptor on hepatic cells and bile duct. Third, hypoxic hepatitis induced by the severe hypoxic respiratory failure and septic shock. Fourth, drug-induced liver injury related to the initial treatment guidelines as Plaquenil, Azythromycin, antivirals medications. Fifth, worsening of previous liver disease in severe COVID19 infection. A study showed bilirubin concentration was significantly higher in patient with severe COVID19 disease, associated with disease progression. In this case, patient's liver function test improved when he recovered from the severe infection, and when potential related liver injury medications were stopped. CONCLUSIONS: COVID19 is an emerging pandemic disease with many unclear aspects. Further studies are needed to understand more the hepatic manifestation and how to prevent and treat these findings, specially for patients with poor liver reserve or liver transplantation. Reference #1: Xu L, Liu J, Lu Mengji, et al. Liver Injury during highly pathogenic human coronavirus infections. Liver International. March, 2020,40(5). Reference #2: Sun J, Aghemo A, Forner A, et al. COVID-19 and liver disease. Liver international. April, 2020, 40(6). Reference #3: Paliogiannis P, Zinellu A. Bilirubin levels in patients with mild and severe Covid-19: A pooled analysis. Liver International. May, 2020. DISCLOSURES: No relevant relationships by Karim Anis, source=Web Response No relevant relationships by Lady Sanchez Fernandez, source=Web Response No relevant relationships by Jesus Vera Fox, source=Web Response