Saddle pulmonary embolism and clot in transit in COVID-19 infection: a case report of catastrophic venous thromboembolism.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with a coagulopathy favouring thrombosis over bleeding that imparts a poor prognosis. Clot in transit (CIT) is considered a rare entity and the most severe form of venous thromboembolism (VTE), carrying a higher mortality than isolated pulmonary embolism (PE). The incidence of this phenomenon in patients with COVID-19 infection is unknown and likely under-recognized. CASE SUMMARY: During the peak of the COVID-19 pandemic in New York City, a 70-year-old Hispanic female presented with syncope due to a saddle PE further complicated by a highly mobile CIT. Polymerase chain reaction was positive for COVID-19 infection, however, there was no evidence of lung parenchymal involvement or hyper-inflammation. Based on consensus from a multidisciplinary team, aspiration thrombectomy was attempted to treat this extreme case of VTE, however, the patient died during the procedure. DISCUSSION: This case raises awareness to the most catastrophic form of VTE, presenting in an early phase of COVID-19 infection without the typical hyper-inflammation and severe lung injury associated with development of COVID-related coagulopathy. It also serves to inform on the critical role echocardiography has in the comprehensive evaluation and re-evaluation of hospitalized patients with COVID-19, and the importance of a multidisciplinary organized approach in clinical decision-making for this complex and poorly understood disease and its sequelae.

Rapid Implementation of Telecritical Care Support During a Pandemic: Lessons Learned During the Coronavirus Disease 2020 Surge in New York City.

OBJECTIVES: We describe the key elements for a New York City health system to rapidly implement telecritical care consultative services to a newly created ICU during the coronavirus disease 2020 patient surge. DESIGN: This was a rapid quality-improvement initiative using public health decrees, a HIPAA-compliant and device-agnostic telemedicine patform, and a group of out-of-state intensivist volunteers to enhance critical care support. Telecritical care volunteers initially provided on-demand consults but then shifted to round twice daily with housestaff in a 12-bed newly created ICU. SETTING: A 457-bed safety net hospital in the Bronx, NY, during the pandemic. SUBJECTS: The 12-bed newly created ICU was staffed by a telecritical care attending, a cardiology fellow, and internal medicine residents. INTERVENTION: Prior to the intervention, the ad hoc ICU was staffed by a cardiology fellow as the attending of record, with critical care support on demand. The intervention involved twice daily rounding with an out-of-state, volunteer intensivist. MEASUREMENTS AND MAIN RESULTS: Volunteers logged 352 encounters. Data from 26 unique encounters during the initial on-demand consult pilot study of tele-ICU support were recorded. The most common interventions were diagnostic test interpretation, ventilator management, and sedation change. The majority of housestaff felt the new tele-ICU service improved the quality of care of patients and decreased anxiety of taking care of complex patients. Likewise, the majority of volunteers expressed making significant alterations to care, and 100% believed critical care input was needed for these patients. The largest lessons learned centered around mandating the use of the telecritical care volunteers and integration into a structured format of rounding. CONCLUSIONS: The need for rapid implementation of ICUs during a major public health crisis can be challenging. Our pilot study supports the feasibility of using an out-of-state telecritical care service to support ICUs, particularly in areas where resources are limited.