Multiorgan Failure and Severe Thrombocytopenia From Massive Pulmonary Embolism With a Challenging Management

Abstract

INTRODUCTION: Thrombocytopenia can make management of pulmonary embolism (PE) challenging due to increased risk of bleeding. We present a case of massive PE with obstructive shock, and severe thrombocytopenia.CASE PRESENTATION: 62-year-old man with no medical history presented with 6-day history of shortness of breath, lethargy, and syncope. Initial vitals showed temperature 100.1, blood pressure 73/62 mmHg, heart rate 91, respiratory rate 34 bpm and oxygen saturation 93% on 3 L oxygen. Examination showed jugular venous distension and right calf swelling. Labs showed severe thrombocytopenia of 31,000/L, elevated D-dimer of 25,384 ng/m, creatinine of 2.6 mg/dL, lactic acid of 9.8 mmol/L, ALT of 6675 IU/L, AST of 6499 IU/L, and troponin of 0.33 ng/mL. Venous doppler ultrasound showed acute thrombosis of right popliteal vein. Patient was started on heparin drip. CTA chest showed extensive bilateral pulmonary emboli, saddle embolus, dilatation of the right heart and 2.7 cm right atrium thrombus. The severe thrombocytopenia precluded thrombolytics. After emergent multidisciplinary round, patient was given steroids, transfused platelets and underwent veno-arterial extra-corporeal membrane oxygenation (VA ECMO). Patient was transferred to center capable of thrombectomy where he underwent embolectomy and subsequently discharged.DISCUSSION: PE remains a leading cause of mortality and morbidity. The management depends on the severity. Massive is defined as acute PE with sustained hypotension, pulselessness, or persistent profound bradycardia. Management of massive PE includes cardiopulmonary support, anticoagulation to prevent extension and recurrence, and reperfusion of the pulmonary artery. Reperfusion therapy includes systemic thrombolysis or mechanical intervention with either catheter directed thrombolysis or thrombectomy. Mechanical embolectomy is indicated in patients with contraindications to thrombolytic therapy, however, mechanical embolectomy is not readily available in many centers. Cardiopulmonary support should first be initiated with supplemental oxygen, intravenous fluid, and inotropic agents. If the right ventricle fails to respond appropriately to inotropes, the initiation of more aggressive adjunctive measures such as surgery or extra-corporeal membrane oxygenation (ECMO) can be considered in preparation for embolectomy. Early institution of ECMO is important before initiation of advanced airway because these patients are preload dependent and mechanical ventilation can decrease their venous return and hence cardiovascular collapse. Our patient was not a candidate for thrombolytic therapy due to severe thrombocytopenia, VA ECMO was performed but transfer.CONCLUSIONS: This case demonstrates the important of multidisciplinary decision making, the role of ECMO in massive PE with severe right ventricular dysfunction; and surgical embolectomy in patients with contraindication to thrombolytics.