Acute Circulatory Collapse and Advanced Therapies in Patients with COVID-19 Infection

INTRODUCTION: In the current COVID era, ICU-level patients typically develop respiratory failure and acute respiratory distress syndrome (ARDS). While less frequent, the management of concomitant acute circulatory collapse has its own challenges and nuances. Early identification of acute circulatory collapse requires appropriate imaging and precise diagnosis of cardiogenic shock. Escalation to mechanical circulatory support such as intra-aortic balloon pump (IABP), Impella and extracorporeal membrane oxygenation (ECMO) have been useful in patients with circulatory collapse from COVID. CASE REPORT: 42-year-old obese female presented with COVID bronchopneumonia 6 days after a positive outpatient COVID swab. In the ED, she was given 3L of fluid bolus for severe sepsis and developed flash pulmonary edema requiring emergent intubation. She also developed hemodynamic collapse, requiring inotrope and pressor support and a TTE demonstrated severely depressed left ventricular ejection fraction (LVEF) of < 10%. Peripheral VA ECMO was placed, and the patient was transferred to our tertiary care center for further management of fulminant COVID-myocarditis with cardiogenic shock. Patient did not have any significant obstructive coronary artery disease on catheterization. An Impella CP was placed for hemodynamic support. She was started on a high-dose steroid, one dose of tocilizumab for severe LV dysfunction, two rounds of IVIG, and CRRT for volume removal. On Day 11 she had improved hemodynamics and there were signs of LV recovery, after which she was decannulated. Impella support was continued until there was complete recovery. Patient was extubated on Day 17 and continues to recover at a long-term acute care facility. SUMMARY: Acute circulatory collapse in COVID-19 infection is a serious complication with high morbidity and mortality. Early recognition of depressed LV function and cardiogenic shock by echocardiography, cardiac MRI, and/or Swan-Ganz catheter assessment is critical. ICU management of hemodynamic function, fluid status, and blood pressure management remains standardized, but prompt medical management with inotropes and mechanical support maximizes patient outcomes. IABP, Impella, and ECMO all play a key role in managing acute circulatory collapse.