Norepinephrine/vasopressin

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 45-year-old woman exhibited lack of efficacy with norepinephrine and vasopressin, while being treated for circulatory shock [routes and dosages not stated].

The woman, who had been diagnosed with COVID-19 three days prior, presented to the emergency department on 10 May 2020 following a progression of dyspnoea, myalgia, postural hypotension and fever. At admission, BP 105/72mm Hg, HR 125 bpm, RR 26 breaths/min and oxygen saturation 100% on room air. She started receiving off label treatment with piperacillin/tazobactam, azithromycin and teicoplanin for COVID-19 prior to the ICU admission. She developed cardiac tamponade, required urgent transthoracic echocardiogram-guided subxiphoid pericardiocentesis. The procedure was unsuccessful; and she was diagnosed with cardiac arrest in asystole. Subsequently, she underwent an emergency thoracotomy followed by internal cardiac compression and pericardial drainage. She had been receiving norepinephrine [noradrenaline], dobutamine, milrinone and vasopressin for circulatory shock. Subsequently, her spontaneous circulation was restored; However, she progressed to refractory circulatory shock, despite the administration of norepinephrine [noradrenaline] and vasopressin (lack of efficacy). Subsequently, she was placed on venoarterial extracorporeal membrane oxygenation. It was noted that possibility of fulminant COVID-19 myopericarditis was considered. She started receiving off label treatment with immune-globulin [immunoglobulin] 1 g/kg/day for 2 days, methylprednisolone at a dose of 750mg on the first and 250mg on second day, followed by 40mg twice a day, tocilizumab at a dose of 400mg single dose and convalescent-anti-SARS-CoV-2-plasma [convalescent plasma] for COVID-19. Subsequently, haemodialysis was started and electroencephalography was suggested following temporary reduction in sedation. Her interleukin-6 levels were elevated. Then, she received second dose of tocilizumab and additional unit of convalescent-anti-SARS-CoV-2-plasma. Multiple blood products during haemodynamic support were required due to recurrent bleeding at cannulation site, despite rigours monitoring of heparin [unfractionated heparin]. Subsequently, echocardiographic biventricular function gradually improved and ECMO was removed after 9 days. Dobutamine and milrinone continued for additional 3 days due to residual right-sided dysfunction. Additionally, she developed pneumonia, which was appropriately managed. Then, mechanical ventilation was removed and successful extubation ensued on 27 May 2020. After two weeks, she developed pseudoaneurysm at the cannulation site, which required angioplasty. Additionally, she developed local soft tissue infection associated with Candida parapsilosis and Candida glabrata, which required surgical drainage and antifungal therapy. On 02 July 2020, haemodialysis was stopped in addition to the development of critical illness myopathy. On 04 July 2020, she was discharged from the ICU and following complete biventricular recovery. On 15 July 2020, she was discharged from the hospital with continuation of physiotherapy and voriconazole for 4 weeks.