THE "CLOT" THICKENS: HYPERKALEMIA DUE TO ACUTE LIMB ISCHEMIA IN COVID-19

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been implicated in a devastating inflammatory response resulting in thromboembolic events. Upwards of 40% of patients have been reported to have venous thromboembolism while the incidence of arterial thrombotic events, including acute limb ischemia (ALI), is estimated to be lower at 5%. This case highlights the importance of early recognition and treatment of ALI in COVID-19 to prevent significant morbidity and mortality. CASE PRESENTATION: A 59-year-old man with hypertension and pre-diabetes presented to our facility with tachypnea and hypoxia with oxygen saturation of 80%. He was placed on high flow nasal cannula but required intubation due to respiratory failure. Initial laboratory values revealed D-dimer 460 ng/mL, C-reactive protein 109 mg/L, ferritin 3,282 ng/mL, and creatine kinase 700 U/L. Right soleal vein thrombosis was identified on lower extremity ultrasound and he was started on intravenous heparin with therapeutic levels. On hospital day 4, he became acutely hypotensive and hyperkalemic to 7.9 mmol/L. Physical exam was notable for cold lower extremities with mottling while laboratory values showed lactate 4.1 mmol/L, D-dimer greater than 10,000 ng/mL, ferritin 23,712 ng/mL, and creatine kinase 21,078 U/L. Upon evaluation with lower extremity arterial duplex, there was no Doppler signal detected in the bilateral common femoral, superficial femoral, popliteal, posterior tibial, and anterior tibial arteries. A subsequent CT angiogram revealed extensive bilateral pulmonary emboli, acute total occlusion of the aorta beginning distal to the renal arteries, and extensive lower limb muscle stranding suggestive of ischemic injury. He was taken to the operating room and underwent emergent thrombolysis and thrombectomy. Unfortunately, he suffered severe reperfusion injury and expired shortly after the procedure. DISCUSSION: ALI presents with the 6 Ps: pain, pallor, paralysis, paresthesia, poikilothermia, and pulselessness. In COVID-19, it is estimated that 71% of arterial thrombotic events involve the lower extremities. Patients at risk are noted to be males over the age of 60 with diabetes and hypertension. Diagnosis can be made with duplex ultrasound, CT angiography, or MR angiography. After initiating therapeutic anticoagulation, vascular surgery should be consulted for management options such as catheter-directed thrombolysis, mechanical thrombectomy, or open surgery. CONCLUSIONS: This case highlights the significance of arterial thrombotic events in COVID-19 and the importance of early recognition of ALI. Unexplained hyperkalemia should be thoroughly investigated as it can be a presentation of myonecrosis secondary to ALI. Prompt initiation of anticoagulation and vascular surgery consult are vital in limiting morbidity and mortality. REFERENCE #1: Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46(6):1089-1098. DISCLOSURES: No relevant relationships by Talha Demirci, source=Web Response No relevant relationships by Himanshu Deshwal, source=Web Response No relevant relationships by ron goldenberg, source=Web Response