Haemodynamic instability in a critically ill patient with covid-19 pneumonia: searching over the chest - report of a clinical case and mini-review of the literature

A 77-year-old male with multiple comorbidities developed COVID-19 pneumonia with severe respiratory distress and required hospitalization and subsequent transfer to the intensive care unit (ICU). The patient was treated according to the COVID-19 Critically Ill Protocol and required mechanical ventilation in both supine and prone positions as well as antimicrobial therapies and deep venous thrombosis prophylaxis. Fourteen days after ICU admission, the patient developed haemodynamic instability with a decrease in haemoglobin levels and renal function deterioration. The contrast-enhanced computed tomography (CT) scan revealed a large retroperitoneal haematoma with signs of active bleeding. The patient underwent surgical removal of the haematoma and haemostatic packing. Spontaneous retroperitoneal bleeding (SRB) is a rare but potentially lethal event with unspecific clinical manifestations that may lead to both misdiagnosis and delayed treatment. SRB can be a potentially fatal complication of anticoagulation therapy. However, in 10-15% of cases, it may also occur without an association with anticoagulant or antiplatelet regimens. Approximately half of patients require invasive management, such as interventional radiology (IR) procedures or surgery in cases of concurrent surgical conditions, abdominal compartment syndrome or failure of previous IR procedures. Anticoagulant therapies are used in critically ill patients with COVID-19 pneumonia to reduce mortality due to thromboembolic events. However, the need for mechanical ventilation and prone positioning in association with anticoagulant/antithrombotic therapies may lead to an increased risk of spontaneous bleeding. SRB should always be taken into account in critically ill patients with severe COVID-19 pneumonia with haemodynamic instability without suspicion of other acute cardiovascular events.