Case Presentation
A 62-year-old man had common cold symptoms and took a polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in his local clinic. Afterward, the patient was transferred to the emergency department of our hospital due to dyspnea. He had a history of partial lung resection for lung cancer and certain comorbidities, such as hypertension, hyperuricemia, and hyperlipidemia. A chest computed tomography (CT) scan showed bilateral ground-glass opacities (GGO) (Figure 1a) with parenchymal bands in the right lower lobe (Figure 1b), while the blood test revealed severe inflammation and Rh-negative blood type. The PCR test for SARS-CoV-2 in the previous clinic also revealed a positive result. Thus, we diagnosed him with COVID-19 pneumonia.
After being admitted to the depressurized room in our ICU, his oxygenation and hemodynamics deteriorated rapidly (Figure 2a). We initiated mechanical ventilation and administered vasopressors, favipiravir, and ciclesonide. It was impractical to perform ECMO with Rh-negative blood products; therefore, we prioritized lung function protection. We severely restricted the amount of fluid volume, while trying to maintain the bare minimum urine output and blood pressure. In fact, as shown in Figure 2b, the average daily fluid intake was about 2000–3000 mL/day during the first seven days.
Furthermore, the hypotension was refractory to vasopressors, although the stroke volume variance was maintained within the normal limits. To stabilize the hemodynamics and avoid more fluid infusion, we replaced hydrocortisone 200mg/day with secondary adrenal insufficiency. Thereafter, we could partially taper the amount of vasopressors. Moreover, the PaO2/FiO2 ratio improved, although it was temporarily around 125, the indication criteria of ECMO for COVID-19 related ARDS.13 Then, we gradually reduced the dose of hydrocortisone until discharge because the hemodynamics collapsed in a short while after suspending the hydrocortisone.
In contrast, his serum creatinine level continued to be elevated owing to lower fluid administration and severe systemic inflammation, and it progressed to anuria. Thus, we performed either peritoneal dialysis or continuous hemodiafiltration from day 7, depending on the preparation status for renal replacement therapy at the time. Thereafter, as the inflammation and body temperature improved over time, the urine output and the P/F ratio also gradually normalized. After confirming a negative result of the PCR test for SARS-CoV-2 and the recovery of adequate urine output, he was extubated on day 26. Finally, he was discharged from our hospital on day 73.