Correct!
3. Supportive care
Treatment in this situation relies heavily on clinical judgment and local expertise. It was thought that the patient was at too high a bleeding risk for anticoagulation or thrombolytic therapy. The patient was considered at too high a risk for surgical embolectomy. Although no controlled trials have been performed, catheter embolectomy is a consideration (2). The presence of the right atrial clot was judged to preclude catheter embolectomy. Therefore, supportive care is the best answer.
Shortly after returning to the pediatric intensive care unit from her CT angiogram, she became acutely anxious, asking for face mask oxygen. She then became agitated and combative. Her eyes rolled back, left eye deviated outwards. Her heart rate declined to the 40's with weak central pulses. Cardiopulmonary resuscitation (CPR) was initiated. She was endotracheally intubated and her pulse increased modestly although her oxygen saturation remained low at 70% with an inspired FiO2 of 100%. A CT scan of the head without contrast revealed no apparent clot or hemorrhage. A repeat thoracic CT scan showed the atrial clot was smaller. A repeat echocardiogram revealed complete ventricular standstill with a severely dilated inferior vena cava. With agitated saline injection, there was no forward flow into the right ventricle nor through the right ventricular outflow tract.
Critically ill patients with an elevated platelet count are known to be at increased risk for pulmonary embolism (3). However, our patient was also at high bleeding risk. Some have advocated leukaphoresis early in the course of leukemia with high leukocyte counts. If respiratory and/or neurologic failure are present, the death rate at one week reaches 90% for patients with chronic mylogenous leukemia (CML). Leukapheresis reduces leukemic blast counts and associated symptoms until chemotherapy can be initiated (4). Whether either would have altered the patient's outcome is unclear.
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