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Sudden Cardiovascular Collapse in a Pregnant Patient and the Role of ECMO
Abstract Number: T-61
Abstract Type: Case Report/Case Series
Introduction: There are many risk factors for thromboembolism, with pregnancy being one of them (1). This is a case of a patient with multiple thromboembolism risk factors who suffered a massive intraoperative pulmonary embolism (PE) and was successfully resuscitated with extracorporeal membrane oxygenation (ECMO).
Case Report: A 30 year-old G6P2032 at 17 weeks gestational age, with a past medical history significant for melanoma, obesity, and scoliosis, presented with a right femoral neck pathologic fracture. Despite appropriate anticoagulation recommendations, given the risk of immobility and other risk factors, some doses were not administered preoperatively. However, the patient proceeded to the operating room for an open biopsy along with a total hip arthroplasty. One hour after an unremarkable anesthetic induction and within 10 minutes of surgical incision, the patient became profoundly hypotensive and tachycardic, unresponsive to fluid and phenylephrine boluses. It was recognized that the patient was likely suffering from a PE; the operation was aborted and cardiopulmonary resuscitation (CPR) was commenced. Invasive monitoring was placed, including a transesophageal echocardiogram (TEE) probe, demonstrating a grossly dilated right ventricle, saddle pulmonary embolism, and hyperdynamic left ventricle. Meanwhile, given the acuity and direness, it was determined that ECMO would be most appropriate, and less than an hour after initiation of CPR, ECMO cannulation was inserted.
Upon arrival to the intensive care unit, Return of Spontaneous Circulation Protocol was initiated. The next day, the patient suffered termination of her pregnancy. However, on postoperative day (POD) #7, the patient’s cardiopulmonary status improved to the point of ECMO decannulation. On POD #14, the patient was extubated, and on POD #37, the patient was discharged to a rehabilitation center, with near resolution of both cardiopulmonary and neurologic function. Three months after the operation, echocardiogram showed normal biventricular systolic function, with a right ventricular systolic pressure of 29 mmHg.
Discussion: This case aims to illustrate the risk factors for PE along with appropriate CPR status post PE with ECMO being a viable option. This patient possessed a number of thromboembolic risk factors, including pregnancy, obesity, immobility, and malignancy. Due to the drastic hemodynamic collapse, it was recognized that the patient was likely developing cardiogenic shock as a result of a PE. As such, CPR was quickly initiated, and the appropriate personnel were called for possible ECMO cannulation. Studies have demonstrated that CPR performed in the operating room by anesthesiologists yield some of the highest resuscitation success rates (2). ECMO is a viable rescue therapy in those suffering from acute cardiopulmonary failure.
1. Marik P, et al. N Engl J Med 2008; 359(19):2025-33.
2. Pembeci K, et al. Resuscitation 2006; 68(2):221-29.