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Severe Refractory Failure Secondary to Flash Pulmonary Edema Requiring Venovenous ECMO
Abstract Number: S3C-5
Abstract Type: Case Report/Case Series
The use of extracorporeal membrane oxygenation (ECMO) has been well described in adult patients with cardiac or respiratory failure that is refractory to conventional therapy1. Severe cardiopulmonary disease requiring ECMO in the peripartum period is rare; the majority of cases documented in the last decade are a result of influenza-related ARDS2. We report a case of acute, rapidly progressive pulmonary edema in a parturient that was unresponsive to conventional therapies and ultimately required initiation of venovenous (VV) ECMO.
A 24 year-old morbidly obese (BMI 40) G2P0010 female at 29 1/7 weeks gestation was hospitalized for management of chronic hypertension and superimposed preeclampsia with severe features by blood pressure. She was managed on labetalol and nifedipine, given magnesium for seizure prophylaxis and IM betamethasone to promote fetal lung maturity.
On hospital day two, the patient complained of dyspnea with a new supplemental oxygen requirement. She was transferred to the labor and delivery ward where she rapidly decompensated into hypoxic respiratory failure. Airway exam revealed an edematous face, large protruding tongue, and a thick neck circumference. On arrival to the operating room, she was unresponsive. Bag mask ventilation was initiated and a rapid sequence induction was performed. Video laryngoscopy showed copious frothy secretions with poor visualization of the glottic opening. 2-handed mask ventilation was performed with great difficulty. On second laryngoscopy attempt, gastric contents were noted in the posterior oropharynx. Suction was applied and a 7.0mm cuffed endotracheal tube was placed successfully. Emergent cesarean delivery was performed and a 990 gram male infant was delivered with Apgar scores of 5, 7, and 8 at 1, 5, and 10 minutes, respectively.
Throughout the procedure, ventilation and oxygenation proved exceedingly difficult with PIPs reaching 50-60 cm H2O. Arterial blood gas analysis showed a profound respiratory acidosis and hypoxemia. Manual ventilation was required to maintain tidal volumes greater than 200 mL. A collaborative decision was made between the anesthesia and surgical teams to move towards initiation of VV-ECMO. Cannulation proved to be difficult requiring multiple attempts from the right internal jugular and bilateral femoral veins. She was ultimately dual cannulated through the right femoral vein and VV-ECMO was initiated approximately 90 minutes after arrival to the OR. She was successfully weaned from extracorporeal support on postoperative day 2, extubated on postoperative day 3, and discharged home on postoperative day 12 with no long-term neurologic or cardiopulmonary sequela. To our knowledge this is the first documented case of severe, refractory pulmonary edema from preeclampsia requiring ECMO support as a salvage therapy.
1. Peek GJ et al. CESAR trial. The Lancet 2009 Oct.
2. Anselmi A et al. ECMO in Pregnancy. J Card Surg 2015 Oct.