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PROLONGED ANTEPARTUM ECMO WITH FULL MATERNAL RECOVERY AND NO EVIDENCE OF IMPACT ON NEONATAL OUTCOME
Abstract Number: S3C-7
Abstract Type: Case Report/Case Series
A 37 year old female, Gravida 9 Para 4, at 24/5 weeks gestation was transferred to our tertiary care center for veno-venous extracorporeal membrane oxygenation (VV-ECMO)evaluation due to hypoxic-hypercarbic respiratory failure secondary to rhinovirus pneumonia leading to acute respiratory distress syndrome (ARDS) with superimposed asthma exacerbation. The patient’s history was significant for ongoing tobacco abuse and asthma requiring intubation approximately 7 years prior. Despite initial success with aggressive medical treatment, including deep sedation, neuromuscular blockade, and lung protective ventilation, adequate ventilation and oxygenation could not be maintained. Ultimately, on hospital day #11, VV-ECMO was initiated. Using Seldinger technique, a 25 French outflow cannula was placed into the right femoral vein, followed by a 19 French inflow cannula in the right internal jugular vein. Flows were initiated at 4.3L/min, with RPMs at 2975, and a sweep of 3 L/min. Arterial blood gas prior to cannulation was 7.27/74/61/33, improving to 7.44/47/99/32 within hours.
The patient tolerated cannulation without incident. She was maintained using a lung protective ventilation strategy (4-7 mL/kg predicted body weight) and high PEEP (12-16 mmHg). Bronchoscopy was performed with clearance of copious bilateral mucus plugs. The patient improved significantly over the next 48 hours. Elective tracheostomy was performed to assist with weaning from the ventilator as the patient had signs and symptoms of ICU-acquired weakness. ECMO was weaned following a total of 6 days of therapy. The patient subsequently tolerated ventilator weaning and was liberated from the ventilator four days after decannulation from ECMO. The patient made a full recovery of respiratory function and required no supplemental oxygen after discharge from the intensive care unit.
On hospital day #28 she began having seizure-like activity while on the ward, along with elevated LFTs in the setting of long-term steroid treatment and negative head CT. The OB team was unable to effectively rule out eclampsia, so she was taken for urgent repeat cesarean delivery after a witnessed seizure on hospital day #29. Inhaled induction via the tracheostomy was performed, followed by a balanced anesthetic including nitrous oxide and sevoflurane. The delivery was uncomplicated and the patient was monitored in the ICU postoperatively for less than 48 hours before transition to the ward.
The neonate was born at 28w6d with APGAR scores of 7 and 9. After bag-mask positive pressure ventilation and transition to CPAP the infant was admitted to NICU for further care. The fetus did not appear to suffer any significant physiologic changes or insults during this process and tolerated the initiation and discontinuation of VV-ECMO without issue. This case illustrates the safe and appropriate usage of VV-ECMO in a patient with severe respiratory failure during pregnancy.