SESSION TITLE: Critical Care Student/Resident Case Report Posters II
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: One-third of pregnant asthmatics develop a critical asthma syndrome. We present the case of a 38 year old pregnant female with refractory status asthmaticus who ultimately improved with the use of extracorporeal membrane oxygenation (ECMO).
CASE PRESENTATION: A 38 year old African-American female, gravida 1 para 0, at 16 weeks gestation presented to our emergency department (ED) with four days of dry cough and shortness of breath. She has a history of poorly-controlled asthma requiring frequent ED visits, BiPap, and two prior intubations. On presentation, the patient was in severe respiratory distress. She received continuous albuterol-ipratropium, IV magnesium sulfate, IV methylprednisolone, subcutaneous terbutaline and was placed on BiPap with initial ABG demonstrating adequate ventilation and oxygenation. Over the next 36 hours, she developed worsening respiratory distress and hypercapnic respiratory failure requiring intubation. She remained difficult to ventilate despite maximal medical therapy including neuromuscular blockade. A permissive hypercapnia strategy was aborted when the patient developed severe acidosis to pH of 6.8 and hyperkalemia to 9 with associated EKG changes. Given her refractory status asthmaticus, a trial of inhaled anesthesia was initiated using isoflurane which led to improvement in her ventilation and acidosis. However, over the next 24 hours she progressively deteriorated and veno-venous ECMO was initiated. She was maintained on solumedrol, continuous albuterol and ipratropium, IV magnesium sulfate, low-dose epinephrine infusion, continuous aminophylline, and furosemide infusion. The patient's ECMO course was complicated by severe mucosal bleeding and a small intracerebral hemorrhage. A 17-week ultrasound of the fetus revealed ventriculomegaly. After eight days, the patient was successfully weaned off ECMO. She was extubated one week later and eventually discharged to an acute rehabilitation facility.
DISCUSSION: Standard medical therapies including permissive hypercapnia are safe and effective treatments for status asthmaticus in pregnancy. Inhaled isoflurane and ECMO have also been used in adults and children with status asthmaticus refractory to conventional therapy. To the best of our knowledge, neither inhaled isoflurane nor ECMO has been described in a pregnant patient with status asthmaticus.
CONCLUSIONS: Our case demonstrates the successful use of ECMO for near-fatal status asthmaticus in pregnancy. The long term effects of this treatment upon our patient’s fetus remain to be seen.
Reference #1: Chan AL, Juarez MM, Gidwani N, Albertson TE. Management of critical asthma syndrome during pregnancy. Clin Rev Allergy Immunol. 2015 Feb;48(1):45-53
Reference #2: Iwaku F, Otsuka H, Kuraishi H, Suzuki H. The investigation of isoflurane therapy for status asthmaticus patients. Arerugi. 2005 Jan;54(1):18-23
Reference #3: King PT, Rosalion A, McMillan J, Buist M, Holmes PW. Extracorporeal membrane oxygenation in pregnancy. Lancet. 2000 Jul 1;356(9223):45-6
DISCLOSURE: The following authors have nothing to disclose: Maria Theodorou, Emily Gilbert
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