SESSION TITLE: Critical Care Cases III
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 28, 2015 at 11:00 AM - 12:15 PM
INTRODUCTION: Amniotic Fluid embolism (AFE) is an extremely rare complication of pregnancy, and affected patients present with severe hypoxemia, hypotension and coagulopathy in immediate peri-partum period. Here we present a case of suspected AFE successfully managed by Extra Corporeal Membrane Oxygenation (ECMO).
CASE PRESENTATION: 35 year old female transferred to our facility for management of acute hypoxemic respiratory failure 18 hours after the cesarean section for her first child. Her past medical history was significant for hypothyroidism and Crohn’s disease. Initially managed with mechanical ventilation, but progressed to severe ARDS refractory to therapy with high FiO2, PEEP of 15, sedatives, paralytics and prostaglandin. CT scan was reported to be negative for pulmonary embolism and echocardiography showed hyperdynamic left ventricle with EF 80% and severe right ventricle dysfunction with mean pulmonary artery pressure of 54 mm Hg. VV ECMO was initiated via right internal jugular Avalon catheter (27 F) 24 hours after presentation and started on vasopressor. Oxygenation improved, lactate started to trend down and vasopressor requirements decreased upon initiation of ECMO. Patient was successfully weaned from ECMO on eighth day. Her hospital course while on ECMO was complicated by rectus sheath hematoma and hemothorax.
DISCUSSION: In the absence of positive cultures and PCR for infectious etiology, negative PE protocol, and the time course of onset of patient’s hypoxemic respiratory failure, we attributed the most likely cause of her severe ARDS was due to amniotic fluid embolization. Exact pathophysiology and risk factors precipitating amniotic fluid embolism is not clearly known. AFE is made by diagnosis of exclusion and appropriate clinical settings. Mortality as high as 86% due to AFE has been reported in literature.
CONCLUSIONS: As in other causes of refractory ARDS, ECMO can be lifesaving in patients with AFE refractory to conventional treatment modalities.
Reference #1: Amniotic fluid embolism: an evidence-based review, Agustin Conde-Agudelo and Roberto Romero, Am J Obstet Gynecol. 2009 Nov; 201(5): 445.e1-445.13
Reference #2: Early Application of Extracorporeal Membrane Oxygenation in a Patient with Amniotic Fluid Embolism Chang-Hsun Ho, Kuen-Bao Chen, Shih-Kai Liu, Yu-Fang Liu, Hung-Chun Cheng, Rick Sai-Chuen Wu, Acta Anaesthesiologica Taiwanica, Taiwan 2009;47(2):99−102
DISCLOSURE: The following authors have nothing to disclose: Devang Sanghavi, Pramod Guru, Troy Seelhammer, J Kyle Bohman, Gregory Schears
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