1
|
Kalbhenn J, Marx O, Müller-Peltzer K, Kunze M, Bürkle H, Bansbach J. [Pregnant women with COVID-19 ARDS on the intensive care unit]. DIE ANAESTHESIOLOGIE 2024; 73:385-397. [PMID: 38671334 PMCID: PMC11164748 DOI: 10.1007/s00101-024-01405-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 02/29/2024] [Accepted: 03/14/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Pregnant women with coronavirus disease 2019 (COVID-19) are at increased risk of severe disease progression. Comorbidities, such as chronic arterial hypertension, diabetes mellitus, advanced maternal age and high body mass index, may predispose to severe disease. The management of pregnant COVID-19 patients on the intensive care unit (ICU) is challenging and requires careful consideration of maternal, fetal and ethical issues. OBJECTIVE Description and discussion of intensive care treatment strategies and perinatal anesthesiological management in patients with COVID-19 acute respiratory distress syndrome (CARDS). MATERIAL AND METHODS We analyzed the demographic data, maternal medical history, clinical intensive care management, complications, indications and management of extracorporeal membrane oxygenation (ECMO) and infant survival of all pregnant patients treated for severe CARDS in the anesthesiological ICU of a German university hospital between March and November 2021. RESULTS The cohort included 9 patients with a mean age of 30.3 years (range 26-40 years). The gestational age ranged from 21 + 3 weeks to 37 + 2 weeks. None of the patients had been vaccinated against SARS-CoV‑2. Of the nine patients seven were immigrants and communication was hampered by inadequate Central European language skills. Of the patients five had a PaO2/FiO2 index < 150 mm Hg despite escalated invasive ventilation (FiO2 > 0.9 and a positive end-expiratory pressure [PEEP] of 14 mbar) and were therefore treated with repeated prolonged prone positioning maneuvers (5-14 prone positions for 16 h each, a total of 47 prone positioning treatments) and 2 required treatment with inhaled nitric oxide and venovenous ECMO. The most common complications were bacterial superinfection of the lungs, urinary tract infection and delirium. All the women and five neonates survived. All newborns were delivered by cesarean section, two patients were discharged home with an intact pregnancy and two intrauterine fetal deaths were observed. None of the newborns tested positive for SARS-CoV‑2 at birth. CONCLUSION High survival rates are possible in pregnant patients with CARDS. The peripartum management of pregnant women with CARDS requires close interdisciplinary collaboration and should prioritize maternal survival in early pregnancy. In our experience, prolonged prone positioning, an essential evidence-based cornerstone in the treatment of ARDS, can also be safely used in advanced stages of pregnancy. Inhaled nitric oxide (iNO) and ECMO should be considered as life-saving treatment options for carefully selected patients. For cesarean section, neuraxial anesthesia can be safely performed in patients with mild CARDS if well planned but the therapeutic anticoagulation recommended for COVID-19 may increase the risk of bleeding complications, making general anesthesia a more viable alternative, especially in severe disease.
Collapse
Affiliation(s)
- J Kalbhenn
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinik Freiburg, Hugstetter Str. 55, Freiburg, Deutschland
| | - O Marx
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinik Freiburg, Hugstetter Str. 55, Freiburg, Deutschland
| | - K Müller-Peltzer
- Klinik für Radiologie, Universitätsklinik Freiburg, Freiburg, Deutschland
| | - M Kunze
- Klinik für Frauenheilkunde, Geburtshilfe und Perinatologie, Universitätsklinik Freiburg, Freiburg, Deutschland
| | - H Bürkle
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinik Freiburg, Hugstetter Str. 55, Freiburg, Deutschland
| | - J Bansbach
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinik Freiburg, Hugstetter Str. 55, Freiburg, Deutschland.
| |
Collapse
|
2
|
Alvarado-Socarras JL, Quintero-Lesmes DC, Martin DT, Vasquez R, Monsalve MM, Cristancho LM, Rojas LS, Martinez JL, Medina CR, Gomez CP. Maternal-Fetal Results of COVID-19-Infected Pregnant Women Treated with Extracorporeal Membrane Oxygenation: A Descriptive Report. Am J Perinatol 2024; 41:e2115-e2123. [PMID: 37216968 DOI: 10.1055/a-2097-1852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE COVID-19 infection may produce severe pneumonia, mainly in the adult population. Pregnant women with severe pneumonia are at high risk of developing complications, and conventional therapy sometimes fails to reverse hypoxemia. Therefore, extracorporeal membrane oxygenation (ECMO) is an option in cases with refractory hypoxemic respiratory failure. This study aims to evaluate the maternal-fetal risk factors, clinical characteristics, complications, and outcomes of 11 pregnant or peripartum patients with COVID-19 treated with ECMO. STUDY DESIGN This is a retrospective descriptive study of 11 pregnant women undergoing ECMO therapy during the COVID-19 pandemic. RESULTS In our cohort, four patients underwent ECMO during pregnancy (36.3%) and 7 during the postpartum period. Initially, they started on venovenous ECMO, and three patients were required to change modality due to clinical conditions. In total, 4/11 pregnant women (36.3%) died. We established two periods that differed in the implementation of a standardized care model for reducing associated morbidities and mortality. Neurological complications were responsible for most deaths. Regarding fetal outcomes at early-stage pregnancies on ECMO (4), we report three stillbirths (75%), and one newborn (twin pregnancy) survived and had a favorable evolution. CONCLUSION At later-stage pregnancies, all newborns survived, and we did not identify any vertical infection. ECMO therapy is an alternative for pregnant women with severe hypoxemic respiratory failure due to COVID-19, and may improve maternal and neonatal results. Regarding fetal outcomes, the gestational age played a definitive role. However, the main complications reported in our series and others are neurological. It is essential to develop novel, future interventions to prevent these complications.
Collapse
Affiliation(s)
| | - Doris C Quintero-Lesmes
- Research Center, Investigation Center, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Delia Theurel Martin
- Department of Pediatric-Neonatal Critical Care, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Raul Vasquez
- Department of Critical Care Medicine, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Mary Mendoza Monsalve
- ECMO Department, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Lizeth Mogollon Cristancho
- Department of Critical Care Medicine, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Leonardo Salazar Rojas
- ECMO Department, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Jenifer Leon Martinez
- Department of Radiology, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Carlos Riaño Medina
- Department of Perinatal Medicine, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Camilo Pizarro Gomez
- Department of Critical Care Medicine, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| |
Collapse
|
3
|
Quintero A, Vinck EE, Pérez LE, Escobar JJ, Rendón JC, Uribe JD. Extra-corporeal membrane oxygenation and emergency C-section for a pregnant COVID-19 positive patient. Perfusion 2023; 38:405-409. [PMID: 34617859 DOI: 10.1177/02676591211049769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Data on extra-corporeal membrane oxygenation (ECMO) therapy for pregnant patients with Coronavirus 2019 (COVID-19) infection are limited. Here we report a case of an emergency cesarean section performed while the COVID-19 positive mother was on ECMO support. CASE REPORT A 36-year-old COVID-19 positive patient at 26 weeks gestational age presented with respiratory failure requiring extra-corporeal membrane oxygenation therapy. Nine days later fetal distress demanded an emergency C-section. After 5 weeks on ECMO, the patient was weaned off. Both mother and child were discharged. DISCUSSION The decision to perform an urgent C-section is one that requires meticulous thought from the attending team. Pulmonary maturation is key as pregnancy may need to be terminated at any time during ECMO. CONCLUSION Data on ECMO support for pregnant patients with COVID-19 infection are scarce. Best results can be achieved ensuring adequate anticoagulation, meticulous choice of cannulas, continued fetal monitoring, early lung maturation, and precision timing of delivery.
Collapse
Affiliation(s)
- Alejandro Quintero
- Department of Cardiovascular Surgery & Mobile ECMO, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - Eric E Vinck
- Department of Cardiovascular Surgery & Mobile ECMO, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - Luz E Pérez
- Department of Clinical Research, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - José J Escobar
- Department of Cardiovascular Surgery & Mobile ECMO, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - Juan C Rendón
- Department of Cardiovascular Surgery & Mobile ECMO, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - Juan D Uribe
- Department of Cardiovascular Critical Care & Mobile ECMO, Cardio VID Clinic, Medellín, Antioquia, Colombia
| |
Collapse
|
4
|
Full-Term Delivery and Complete Lung Recovery following VV ECMO Support Midpregnancy in a Patient with COVID-19 ARDS. Case Rep Crit Care 2023; 2023:3472718. [PMID: 36923498 PMCID: PMC10010870 DOI: 10.1155/2023/3472718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 09/16/2022] [Accepted: 01/09/2023] [Indexed: 03/08/2023] Open
Abstract
Pregnant women are especially vulnerable to coronavirus disease 2019 (COVID-19). We present a twin pregnancy case with acute respiratory distress syndrome following COVID-19 infection at 19 weeks. The patient's ARDS was successfully managed with veno-venous extracorporeal membrane oxygenation (VV ECMO). She recovered completely and delivered healthy twins.
Collapse
|
5
|
Kaplow R, Miller C. Use of Extracorporeal Membrane Oxygenation Therapy During Pregnancy and COVID-19: A Case Study. AACN Adv Crit Care 2022; 33:247-252. [PMID: 36067262 DOI: 10.4037/aacnacc2022111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation is emerging as a vital resource for survival of patients with acute respiratory distress syndrome related to COVID-19. Although recent research provides much insight into the advantages of extracorporeal membrane oxygenation in this patient population, little has been published on its use in pregnancy. This case study describes the use of venovenous extracorporeal membrane oxygenation in a young pregnant woman with acute respiratory distress syndrome due to COVID-19. It illustrates the benefits of a multidisciplinary approach to this treatment modality, allowing time for a fetus to become viable while preserving the life of the mother. In this case, the mother was able to return home after receiving this therapy and resume normal activities of daily living independently.
Collapse
Affiliation(s)
- Roberta Kaplow
- Roberta Kaplow is Clinical Nurse Specialist in the Acute Respiratory ICU, Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA 30319
| | - Casey Miller
- Casey Miller is ECMO Coordinator, Emory University Hospital, Atlanta, Georgia
| |
Collapse
|
6
|
Abstract
Pregnant women are at increased risk for severe coronavirus disease 2019 (COVID-19) and COVID-19-related complications. Their increased risk in conjuncture with the normal physiologic changes in pregnancy poses unique challenges for the management of the critically ill pregnant patient. This article will review the initial management of pregnant patients who develop acute hypoxic respiratory failure and subsequent treatment of those that deteriorate to acute respiratory distress syndrome and require advanced therapies. Moreover, fetal monitoring and timing of delivery will be reviewed.
Collapse
Affiliation(s)
- Matthew Levitus
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston MA 02215, USA
| | - Mai Colvin
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| |
Collapse
|
7
|
Abstract
The purpose of this review is to describe updates following initial recommendations on best anesthesia practices for obstetric patients with coronavirus disease 2019. The first surge in the United States prompted anesthesiologists to adapt workflows and reconsider obstetric anesthesia care, with emphasis on avoidance of general anesthesia, the benefit of early neuraxial labor analgesia, and prevention of emergent cesarean delivery whenever possible. While workflows have changed to allow sustained safety for obstetric patients and health care workers, it is notable that obstetric anesthesia protocols for labor and delivery have not significantly evolved since the first coronavirus disease 2019 wave.
Collapse
|
8
|
Chang EE, Cordoba M, Vellanki S, Trikannad Ashwini Kumar AK, Segura E. Critical Care Management of a Severe Acute Respiratory Distress Syndrome COVID-19 Patient With Control Cesarean Section. Cureus 2022; 14:e22660. [PMID: 35371736 PMCID: PMC8964022 DOI: 10.7759/cureus.22660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/05/2022] Open
Abstract
We share our experience of one 29-year-old female, G2 P1, with acute respiratory distress syndrome (ARDS) and at 30 weeks of pregnancy. The 30-week gravid uterus in combination with a poor ventilation-perfusion ratio creates a restrictive lung pattern that may prove to be lethal for both the mother and baby. Due to her rapid deterioration and increased hemodynamic instability we opted for controlled delivery in the operating room with an ICU physician, a Neonatologist, and an Obstetric team. At 3.27 minutes from induction, the baby was born with Apgar scores of 7 and 8. The mother was placed on a RotoProne® bed, treated with remdesivir, steroids, and was subsequently extubated seven days later. The newborn was admitted to the Neonatal Intensive Care Unit (NICU) after delivery. We have reviewed the literature and provided a concise set of recommendations based on our field experience and current world literature review. Prompt delivery in a controlled environment with multiple resuscitating teams provided expeditious treatment of both patients, maintaining oxygenation and perfusion while keeping hemodynamic stability. The controlled environment and the proximity of all teams avoided deleterious consequences to the unborn baby. This is an example where the risk of keeping the baby in the womb outweighs the premature delivery into a NICU. Both mother and baby were downgraded from their respective Intensive Care Units (ICUs) and discharged home in one month.
Collapse
|
9
|
Khalil M, Butt A, Kseibi E, Althenayan E, Alhazza M, Sallam H. COVID-19-Related Acute Respiratory Distress Syndrome in a Pregnant Woman Supported on ECMO: The Juxtaposition of Bleeding in a Hypercoagulable State. MEMBRANES 2021; 11:membranes11070544. [PMID: 34357194 PMCID: PMC8307442 DOI: 10.3390/membranes11070544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 01/29/2023]
Abstract
A 40-year-old pregnant woman at 28 weeks of gestation was diagnosed with severe acute respiratory failure syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). She had severe hypoxemia despite the use of mechanical ventilation and muscle relaxant infusion. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) was used, and she had a cesarian section while on ECMO support. She developed disseminated intravascular coagulation (DIC) with overt bleeding. This was managed by a multidisciplinary team (MDT) and a change of the ECMO circuit resulted in a dramatic improvement of her coagulation profile. Both the mother and the baby were discharged and went home in good condition.
Collapse
|
10
|
Tran DH, Peng CCH, Wolde-Rufael DA, Devkota H, Diaz-Abad M, Baghdadi J, Chow RD, Verceles AC. A successful case of extracorporeal membrane oxygenation for COVID-19: walking home without oxygen supplementation. J Community Hosp Intern Med Perspect 2021; 11:480-484. [PMID: 34211653 PMCID: PMC8221150 DOI: 10.1080/20009666.2021.1918442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged from Wuhan, China in December 2019 and is the strain of coronavirus that causes coronavirus disease 2019 (COVID-19). Approximately one-third of the patients with COVID-19 require intensive care unit (ICU) admission, and almost 30% of the patients develop acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used as salvage therapy for severe ARDS. The role of ECMO in the treatment of COVID-19 remains unclear, although there is emerging evidence that this approach may be an effective salvage therapy for severe ARDS. Case Presentation: We present a case of a previously healthy 39-year-old Hispanic male who presented to the hospital with flu-like symptoms, including headache, fatigue, and myalgia for 8 days in late April 2020. He denied dyspnea on exertion. The patient's symptoms progressed, resulting in pneumonia and acute respiratory distress syndrome (ARDS). The patient was managed with prone positioning, convalescent plasma and veno-venous extracorporeal membrane oxygenation (VV-ECMO) for 35 days. The patient successfully recovered and was able to ambulate independently and was discharged home from an acute care hospital without oxygen supplementation on hospital day 63. Conclusion: We present one of the first few documented cases of ECMO for severe ARDS due to COVID-19. After a prolonged hospital course requiring VV-ECMO, the patient was discharged home from an acute care hospital without oxygen requirement and ambulated independently, likely as a result of daily aggressive mobility-focused rehabilitation.
Collapse
Affiliation(s)
- Dena H Tran
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Carol Chiung-Hui Peng
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Daniel A Wolde-Rufael
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA.,Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hari Devkota
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Montserrat Diaz-Abad
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan Baghdadi
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - R Dobbin Chow
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Avelino C Verceles
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
11
|
Rushakoff JA, Polyak A, Caron J, Parrinella K, Salabat R, Wong M, Emerson D. A case of a pregnant patient with COVID-19 infection treated with emergency c-section and extracorporeal membrane oxygenation. J Card Surg 2021; 36:2982-2985. [PMID: 33974311 PMCID: PMC8242885 DOI: 10.1111/jocs.15623] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 12/25/2022]
Abstract
Coronavirus disease 2019 (COVID‐19) causes the development of severe acute respiratory distress syndrome. Pregnant women may be at increased risk for the development of severe disease. We present the case of a pregnant patient who developed respiratory failure due to COVID‐19 and rapidly decompensated requiring intubation. Despite mechanical ventilation, the patient's respiratory status continued to worsen. At bedside, cardiothoracic surgeons, obstetricians, intensivists, and neonatologists discussed balancing the risk of COVID‐19 and respiratory failure to the patient, premature delivery to the neonate, potential coagulopathy associated with COVID‐19, and the need for anticoagulation with mechanical circulatory support. Ultimately, the decision was to proceed with emergency cesarean section delivery in the intensive care unit followed by peri‐partum veno‐venous extracorporeal membrane oxygenation initiation. The patient and neonate were both discharged home in stable condition.
Collapse
Affiliation(s)
- Joshua A Rushakoff
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Alexander Polyak
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jayne Caron
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kristin Parrinella
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Reza Salabat
- Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Melissa Wong
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dominic Emerson
- Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| |
Collapse
|