2012 OPEN FORUM Abstracts
AGGRESSIVE MANAGEMENT OF H1N1 IN A PREGNANT PATIENT.
Andrea Boersen, Faith A. Carrier, Doug Campbell, Stephen J. Fitch; Spectrum Health, Grand Rapids, MI
Introduction: A 29 year old female presented to an outlying hospital with shortness of breath, cough and tachycardia. Upon exam patient had decreased oxygen saturations and was transported to our facility for management of suspected H1N1 pneumonia. At admission patient was 26 0/7 weeks pregnant with a history of hypertension, GERD, asthma. Case Summary: After an initial BiPAP trial, the patient was intubated and mechanically ventilated due to hypoxia, tachypnea, and increased work of breathing. Within 18 hours, the patient was transitioned to high frequency oscillatory ventilation (HFOV) secondary to increasing plateau pressures and worsening respiratory acidosis. The patients acidosis resolved after two hours of HFOV though the PaO2/FiO2 (PF) ratio remained low. After four days of HFOV, with limited success weaning FiO2 and maintaining PaO2, veno-venous (VV) double lumen extracorporeal membrane oxygenation (ECMO) was initiated. ECMO was utilized for a total of eight days prior to decannulation. Five days post ECMO, while still mechanically ventilated and sedated, the patient experienced preterm premature rupture of membranes. Labor was induced due to fetal heart rate decelerations. The infant was delivered vaginally at 28 5/7 weeks. The infant had an uncomplicated neonatal course requiring short term CPAP. Discussion: The patients high cardiac output resulted in an intrapulmonary shunt creating a challenge to adequately oxygenate both the patient and fetus. Lung protective strategy was utilized early in this patient in order to minimize volutrauma. Initial tidal volume (VT) was 6.7 mL/kg predicted body weight (PBW) with a plateau pressure of 25 cmH2O. Tidal volumes were progressively decreased due to elevated plateau pressures. Prior to initiation of HFOV VT was 4.8 mL/kg PBW with a plateau pressure of 32 cmH2O. Although the patient initially improved with HFOV, continued low PF ratios and a persistent FiO2 requirement of 1.0 led to the initiation of ECMO. Transition to conventional ventilation from HFOV occurred six days into the ECMO course; with a total course of HFOV of ten days. The ECMO course was complicated by the migration of the VV cannula into the right atrium, causing ectopy. This required emergent adjustment by the surgeon at the bedside. The patient weaned successfully from HFOV, ECMO and mechanical ventilation. The total course of mechanical ventilation was 29 days; and the patient was discharged to home after 34 days. Sponsored Research - None