Successful recovery of a critically ill pregnant covid-19 patient treated with extracorporeal membrane oxygenation (ECMO) in Sanglah General Hospital, Bali, Indonesia: A case report

I Made Susila Utama; Cokorda Agung Wahyu Purnamasidhi; Putu Agus Surya Panji; Made Bagus Dwi Aryana; Komang Adhi Parama Harta

doi:10.4103/bjoa.bjoa_164_22

CASE REPORT

Year : 2022 | Volume : 6 | Issue : 4 | Page : 235-238

Successful recovery of a critically ill pregnant covid-19 patient treated with extracorporeal membrane oxygenation (ECMO) in Sanglah General Hospital, Bali, Indonesia: A case report

I Made Susila Utama¹, Cokorda Agung Wahyu Purnamasidhi¹, Putu Agus Surya Panji², Made Bagus Dwi Aryana³, Komang Adhi Parama Harta⁴
¹ Tropical and Infectious Diseases Division, Internal Medicine Department, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
² Anesthesiology and Reanimation Department, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
³ Obstetrics and Gynecology Department, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
⁴ Cardiothoracic Surgery Department, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia

Date of Submission	02-Jun-2022
Date of Decision	21-Jul-2022
Date of Acceptance	06-Aug-2022
Date of Web Publication	31-Oct-2022

Correspondence Address:
I Made Susila Utama
Tropical and Infectious Diseases Division, Internal Medicine Department, Udayana University/Sanglah General Hospital, Denpasar, Bali
Indonesia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.bjoa_164_22

Abstract

Extracorporeal membrane oxygenation (ECMO) has been shown to be effective as a form of a life-sustaining modality in previous outbreaks such as Middle East respiratory syndromes covariant and H1N1. A 28-year-old woman was referred from a military hospital after experiencing prolonged dyspnea and a loss of consciousness. At the time of admission, the patient was pregnant with a gestational age of 24–25 weeks and has a history of hypertension and a caesarian section. Respiratory failure forced a caesarean section, which was followed by an intensive care unit admission. Five days after admission, the patient was placed on ECMO with a heparin drip. The patient suffered coinfections identified in the patient’s sputum, blood, and urine samples. Significant clinical improvement observed after the second ECMO weaning and was followed by successful discharge. The successful treatment of a critically ill COVID-19 pregnant patient with ECMO as a life-sustaining critical-care modality is uncommon. However, potential coinfections must be considered, and physicians must prepare for waves of clinical worsening and improvement.

Keywords: COVID-19, critically ill, extracorporeal membrane oxygenation, pregnant

How to cite this article:
Utama I M, Purnamasidhi CA, Panji PA, Aryana MB, Harta KA. Successful recovery of a critically ill pregnant covid-19 patient treated with extracorporeal membrane oxygenation (ECMO) in Sanglah General Hospital, Bali, Indonesia: A case report. Bali J Anaesthesiol 2022;6:235-8

How to cite this URL:
Utama I M, Purnamasidhi CA, Panji PA, Aryana MB, Harta KA. Successful recovery of a critically ill pregnant covid-19 patient treated with extracorporeal membrane oxygenation (ECMO) in Sanglah General Hospital, Bali, Indonesia: A case report. Bali J Anaesthesiol [serial online] 2022 [cited 2023 Mar 22];6:235-8. Available from: https://www.bjoaonline.com/text.asp?2022/6/4/235/359926

Introduction

In December 2019, a mysterious pneumonia-like viral outbreak known as COVID-19 started its conquest to take over the world.^[1] A form of a treatment modality proven efficaciously used as a rescue therapy during previous outbreaks such as those of Middle East Respiratory Syndromes covariant and H1N1 was extracorporeal membrane oxygenation (ECMO).^[2],[3] ECMO is an extracorporeal supportive modality that facilitates gas exchange. In most of the cases, the treatment modality was required to be sustained for more than one week, indicating that its usage helps prolonged life in its edge of criticality until the body and treatment are adequate to combat the disease.^[2] Hemostatic complications and ECMO-related infections became a huge concern for physicians when deciding the usage of ECMO.^[3] ECMO is a finite resource and requires the utilization of other finite resources, particularly intensive care unit (ICU) beds and qualified staff. In Indonesia, both ECMO itself and staffs qualified to operate the machine are scarce. There are only few who are well versed in operating the machine and know what to do when the equipment is malfunctioned or complications arose. The use of ECMO in Indonesia is possible only in huge medical referral centers, which can provide equipment, financial, and manpower.^[4]

Case Report

The patient is a 28-year-old woman admitted with a chief complaint of dyspnea 2 days prior to being hospitalized in our hospital. The patient was referred from a level two healthcare facility because of prolonged dyspnea accompanied by the second pregnancy at a gestational age of 24–25 weeks. We recorded a decrease in consciousness and a progressive dyspnea worse than the previous day. The patient had no complaints of intermittent abdominal pain, discharge of water, mucus, and vaginal blood. The patient denied drug and food allergies, asthma, diabetes, and other systemic diseases. However, the patient had a history of caesarian section without complication 1 year ago and tests performed recorded stage two hypertension. At admission, the patient had a SpO₂ of 90% in non-rebreather mask at 15 L/min with bilateral basal rhonchi supported with a chest x-ray showing bilateral pneumonia and a positive COVID-19 test by a real-time polymerase chain reaction. Therefore, the patient was diagnosed with critically ill COVID-19, acute respiratory distress syndrome (ARDS), with single pregnancy (G2P1001 24–26 weeks). We consulted obstetrics and gynecology and intensive care and reached a plan for therapeutic termination and intubation if the high-flow nasal cannula (HFNC) failed.

During hospitalization, respiratory failure due to COVID-19 compelled the medical team to perform cesarean section followed by admittance to the ICU and ventilator installation. The baby was born alive but died a month later because of prematurity. Five days post-ICU admission, the patient suffered a type one respiratory failure that, again, compelled the team to put the patient under the support of venous to venous-ECMO FiO₂ 70% combined with a heparin drip. According to the algorithm for the management of ARDS, indications of ECMO were PaO₂ to FiO₂ ratio (P:F ratio) of ≥150 combined with arterial pH < 7.25 and PaCO₂ ≥ 60 mmHg.^[5]

Three days after ECMO installation, urine and sputum culture indicates that the patient suffered coinfections of Candida tropicalis and Acinetobacter baumannii. Therefore, we started an administration of fluconazole and tigecycline. Chest radiology showed an improvement in lung consolidation on day 7, but worsening on day 9 [Figure 1]. On day 11, vital signs were unstable and laboratory results showed thrombocytopenia. We suspected that it was caused by HIT (heparin-induced thrombocytopenia). Our cardiologist suggested the administration of nifedipine and nicardipine, followed by a decrease in heparin. On days 13–14, we recorded a clinical improvement; therefore we stopped tigecycline and attempted weaning on day 16. However, it failed and the day after, the blood and sputum culture showed positive coinfections of Candida tropicalis, Acinetobacter baumannii, Klebsiella pneumoniae, Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli, which are sensitive to tigecycline. We started again tigecycline accompanied by amikacin therapy. On day 18, weaning in succession with switching from ventilator to HFNC and from HFNC to nasal cannula directly on the following days was done properly. The patient’s ARDS and sepsis improved and was discharged 9 days after the second successful ECMO weaning.

Figure 1: Serial chest x-ray

Click here to view

Around a month after being discharged, the patient went back for monitoring. Radiological and clinical signs showed that the patient suffered from post-COVID-19 syndrome though all parameters were normal. A full serial chest x-ray has been shown in [Figure 1], and a full clinical course has been shown in [Figure 2].

Figure 2: Clinical course

Click here to view

Discussion

The use of ECMO has been recommended by the World Health Organization for COVID-19 patients with severe ARDS.^[6] Several countries have adopted the use of ECMO for COVID-19 patients with severe respiratory distress and was showing substantially different outcomes, which probably related to differences in clinical settings and resource management.^[7],[8]

ECMO is a form of an extracorporeal life support that is mainly used to oxygenate the blood to temporarily compensate for failing lungs or heart while minimizing further ventilator-induced lung injury. ECMO operates mainly under two modes, veno-venous (V-V) and veno-arterial (V-A), depending on the auxiliary organ. The V-V mode is mainly used for COVID-19 patients present with respiratory failure.^[8] However, the cardiovascular system can also be affected by SARS-CoV-2, resulting in a circulatory failure, and the V-A mode is used for this situation. The patient in our case received the V-V mode because there was no circulatory deterioration observed in our patient, and these two factors might contribute to the favorable outcome in our patient.

Previous studies reported a successful use of ECMO in appropriately selected COVID-19 patients with severe ARDS.^[9],[10] However, patients receiving circulatory support (V-A mode) were significantly associated with in-hospital mortality (HR = 1.89, 95% CI = 1.20–2.97). The risk factors for a poor outcome for COVID-19 patients undergoing ECMO are old age (>65 years old), low PaO₂/FiO₂, immunocompromised status, chronic respiratory diseases, acute kidney injury, and the need for V-A ECMO.^[11] None of those risk factors were observed in our patient, therefore resulting in a successful outcome in our case.

However, our case was presented with pregnancy, which confers significant challenges in COVID-19 treatment, either the potency of exhibiting more severe infection or resulting in significant pregnancy complications.^[12] Two previous studies have reported the successful use of ECMO for pregnant patients with critical COVID-19.^[12],[13] Pregnant patients in those studies were also receiving the V-V mode, similar to our case.

In this study, we report a relatively young pregnant patient infected with SARS-CoV-2. The patient came from a level two healthcare facility, and during referral, there is no plan to terminate pregnancy. The patient was referred due to the healthcare facility being inadequate to handle pregnant COVID-19 patients. During hospitalization, our team recorded worsening clinical symptoms and respiratory failure that prompts the usage of respiratory and circulatory life support modalities, starting from noninvasive to invasive ventilating aid to ECMO.

Referring to the literatures, venous to venous-ECMO is indicated for patients with, and is mainly intended for, life-threatening respiratory failure where conventional ventilatory support is inadequate.^[8] However, our intensivist recorded an inadequate tidal volume with other respiratory supports. A heparin drip is used to control coagulation and bleeding, where the idea is to prevent an excessive clot formation while maintaining normal coagulative capabilities to prevent bleeding.^[14] However, the prolonged usage of a heparin drip aggregately adds up to high doses of anticoagulants; therefore, close monitoring must be performed in parallel to the duration of hospitalization.

The use of ECMO in patients with COVID-19 was also associated with common complication, for instance, bleeding and thrombosis, in addition to the promotion of thrombosis by COVID-19 itself. The initial establishment of ECMO results in an overall procoagulant effect, and as time follows, coagulation factors irreversibly bind with the ECMO surface coating material. In our case, we did not observe overt bleeding due to the use of anticoagulation. However, we suspected the thrombocytopenic episode on day 11 of treatment related to the use of heparin (HIT), and it was well managed by decreasing the dose of heparin. The usage of ECMO generally carries the risk of complication development, especially coinfections that may lead to waves of progressive clinical worsening and improvement. It is important to thoroughly assess and monitor the patient to record even slight changes in clinical course. Serial blood and sputum culture combined with sensitivity testing may help physicians in preventing bad clinical outcomes.

We observe the coinfections of Candida tropicalis, Acinetobacter baumannii, Klebsiella pneumoniae, Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli identified via sputum, blood, and urine samples. Previous articles reported that nosocomial coinfections during ECMO were not a rare occurrence, with frequently involved pathogens being Staphylococcus spp., Enterobacteria spp., Candida spp., Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa, a match to what our patient suffers from.^[15]

Conclusion

The treatment of a critically ill COVID-19 with ECMO as a life-sustaining critical-care modality is uncommon. Potential coinfections must be considered, and physicians must prepare for periods of clinical worsening and improvement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Ryalino C, Irawan A, Aribawa IGNM, Pradhana AP, Novianti PA, Sitanggang FP, et al. Fatal iliopsoas and rectus sheath hemorrhage in a critically ill patient with COVID-19 on therapeutic anticoagulation. Int J Crit Illn Inj Sci 2022;12:51-3. [Full text]
2.	Zangrillo A, Biondi-Zoccai G, Landoni G, Frati G, Patroniti N, Pesenti A, et al. Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: A systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO. Crit Care 2013;17:R30.
3.	Bartlett RH, Gazzaniga AB, Huxtable RF, Schippers HC, O’Connor MJ, Jefferies MR. Extracorporeal circulation (ECMO) in neonatal respiratory failure. J Thorac Cardiovasc Surg 1977;74:826-33.
4.	Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, et al; ELSO COVID-19 Working Group Members. Extracorporeal membrane oxygenation for COVID-19: Updated 2021 guidelines from the extracorporeal life support organization. ASAIO J 2021;67:485-95.
5.	Bartlett RH, Ogino MT, Brodie D, McMullan DM, Lorusso R, MacLaren G, et al. Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure. ASAIO J 2020;66:472-4.
6.	World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected: Interim guidance, 28 January 2020; 2020. p. 10. Available from: https://apps.who.int/iris/handle/10665/330893.
7.	Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al; COVID-19 Lombardy ICU Network. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA 2020;323:1574-81.
8.	Schmidt M, Hajage D, Lebreton G, Monsel A, Voiriot G, Levy D, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: A retrospective cohort study. Lancet Respir Med 2020;8:1121-31. Available from: http://www.thelancet.com/article/S2213260020303283 and https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-021-01479-6.
9.	Le Breton C, Besset S, Freita-Ramos S, Amouretti M, Billiet PA, Dao M, et al. Extracorporeal membrane oxygenation for refractory COVID-19 acute respiratory distress syndrome. J Crit Care 2020;60:10-2.
10.	Ziehr DR, Alladina J, Petri CR, Maley JH, Moskowitz A, Medoff BD, et al. Respiratory pathophysiology of mechanically ventilated patients with COVID-19: A cohort study. Am J Respir Crit Care Med 2020;201:1560-4.
11.	Barbaro RP, MacLaren G, Boonstra PS, Iwashyna TJ, Slutsky AS, Fan E, et al; Extracorporeal Life Support Organization. Extracorporeal membrane oxygenation support in COVID-19: An international cohort study of the extracorporeal life support organization registry. Lancet 2020;396:1071-8.
12.	Tambawala ZY, Hakim ZT, Hamza LK, Al Rayes M. Successful management of severe acute respiratory distress syndrome due to COVID-19 with extracorporeal membrane oxygenation during mid-trimester of pregnancy. BMJ Case Reports CP 2021;14:e240823. Available from: https://casereports.bmj.com/content/14/2/e240823. [Last accessed on 2022 Apr 27].
13.	Barrantes JH, Ortoleva J, O’Neil ER, Suarez EE, Beth Larson S, Rali AS, et al. Successful treatment of pregnant and postpartum women with severe COVID-19 associated acute respiratory distress syndrome with extracorporeal membrane oxygenation. ASAIO J 2021;67:132-6.
14.	Yeo HJ, Kim DH, Jeon D, Kim YS, Cho WH. Low-dose heparin during extracorporeal membrane oxygenation treatment in adults. Intens Care Med 2015;41:2020–1.
15.	Biffi S, Di Bella S, Scaravilli V, Peri AM, Grasselli G, Alagna L, et al. Infections during extracorporeal membrane oxygenation: Epidemiology, risk factors, pathogenesis and prevention. Int J Antimicrob Agents 2017;50:9-16.