Extracorporeal Membrane Oxygenation in Pregnant Women With COVID-19.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and lung involvement is common. Patients with COVID-19 may progress to acute respiratory distress syndrome (ARDS) for which they may require mechanical ventilation. When conventional ventilation strategies are unable to achieve the desired oxygenation and gas exchange, extracorporeal membrane oxygenation (ECMO) might be an option in selected patients. The literature on the use of ECMO in peripartum women with COVID-19 is limited. We present a series of ten cases involving pregnant and recently pregnant women who rapidly developed ARDS after the onset of COVID-19 for which they received ECMO. Nine of the 10 patients survived intensive care unit discharge after a gradual recovery of their pulmonary function and weaning from mechanical ventilation and ECMO. In addition, 9 out of the 10 delivered neonates survived neonatal intensive care unit discharge.

Severe Intraoperative Bradycardia during Laparoscopic Cholecystectomy due to Rapid Peritoneal Insufflation.

Laparoscopy is becoming increasingly popular in gynecological and general surgical operations. There are complications that are inherent to the laparoscopy techniques; amongst them is intraoperative vagal-mediated bradycardia that results from peritoneal stretching. This can occur due to high flow rate of gas during peritoneal insufflation, a practice still happening nowadays. We report a case of a middle-aged hypertensive patient who was undergoing elective laparoscopic cholecystectomy. The patient was assessed more than once preoperatively by the anesthesia team for blood pressure optimization. The patient underwent general anesthesia and developed severe bradycardia immediately after peritoneal insufflation. The management started immediately by stopping the insufflation and deflating the abdomen. Afterwards, atropine was administered intravenously, and CPR was started preemptively according to the ACLS protocol to prevent the patient from progressing into cardiac arrest. She responded to the management and became vitally stable within one minute. After confirming that there was no cardiac or metabolic insult through rapid blood investigations and agreeing that the cause of bradycardia was the rapid insufflation, the surgical team proceeded with the surgery in the same setting using low flow rate of CO2 to achieve pneumoperitoneum. There were no complications in the second time and the operation was completed smoothly. The patient was extubated and shifted to the postanesthesia care unit to monitor her condition. The patient was stable and conscious and later shifted to the wards and discharged on routine follow-up after confirming that there were no complications in the postoperative follow-up. Therefore, it is important to monitor the flow rate of CO2 during peritoneal insufflation in laparoscopic surgery as rapid peritoneal stretch can cause severe bradycardia that might progress into cardiac arrest, especially in hypertensive patients. It is also important for the anesthetist to be vigilant and ready to manage such cases.