DP22: ADDITION OF LIPID EMULSION THERAPY DURING AMNIOTIC FLUID EMBOLISM CARDIOVASCULAR COLLAPSE.
Christine McLaughlin, MD; Osereimen Omoike, MD; Enrico M Camporesi
University of South Florida Morsani College of Medicine
Background: A 40-year-old G3P2 at 18w2d presented to the ED one day before her scheduled procedure for dilation and evacuation for spontaneous abortion with fever and thick vaginal discharge. She consented to urgent D&E for septic abortion and received broad-spectrum antibiotics. After admission to the OR, general anesthesia was started without complications. The patient was placed in the dorsal lithotomy position and received a paracervical block with a total of 20 mL of 1% lidocaine and 4 units of vasopressin. A curved suction curette was introduced into the uterine cavity with a notable return of amniotic fluid and placental tissue. Within seconds, the patient was found to be in pulseless ventricular tachycardia. The procedure stopped, and the patient was moved from dorsal lithotomy to the supine position while chest compressions were simultaneously started.
Methods: Due to the recent administration of lidocaine, local anesthetic systemic toxicity (LAST) was suspected, and the patient was rapidly treated with an intravenous bolus injection of 20% lipid emulsion at 1.5 mL/kg, followed by an infusion. After several rounds of chest compressions and the administration of epinephrine, the patient returned to spontaneous circulation. An EKG showed a prolonged QT with an interval above 600 milliseconds. Brisk bleeding was then noted from the uterus by the surgical team, and there was a strong suspicion of amniotic fluid embolism (AFE). Thromboelastogram results were consistent with DIC.
Results: A Foley catheter was inflated in the uterus to tamponade bleeding. During this time, bleeding slowed. Following transfer to the ICU, a CT angiogram was completed, showing right upper lobe subsegmental pulmonary artery filling defects compatible with pulmonary emboli with no CT evidence for acute right heart strain. After blood product administration, a follow-up TEG was normal, and the patient was extubated later that day.
Discussion: This case, in addition to a few other pre-existing published reports, suggests a potential benefit to adding lipid emulsion as an adjunct in treating cardiovascular collapse caused by AFE. It has been demonstrated in a rat model how lipid emulsion plays a role in preventing and rescuing fatal pulmonary hypertension and right heart failure as it contains a precursor to prostacyclin and a phytoestrogen that has been shown to reduce pulmonary hypertension. In addition to carefully selecting cardiovascular supportive pharmacotherapy and intervention, the early administration of lipid emulsion therapy is important to consider when approaching a case where the differential of AFE alone and/or with the concurrent potential of LAST occurs.