Use of systemic steroids in management of a pregnant patient with ARDS.
Kothari V, Joseph N, and Uduman J. Use of systemic steroids in management of a pregnant patient with ARDS. Crit Care Med 2018; 46:568.
Crit Care Med
Learning Objectives: Steroids have been used in the management of ARDS. All studies which have shown the benefit of using steroids in ARDS excluded pregnant patients and there is no data to support the use of steroids in pregnant patients with ARDS. Methods: 16 y/o female with a past medical history of childhood asthma, pregnant in her 33rd week, who failed outpatient mild UTI treatment with Nitrofurantoin presented to the ER with fever, chills and worsening back pain. She was found to be febrile, tachycardic with leukocytosis. She was admitted for sepsis secondary to pyelonephritis due to pan-susceptible E Coli and was started on Ceftriaxone. The following day, she had worsening respiratory distress with increasing oxygen requirements. Imaging showed complete consolidation of the almost entire right lung. She required 12L HFNC. Antibiotics were escalated and she was transferred to a tertiary care center for escalation of care. Blood cultures and tests for respiratory pathogens remained negative. She was intubated after 2 days for worsening respiratory distress and hypoxic respiratory failure. Despite 5 days of broad spectrum antibiotics, her respiratory status was unchanged. Repeat imaging now showed diffuse airspace opacities in the left lung. She had no evidence of cardiogenic pulmonary edema and a diagnosis of ARDS was made. Her ventilator settings were then managed per ARDSNet protocol. 2 days later she was started on Methylprednisolone per Meduri protocol for ARDS. After 7 days of broad spectrum antibiotics, she was continued on Ceftriaxone to complete total 14 days of antibiotics for pyelonephritis. 3 days after starting corticosteroid, she underwent cesarean section due to pre-eclampsia. She required high FiO2 and PEEP to maintain oxygenation. Weaning her ventilator settings was a gradual process. She was extubated to HFNC after 17 days of intubation. Hospital course complicated by pneumomediastinum and pneumothorax requiring drainage catheter and mood disorder. Clinical status then improved and the patient was transferred to a general medical floor. After 1 month of hospitalization, she was discharged home on 2L NC and a tapering dose of prednisone. PFTs done a week after her discharge showed severe restriction with severely reduced DLCO at 24% with 92%oxygen saturation on room air. Results: This case demonstrated successful use of steroids in a pregnant patient with ARDS. Adverse effects like pregnancy induced hypertension, muscle weakness, mood disorder should be kept in mind.