WHOLE RANGE OF RESPIRATORY SUPPORT IN A PREGNANT WOMAN WITH A SEVERE FORM OF COVID-19 INFECTION: A CASE REPORT.

Acute respiratory syndrome caused by a novel coronavirus (SARS-CoV-2) in pregnant women can progress to a critical condition. In this paper, we present a case of a woman in the 28th week of gestation hospitalized due to respiratory insufficiency caused by COVID-19 infection and consequent bilateral pneumonia with development of severe acute respiratory distress syndrome. Noninvasive ventilation through a face mask was started but due to progression of respiratory insufficiency with high FiO2 and positive end expiratory pressure (PEEP), we decided to intubate the patient, after which obstetricians agreed to complete pregnancy by cesarean section. The clinical course was complicated by desaturation and bradycardia with recurring asystole which recovered after the use of atropine. The patient was increasingly difficult to mechanically ventilate on the PSIMV modality (tidal volume [TV] <200 mL). She was switched to ASV modality (TV up to a maximum of 350 mL, ASV 130%, PEEP 16 cm H2O, FiO2 100%, RR 25/min, pPeak 35 cm H2O, pPlateau 35 cm H2O), after which peripheral saturation recovered to 89%. Due to inadequate mechanical ventilation, the patient was transferred to Dr. Fran Mihaljevic University Hospital for Infectious Diseases in order to perform extracorporeal membrane oxygenation (ECMO). Owing to all of the measures taken, recovery followed after 13 days on ECMO.

AIRWAY MANAGEMENT GUIDELINES IN OBSTETRICS.

Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents.

BLUNT TRAUMA INTERCOSTAL LUNG HERNIATION AND DELAYED EXTRA PLEURAL HEMATOMA.

Blunt chest trauma is an important cause of morbidity and mortality in traumatized emergency patients. We report the case of a 74-year-old man who suffered a glenohumeral joint dislocation, trans trochanteric femur fracture, multiple rib fractures, diaphragmatic rupture with chest herniation of the spleen and stomach associated with herniation of the lung through an anterior chest wall defect after blunt trauma. Although immediate surgical repair was performed, he developed a delayed complication of multiple rib fracture in the form of large extrapleural hematoma that had to be surgically removed. Due to massive pulmonary contusion and prolonged pulmonary collapse, we used surfactant to facilitate alveolar opening after evacuation of the hematoma.