Case #4
A 32 years old non-Hispanic white G5P2022 at 29 weeks transferred from an OSH with severe COVID-19. The PMH was significant for obesity and diabetes mellitus. During the first three days, the patient was managed on a high-flow nasal cannula and CPAP. Remdesivir was initiated, and the patient was enrolled in the Canakinumab trial (NCT04362813). During the next two days, the patient self-proned three times for 7.3, 8, and 1 h. The instructions for self-proning can be seen in Video 2. The last self-proning session was discontinued, and the patient intubated as the SpO2 was below the goal despite being on maximum non-invasive support (high flow NC at FiO2 of 100% providing 40 L/m with a non-rebreather mask on top at 15 L/m). Immediately after intubation, the patient had transient hypoxia episodes with SpO2dropping to 70%. A gradual recovery was achieved once PEEP was increased to 16 and FiO2 to 100%. The patient’s respiratory status remained precarious (P/F ratio of 147 at FiO2 of 80%). This prompted proning (16h45m), which improved oxygenation (P/F ratio of 293 at FiO2 of 60%). The following day the patient was proned (16h) due to intermittent desaturations to 80. The second session also resulted in improved oxygenation (P/F ratio of 371 at FiO2 of 60%, SaO2 ≥ 94% was maintained as well) (Figure S 3.1). Concomitant with the second proning session, the patient developed new high-grade febrile morbidity. The following day patient started again to have intermittent episodes of desaturation, responsive to temporary increases in PEEP to 16 and FiO2 to 100%. With a declining P/F ratio (151 on FiO2 60%) patient was proned for the 3rd time (15h45m). Once returned to the supine position, the patient was desaturating, requiring the FiO2 to be increased to 80%. The decision was made to re-prone earlier (16h15m). Oxygenation improved (P/F ratio increased to 232 at FiO2 of 40%), and desaturation episodes ceased (Figure S 3.2). Sputum cultures grew a multidrug-resistant Acinetobacter Baumannii that was successfully treated with a combination of high dose antibiotics. The patient was extubated five days after the last proning session. The total hospital length was 23 days. One month after discharge patient had an uncomplicated term repeat cesarean delivery.