Norepinephrine

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

In a report of 2 women, a 44-year-old woman was described, who exhibited lack of efficacy to norepinephrine administered to maintain mean arterial pressure.

An obese, nulliparous woman with a singleton pregnancy, presented at the emergency room at 32 weeks of gestation with myalgia and dry cough, which had started 15 days prior (COVID day 1). She had fever from the past 7 days (COVID day 7), and dyspnoea since 24 hours (COVID day 14). Her medical history included breast cancer, which was treated before 4 years with radiotherapy, unspecified chemotherapy and surgery. While receiving chemotherapy, she had developed right upper arm thrombosis, and was treated with enoxaparin-sodium [enoxaparin]. After admission (current presentation), her nasopharyngeal swab for SARS-CoV-2 (RT-PCR) was tested positive, and she was admitted to the ICU. She then started receiving oxygen 2 L/min through a nasal cannula and an initial improvement in oxygen saturation was noted. She received off label treatment with hydroxychloroquine, azithromycin, oseltamivir and ceftriaxone for COVID-19. Imaging results of chest showed faint bilateral patchy opacities and bilateral ground-glass opacities involving >50% of the lungs. Over the next 12 hours, the respiratory pattern worsened and RR increased. Her partial pressure of arterial oxygen/fraction of inspired oxygen (PaO₂/FIO₂) decreased from 246 to 177, and her oxygen supplementation was increased to 6 L/min. She was intubated in the ICU under rapid sequence and put on lung protective ventilation. She received norepinephrine [noradrenaline; route and dosage not stated], and continuous sedation with fentanyl and midazolam. After 6 hours of intubation, norepinephrine dose was increased to maintain mean arterial pressure pressure at 65mm Hg. However, her PaO₂/FiO₂ worsened and was shifted to the operating room for an emergency caesarean section because of cardiovascular instability. The surgery was carried out without any events and normal blood loss (575mL).

The woman delivered a 1900g male baby (Apgar scores 1 and 2 at 1 min and 5 min, respectively). The baby was intubated and transferred to the NICU. However, the baby died 9 hours after the birth. At day 4 of admission, in the immediate postoperative period (COVID day 18), her PaO₂/FiO₂ improved. She remained clinically stable over the next 2 days, despite worsening in lung X-ray. On day 7 of admission (COVID day 21), her condition again worsened, and her PaO₂/FiO₂ declined with increase in leucocytes, platelets, troponin, D-dimer and ferritin. She was suspected of having pulmonary microthrombi, and she was treated with full dose enoxaparin-sodium. On day 12 of admission (COVID day 26), her laboratory parameters and imaging results improved and she was extubated. On day 15 of admission (COVID day 29), her PaO₂/FiO₂ was stable, and she was discharged.