RevBrasAnestesiol.2015;65(6):525---528
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
CLINICAL
INFORMATION
Anesthesia
for
ex
utero
intrapartum
treatment:
renewed
insight
on
a
rare
procedure
Miguel
Vieira
Marques
a,∗,
João
Carneiro
a,
Marta
Adriano
b,
Filipa
Lanc
¸a
aaServic¸odeAnestesiologia,HospitalUniversitáriodeSantaMaria,CentroHospitalardeLisboaNorte,E.P.E.,Lisboa,Portugal
bServic¸odeAnestesiologia,HospitalCurryCabral,CentroHospitalardeLisboaCentral,Lisboa,Portugal
Received29October2013;accepted4December2013 Availableonline10January2014
KEYWORDS
Airway---obstruction; Anesthesia---fetal; Anesthesia ---obstetric; Cervical lymphangioma; EXIT
Abstract Theexuterointrapartumtreatmentisararesurgicalprocedureperformedincases ofexpectedpostpartumfetalairwayobstruction.Thetechniqueliesonasafeestablishmentof apatentairwayduringlaborinanticipationofacriticalrespiratoryevent,withoutinterrupting maternal---fetalcirculation.
Anesthetic managementis substantially different from that regarding standard cesarean delivery anditsmaingoalsincludeuterine relaxation, fetal anesthesiaandpreservation of placentalbloodflow.
Wepresentthecaseofanexuterointrapartumtreatmentprocedureperformedonafetus withalargecervicallymphangiomaandprenatalevidenceofairwaycompromise.Modifications totheclassicexuterointrapartumtreatmentmanagementstrategiesweresuccessfullyadopted andwillbediscussedinthefollowingreport.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
PALAVRAS-CHAVE
Viasaéreas ---obstruc¸ão; Anestesia---fetal; Anestesia ---obstétrica;
Linfangiomacervical; EXIT
Anestesiaparatratamentoex-úterointraparto:visãorenovadasobreum
procedimentoraro
Resumo Otratamentoex-úterointrapartoéumprocedimentocirúrgicofeitoemcasosraros deobstruc¸ãoesperadadasviasaéreasfetaisnopós-parto.Atécnicatemcomobaseo estab-elecimentosegurodeviasaéreaspermeáveisduranteotrabalhodepartoemantecipac¸ãoaum eventorespiratóriocrítico,seminterromperacirculac¸ãomaterno-fetal.
Omanejoanestésicoésubstancialmentediferentedaqueledestinadoàcesarianapadrãoe temcomoprincipaisobjetivosorelaxamentouterino,aanestesiafetaleapreservac¸ãodofluxo sanguíneoplacentário.
Apresentamoso caso deum procedimento para tratamentoex-útero intrapartofeito em fetocomumgrandelinfangiomacervicaleevidênciapré-nataldecomprometimentodasvias
∗Correspondingauthor.
E-mails:[email protected],[email protected](M.V.Marques).
526 M.V.Marquesetal.
aéreas.Asmodificac¸õesdasestratégiasadotadasnotratamentoex-úterointrapartoclássico foramfeitascomsucessoeserãodiscutidasnorelatoaseguir.
©2013SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
The ex utero intrapartum treatment (EXIT) is a rare sur-gicalprocedure performedtoensurefetalairwaypatency during labor in situations of expectedsevere, potentially life-threatening respiratory failure secondary to airway obstruction.
Also knownas operation on placental support1 (OOPS)
andairwaymanagementonplacentalsupport2(AMPS),EXIT
surgery was first described in the late 1980s by Norris
and colleagues3 and was initially performed in tracheal
occlusion reversion protocols for fetuses with congenital
diaphragmatichernia.4,5Theindisputableusefulnessofthis
technique later extended its applicability toa variety of
obstetricclinicalscenarios,6---8includingfetalheadandneck
tumorsurgicalapproaches.9
Theprocedureconsistsofapartialcesareansectionwith
simultaneousmaintenanceofplacentalcirculationasaway
topreserve fetal gas exchanges during the establishment
of a definitive airway through direct laryngoscopy,
bron-choscopy,ortracheostomy.
Theanestheticapproachissignificantlydifferentfroma
conventionalcesarean sectionandinvolvesadeepvolatile
anesthesiawithmaximumuterinerelaxation,preservation
ofuteroplacentalbloodflowandfetalanesthesia.
The success of an EXIT depends on a rigorous
strate-gicplanning withinvolvement of amultidisciplinary team
where the anesthesiologist often takes the leadership
role.
Inourreportwedescribetheanestheticmanagementofa
parturientscheduledforEXITsurgeryafterprenatal
diagno-sisofcervicallymphangiomawithmediastinalinvolvement,
highlightingbothfetalandmaternalsingularitiesinthelight
ofcurrentclinicalpractice.
Case
report
Ahealthy25-year-oldwoman,gravida1,para0,was
sched-uled for elective EXIT at 38 weeks of gestation due to
aprenatalultrasound diagnosis offetalcervical
lymphan-giomawithtrachealdeviationandriskofpostdeliveryairway
compromise.
Preparation for the procedure involved a
multidisci-plinaryteamof anesthesiologists,obstetricians,
neonatol-ogists,pediatricsurgeons,otolaryngologistsand
pulmonolo-gists. Several preliminary meetings were held and every
stakeholder’s role and positioning in the operatory room
wereclearlydefined.
Anesthesia material, room temperature, blood
group-ing,hemoderivativesavailabilityandbothneonatologyand
postanestheticcareunitvacancieswereallpreoperatively
confirmed.
Additional pharmacological preparation included
tocolyticsupportwithintravenousnitroglycerinsolutionat
aconcentrationof50mgmL−1anddrugsforsupplementary
intramuscularfetalanesthesia:fentanyl10gkg−1,
vecuro-nium0.2mgkg−1andatropine100
g,withatotalvolume
of2mL.
Standardmonitoringwasappliedwiththeparturientin
supine and leftlateral tilt positionunder manual uterine
displacement. Twointravenous 16Glineswere placedand
urinarycatheterizationwasperformed.
Balancedgeneralanesthesiawasinitiatedafter
preme-dicationwithfentanyl2gkg−1.Rapidsequenceinduction
was performed with propofol 2mgkg−1 and rocuronium
1.2mgkg−1, followed by endotracheal intubation and
mechanicalventilationinvolume-controlledmode.Aradial
arterycatheterwasplacedforinvasivebloodpressure
moni-toring.Anesthesiawasmaintainedwithlow-dosedesflurane
and nitrous oxide in oxygen mixture. Goal-directed fluid
therapywasmanagedwithcrystalloids.
Surgery began with a low segmental abdominal
inci-sionandhysterotomyfollowedbyfetalcephalicextraction
uptothe nippleline. Warm Hartmann’ssolution
amnioin-fusion was further initiated. The fetus’ airway was
exposed and evaluated by the neonatologist and
tra-cheal intubation successfully achieved after a single
attempt.
After full extraction the newborn was stabilized and
transportedinaneonatalincubatorundermechanical
ven-tilationtotheneonatologyunit.Totalplacentalbypasstime
was 4min and 46s. Amnioinfusion was discontinued and
uterinehypotonicityeffectivelyreversedwithoxytocinand
volatileconcentrationreduction.
The parturient remained hemodynamically stable
throughouttheprocedurewithMAP>70mmHg,equivalent
topreoperativerecords.Anesthesiaemergenceprogressed
uneventfully. Intravenous analgesia was performed with
paracetamol, ketorolac and tramadol and nausea and
vomitingprophylaxiswithdroperidol.
Discussion
Theidealconstitutionofamultidisciplinaryteam
interven-ingin an EXITsurgery isnotconsensual6,10,11 anddepends
onthe natureandpurposeof thesurgery:EXIT-to-airway,
EXIT-to-ECMOorEXIT-to-ressection.11
Inthiscase sixmedicalteams wereinvolved.
Anesthe-siology, obstetrics andneonatology weredirectly involved
intheprocedure. Additionalparticipationofpulmonology,
otolaryngology and pediatric surgery teams was justified
by their assistance in the event of a difficult
EXIT----renewedinsightonarareprocedure 527
establishasurgicalairwayorperformapartialtumor
resec-tion.
ThetwomainphysiologicalgoalsduringEXITareuterine
hipotonicitypreservation---whichfacilitatespartial
extrac-tionofthefetusandpreventsplacentaldissociation---and
placentalperfusionpressureconservationthatensuresfetal
oxygenation.1---15
Although associated with higher rates of morbidity
and mortality among global obstetric population,12
gen-eralanesthesiaisusuallyfavoredover regionaltechniques
in this procedure. Although not contraindicated, regional
anesthesia presents important disadvantages regarding
the cited precepts, particularly the risk of severe
hypotension and placental hypoperfusion.8 Aside from its
contribution to an adequate uterine relaxation, general
anesthesia allows simultaneous induction of both mother
and fetus through placental penetration of anesthetic
agents.
Maternal blood pressure must be keptwithin thelimit
of 10% of baseline.7,11 As a result, anesthesia induction
should be performed with the lowest possible
hemody-namicrepercussion,ideallyundercontinuousbloodpressure
monitoring.Inductionwithoutconsiderationforfetal
respi-ratorydepressionortimerestrictiontotheexpulsionhelps
to moderate the hypotensive effect of general
anesthet-ics.
Contrarytotheclassicrecommendationofdeep
inhala-tional anesthetic maintenance,6,13 the use of 0.5---1.0
halogenatedminimumanestheticconcentration(MAC),
sup-plementedifnecessarybyatocolytic,isbecomingaccepted
asaneffectivestrategyforuterinetonecontrol14with
min-imalcardiovascularimpactandlowerriskofpostoperative
uterineatony.6
Inthisparticularcase,pre-inductionopiate
administra-tion,rapidsequenceinduction withlowdosepropofoland
maintenancewith0.5MACdesfluraneprovidedanadequate
depthofanesthesia(BIS35---45)andastablehemodynamic
profile(MAP<10%).
The obtained uterine relaxation was in this case
con-sideredsufficientandintravenousnitroglycerin,previously
preparedasafirst-linetocolyticalternative,wasnot
admin-istered. Without uteroplacental circulation impairment,
fetalanesthesiawasenabledandadequatelydemonstrated
throughcompleteakinesiaatthetimeofairwayapproach,
alsoeliminatingtheneedfor supplementalexutero
anes-thesia.
After complete fetal extraction and umbilical cord
clamping, priorityfocused onpharmacologicalreversal of
uterinehipotonicitywithoxytocinandonfetusstabilization
forpediatricintensivecareunittransportation,whichwere
both held uneventfully. Cesarean section was completed
under close supervision of uterine contractility evolution
andhemostasis.
Developmentofahypocoagulablestatefollowinguterine
atony and massive postpartum bleeding has
occasion-ally been associated with the occurrence of epidural
hematoma.15 Considering the particular risks of
uter-ine atony and hemorrhage requiring blood transfusion
associated with EXIT surgery,7 we decided to replace
neuraxialregionalanalgesiafor aconventional
postopera-tiveintravenous analgesiaprotocol.Effective paincontrol
and patient satisfaction were observed. No reports of
hemorrhagicincidentswereissuedfollowingtheparturient’s
transferencetothepostanestheticcareunit.
Conclusion
The EXIT is an exceptional obstetric procedure bound for
life-savingfetalairwayinterventions.
PreparationforanEXITsurgeryinvolvesadetailed
multi-disciplinaryplanning,criticalfortheprocedure’ssafetyand
success.
Consideringcurrent literature,anesthesiamanagement
for this procedure is far from unequivocal. Even so and
despitetheadoptedstrategy,uteroplacentalcirculationand
uterusrelaxationaretobepreserveduntilthefetus’airway
issecured.
Anticipationofpostoperativecoagulationcomplications
mayprecludeuseofunrestrictedneuraxialanalgesic
tech-niques.
Authorship
Allauthorsparticipatedintheprocedurethatoriginatedthe
report.Datacollectionwasperformedbyall.Thereportwas
draftedbyM.M.andrevisedbyallauthors.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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