///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Remifentanil for fetal immobilization during tracheotomy by ex-utero intrapartum treatment (EXIT) procedure

Abstract Number: 174
Abstract Type: Case Report/Case Series

Hiroyuki Sumikura M.D.1

A 30 year old female with a diagnosis of polyhydramnios was referred to our hospital at 25 weeks gestation. Subsequent MRI images obtained revealed a giant tumor, approximately 7 cm in diameter protruding out of the oral cavity (Fig. 1). At 30 weeks' gestation, the mother developed preterm labor so the EXIT procedure was offered. In order to provide adequate fetal immobilization during the procedure, maternal intravenous remifentanil and inhalational sevoflurane were planned in addition to fetal intramuscular administration of fentanyl and vecuronium.

Induction of anesthesia was performed using propofol and succinylcholine. Sevoflurane, administered at 3% in Oxygen 3l/min and Nitrous oxide 3l/min provided uterine relaxation. A remifentanil infusion was also started after intubation in order to immobilize the fetus. Remifentanil was started initially at a rate of 0.1mcg/kg/min and subsequently increased to 0.25mcg/kg/min just prior to hysterotomy.

Upon partial delivery of the fetus, head extension and cephalad manipulation of the tumor provided clear access to the ventral aspect of the neck for the tracheostomy. Once the babys neck was positioned, the tracheotomy was successfully performed on a well anesthetized baby. The umbilical cord was subsequently clamped to deliver the baby. Immediately after delivery, oxytocine and methylergometrine were administered intravenously for uterine contraction. Sevoflurane was discontinued once the airway was secured in order to allow restoration of uterine tone and minimize post-partum bleeding. The remifentanil infusion was also stopped at this time.


In order to provide fetal immobilization, opioid and muscle relaxant medications have traditionally been administered to the fetus either through the intramuscular route or via the umbilical vein. However, difficulties of treatment for umbilical cord administration and delayed effect of intramuscular administration has been claimed. Sevoflurane has a high placental transfer and has been thought to contribute to fetal immobilization to some extent, however, its relaxing effect on the uterus should be minimized to avoid post-partum bleeding.

In the present case, sufficient fetal immobilization was achieved using remifentanil. However, the degree of contribution of remifentanil to immobilization of the fetus in this case is not clear as both maternal sevoflurane and fetal vecuronium and fentanyl could have contributed simultaneously.

SOAP 2009