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Two EXIT Procedures at an Academic Institution: A Case Report
Abstract Number: SU-18
Abstract Type: Case Report/Case Series
Introduction: The ex utero intrapartum therapy (EXIT) procedure is becoming more frequent. In a fetus with a known compressed airway, the goal is to allow a planned, controlled cesarean delivery in order to secure the airway while the fetus remains connected to the maternal circulation, in order to avoid neurological devastation or death of the fetus. The anesthesiologist must know how to manage the parturient’s anesthetic to facilitate the success of the procedure and good outcomes for both mother and neonate.
Case Description: Two EXIT procedures are performed for fetuses with large neck masses causing airway compression. Both masses are discovered upon routine prenatal ultrasound. They are scheduled for first case of the day with an entire team assembled and present prior to beginning. In the first case, the decision is made to defer obtaining large bore IV access and arterial line placement until after induction due to patient anxiety. The patient is induced under general anesthesia and intubated without issue. While intravenous and arterial catheterization are being obtained, the patient’s blood pressure lowers slightly but remains within 10% of baseline. However, the fetus becomes bradycardic to 40 and lower. The case becomes a STAT cesarean. The vessel catheterizations are quickly secured while the patient is splash prepped and the obstetricians don sterile attire. Simultaneously, the patient’s hypotension is treated with phenylephrine boluses and infusion. The infant is quickly delivered from the uterus, the airway is secured, and neonate is disconnected from maternal circulation and taken to the NICU. The total EXIT procedure portion lasts only 9 minutes. In the second case, all intravenous and arterial catheterizations are performed prior to induction. The patient is induced and intubated. The EXIT procedure proceeds, but the fetus’s airway is not able to be secured, so the surgeon performs surgical cricothyrotomy after difficult dissection of the tumor, and the airway is secured. The rest of the tumor is removed en block while the pediatric anesthesiologist manually ventilates the fetus using a self-inflating bag while remaining connected to the maternal circulation. The total EXIT procedure portion lasts 63 minutes. The neonate is taken to the NICU. Both mothers and neonates have good outcomes.
Discussion: It is important to remember that the primary patient is the pregnant woman and therefore the surgery is done at a general hospital rather than a pediatric hospital, though the general hospital should have a neonatal ICU. There must be two anesthesiologist present, one for the mother and the neonate. A walkthrough of the procedure should be performed in the OR with the entire team. The fetus's heart rate may change quickly due to any number of reasons and the team must be prepared for emergent delivery.
Conclusion: The anesthesiologist must be prepared for EXIT procedures that may have varying course and duration.