///2016 Abstract Details
2016 Abstract Details2019-07-15T10:10:51-05:00

Neuraxial anesthesia for the parturient undergoing an Ex-Utero Intrapartum Treatment (EXIT Procedure).

Abstract Number: SU-76
Abstract Type: Case Report/Case Series

Laura J Alexander MD1 ; Jie Zhou MD, MS, MBA2; Irem Kaplan MD3

Introduction:

An EXIT procedure is aimed at increasing survival rates for life threatening fetal congenital malformations during the peri-partum period. This is achieved by partially delivering a fetus through cesarean delivery and performing the necessary treatment with the maintenance of maternal-placental-uterine circulation. Classically, the anesthetic approach for this obstetric population has been general endotracheal tube anesthestia with inhalational agents, to allow for uterine relaxation. We present a case report of a parturient that underwent a successful EXIT procedure under combined spinal-epidural anesthesia with a natural airway. Considerations for this specific anesthetic setting are being discussed.

Case:

A 24-year-old G4P1021 at 38w1d presented for a cesarean for severe fetal congenital diaphragmatic hernia (CDH). Perinatal ultrasounds revealed fetus at 96th percentile, moderate polyhydramnios, liver displacement into the right sided chest, and displacement of both the heart and stomach. A multidisciplinary team from Boston Children’s and Brigham and Women’s Hospitals conducted several meetings prior to the date of surgery. A combined spinal-epidural technique was used for the procedure. Intravenous nitroglycerin infusion was administered for uterine relaxation. Upon unsuccessful intubation by the ENT team, cardiac surgical team quickly proceeded and established ECMO.

Discussion:

Providing anesthesia for an EXIT procedure involves optimizing placental perfusion, uterine relaxation, and minimizing untoward fetal drug effects. Classically, the use of a general endotracheal anesthesia with sevoflurane maintenance is described. However, equal consideration must be given to the cardiovascular depressant effects of these inhalational agents as it relates to hypotension and decreased placental perfusion. The implementation of a combined spinal-epidural neuraxial technique in our EXIT procedure provided a very stable hemodynamic profile throughout the case. Risks of a failed CSE include inadequate analgesia/anesthesia, intolerance to being awake and aware, and the possibility of a total spinal. To ease the anxiety of undergoing this procedure awake, the patient was offered headsets for music, was accompanied by the father of the baby, and had a social worker present in the room as well. However, with proper planning and in experienced hands, the CSE can prove to be a very valuable tool in providing a safe, effective anesthetic for the parturient undergoing EXIT procedure. A multidisciplinary approach across two institutions contributed to not only the complexity of the case, but also to the success.

References:

1. Schwartz DA, et al. J Clin Anesth. 2001;13:387–391

2. Lee IH, et al. Korean J Anesthesiol. 2008;55:446–451.

3. George RB, et al. Can J Anaesth. 2007;54:218–222

SOAP 2016