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A novel approach to general anesthesia for the EXIT (ex utero intra-partum therapy) procedure, a case series
Abstract Number: SAT-63
Abstract Type: Case Report/Case Series
Introduction: There are many ways to provide anesthesia for EXIT procedures; the largest case series used GA with 2-3 MAC volatile anesthetic.1 Others have combined neuraxial anesthesia with nitroglycerin (NTG) infusions for uterine relaxation,2 and added remifentanil for fetal anesthesia.3 One case combined two approaches, using 1 MAC GA with NTG.4 We report using 1 MAC GA with both NTG and remifentanil infusions.
Case 1: A 32 yo G3P1, at 35 wks, with history of IVDA, polyhydramnios, and fetal anomalies, including severe micrognathia. Due to an anticipated difficult EXIT, and patient desire, an RSI-GETA was performed, followed by insertion of an a-line. Anesthesia was maintained with 2.1% sevoflurane and remifentanil (0.3 mcg/kg/min) and ketamine infusions, with NTG (0.1 mcg/kg/min) and phenylephrine infusions before uterotomy.
After delivery of the fetus to shoulders, ENT noted an absent mandible and tongue, small mouth, low-set ears, and a blind end to the mouth and nares. Tracheostomy was performed. The radiologist confirmed normal FHR and correct tracheostomy tube position. EXIT time was 45 min with stable maternal vitals, minimal bleeding, and no fetal movement.
The remainder of the case was uneventful, with a change to TIVA after delivery. One dose of methylergonovine was needed. US-guided bilateral TAP catheters were placed before emergence. Post-op multimodal analgesia achieved good results. The patient was discharged on POD 3 and lost to follow-up. The neonate survived for 6 hrs; autopsy showed agnathia-otocephaly complex.
Case 2: A 107 kg 26 yo nulliparous patient at 37 wks presented with pre-eclampsia and a fetus with a 10 x 5 cm neck mass. The anxious patient strongly desired GA. In the OR, a thoracic epidural was placed at T10-11, and the patient underwent a RSI-GETA, with subsequent insertion of an a-line. Anesthesia was maintained with 1.7% sevoflurane and remifentanil (0.1 mcg/kg/min), with NTG (0.5 mcg/kg/min) and phenylephrine infusions before uterotomy.
The fetus was delivered to shoulders. A mass in the right piriform sinus obstructed the airway but spared the vocal cords. The fetus was intubated; a radiologist confirmed correct ETT location and a normal FHR. EXIT time was 5 min with stable maternal vitals, minimal bleeding, and no fetal movement. TIVA was used for the uneventful remainder of the case.
The epidural was bolused prior to emergence and used for a day. The patient was discharged on POD 3. The neonate was safely transported to a local pediatric hospital.
Conclusion: We performed two EXIT procedures with different fetal issues, using a novel technique of 1 MAC GA with remifentanil for maternal and fetal analgesia, and NTG for uterine relaxation. This combination provided excellent and safe surgical anesthesia for both mother and fetus, with quick return of uterine tone, unlike using high MAC alone.
1- Lin, A&A 2016
2- George, CJA 2007
3- Fink, BJA 2011
4- Braden, J Clin Anes 2016