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Ideal Balanced Anesthetic Technique for Ex Utero Intrapartum Treatment (EXIT) Procedure Performed Due to Severe Fetal Anomalies
Abstract Number: SUN-39
Abstract Type: Case Report/Case Series
Introduction: The ex utero intrapartum treatment (EXIT) procedure has several stages with sequentially opposing physiologic goals. Prior to fetal delivery the goal is prolonged stable uterine tone; followed by intentional profound uterine atony just prior to and during the hysterotomy and EXIT portion; followed immediately by rapid return to stable uterine tone once the fetus is fully delivered1. An anesthesiologist must meet these surgical goals whilst maintaining maternal hemodynamic stability and adequate anesthesia and analgesia.
Case Report: The indication for performing the EXIT procedure was fetal bilateral cleft lip and cleft palate with severe micrognathia. In the operating theater, two large bore peripheral IVs and an arterial line were placed. The patient received a single-shot spinal containing intrathecal fentanyl and morphine, followed by induction of general anesthesia. Maintenance was via a Propofol and Remifentanil total-intravenous-anesthesia (TIVA) technique. Just prior to hysterotomy the anesthetic was converted from TIVA to an inhalation technique with Sevoflurane titrated to 2 minimum alveolar concentration (MAC) and Nitroglycerin infusion. A Phenylephrine infusion was titrated throughout the case for maintenance of appropriate mean arterial pressures (MAPs) >65. The fetal head and shoulder was delivered and the airway was secured by an ENT surgeon. Upon complete delivery of the now intubated baby, the Nitroglycerin and Sevoflurane were discontinued and the prior TIVA technique was reinstated for the duration of the surgical closure. Total time from hysterotomy to cord clamping and delivery was 6 minutes. Oxytocin infusion and prophylactic intramuscular Methylergonovine were administered with ensuing rapid return of appropriate uterine tone. During the case, maternal MAP deviated less than 10% from baseline and there were no noted fetal hemodynamic or heart rate abnormalities pre or post delivery. The mother was extubated shortly after closure and had an uneventful postoperative stay.
Discussion: The mixed TIVA and inhalation agent with Nitroglycerin techniques were chosen to optimize patient hemodynamics while facilitating EXIT procedure uterine goals. Uterine atony was rapidly achieved with the inhalational agent technique and just as quickly reversed after airway securement and delivery. This mixed anesthetic method appears to have met the goals of ideal conditions for uterine tone, maternal hemodynamic stability, maternal intra and post op analgesia, fetal hemodynamic stability, and minimal contribution to blood loss from atony.
Conclusion: Anesthetic delivery for EXIT procedure by intrathecal narcotic and TIVA followed by inhalational agent plus Nitroglycerin then return to TIVA provides ideal surgical and anesthetic conditions for the EXIT procedure.
References: 1) Ngamprasertwong et al. Update in fetal anesthesia for the ex utero intrapartum treatment (EXIT) procedure. Int Anesthesiol Clin. 2012 Fall; 50(4): 26-40