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Procedure Requiring Second Team in Operating Room (PRESTO): Experience with a Novel Approach
Abstract Number: F4C-5
Abstract Type: Case Report/Case Series
Introduction. Advances in prenatal diagnostics have made fetal anomaly identification common. Airway obstructions, including Pierre Robin Sequence, cystic hygromas and other upper airway masses, often require peripartum interventions, to avert transitional morbidity. Fetal airway anomalies may be managed by Ex Utero Intrapartum Therapy (EXIT) procedure1. However, in cases where placental perfusion maintenance by EXIT is not mandatory, Procedure Requiring Second Team in Operating Room (PRESTO) expedites definitive airway management. In PRESTO, cesarean delivery is followed by neonatal hand-off to waiting pediatric specialists. Expedited airway management enhances coordination of sub-specialty services at peak hours, minimizes risk of delivery when services are not available, enables swift implementation of ECMO, and establishes a secure airway. Furthermore, maternal risk is reduced compared to EXIT. We describe a single institutional experience with two PRESTO procedures.
Case 1. 42-year-old G3P2 had a fetus with retro/micrognathia, cleft palate, and concern for Pierre Robin Sequence. Multidisciplinary review and lack of obstructive sequalae on imaging suggested EXIT was not indicated. Cesarean delivery at 37 weeks occurred under spinal anesthesia. On delivery, the neonate was transferred to awaiting surgical and NICU teams. Initial noninvasive resuscitation was insufficient and severe ankyloses noted; tracheostomy was performed in an adjacent OR. The neonate was taken to NICU in stable condition.
Case 2. 23-year-old G2P1 whose fetus was found to have an oral mass, likely an epignathus. Multidisciplinary collaboration determined that EXIT was not mandatory, yet given the mass size, the infant airway team was present. Cesarean delivery at 38 weeks occurred under spinal anesthesia. Neonate was handed off to awaiting surgical and NICU teams. Two sessile masses were resected. An LMA was placed, but difficulty with maintaining adequate ventilation led to intubation. The neonate was taken to NICU in stable condition.
Discussion. Composition of the PRESTO team is as important as patient selection. Nursing, maternal-fetal medicine obstetricians, neonatologists, pediatric otolaryngologists, pediatric surgeons and anesthesiologists must be involved in preoperative planning and execution. Special consideration should be given to the need for pediatric as well as obstetrical anesthesiologists2. In some Level 3 or 4 centers3, there may be no in-house subspecialty services, and additional coordination is necessary. Anesthesiologists are helpful to provide safe and adequate sedation, close hemodynamic monitoring, and airway support if necessary. Each hospital will need to tailor team composition based on individual patient needs and hospital resources.
1. Taghavi K. Journal of Paediatrics and Child Health 2013;49.
2. Moldenhauer JS. Seminars in Pediatric Surgery 2013; 22: 44–9.
3. ACOG Levels of Care. Obstet Gynecol 2015;125:502–15.