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Fetal Surgery Meets ERAS: Implementation of a New Anesthetic Protocol for Fetoscopic Myelomeningocele Repairs
Abstract Number: T2C-2
Abstract Type: Case Report/Case Series
The majority of open fetal surgery is typically performed under general anesthetic with a high-dose inhalational agent in order to provide uterine relaxation. Concerns regarding fetal exposure to high-dose agents at critical periods in fetal neurodevelopment as well as desire for rapid maternal recovery have ignited interest in alternative anesthetic approaches to these procedures.
Our Center has been performing laparotomy with fetoscopic myelomeningocele repair since 2016, and starting in September 2017 we begin using a protocol that is inspired by our institution’s drive towards ERAS for abdominal surgery. This protocol revolves around the use of IV anesthetics over inhalational agents, opioid-sparing techniques such as regional anesthesia and limiting the use of supplemental IV fluids while encouraging early ambulation and oral hydration. Our protocol is divided into preoperative, intraoperative and postoperative goals.
Preoperatively, patients remain on a clear liquid diet until 2 hours prior to OR time. They are given carbohydrate-rich drinks prior to surgery, with maintenance fluids administered sparingly. An epidural catheter is placed for intraoperative and postoperative use. Indomethacin is administered for tocolysis.
Intraoperatively, our operating room temperature is set to 80ºC and the patient is placed on a forced air warming blanket. Anesthesia is typically induced with propofol and rocuronium, and anesthesia is maintained with either inhalational agent or a propofol infusion. Magnesium infusion is begun, and if inhalational agent is used a propofol infusion is started for postoperative nausea & vomiting prophylaxis. A nitroglycerin infusion is used for uterine relaxation. Transthoracic echocardiography is performed to evaluate volume status intraoperatively, and small boluses of IV crystalloid or colloid are administered along with a phenylephrine infusion to maintain adequate uteroplacental perfusion and maternal blood pressure. The epidural catheter is connected to an infusion of 0.125% bupivacaine & 2 mcg/mL fentanyl at 12 mL/hr. Goal fluid administration is typically 1-2 liters.
Postoperatively, neuromuscular blockade is reversed with sugammadex and the patient is extubated with the epidural catheter running and magnesium infusion continued. The epidural catheter is discontinued on postoperative day 1 or 2, and indomethacin is continued for up to 48 hours as needed. Furosemide 20mg was given immediately postoperatively at the discretion of the treatment team.
Since this protocol was initiated, none of our three patients have required additional supplemental diuresis in the postoperative period (as compared with ⅔ of our patients prior to this initiation) and the patients have verbalized satisfaction with their analgesia.
This protocol illustrates that common techniques used for general abdominal surgery can safely be adopted for fetal surgery, decreasing the morbidity of these groundbreaking procedures.