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EXIT procedure for debridement, sternotomy, and intubation in the setting of massive fetal intrathoracic and extrathoracic tumor
Abstract Number: T2C-5
Abstract Type: Case Report/Case Series
Introduction: Ex utero intrapartum treatment (EXIT) procedure allows surgical intervention on a fetus which is supported by placental circulation (Liechty 2010). We present the case of a fetus undergoing EXIT procedure for debridement, sternotomy, and intubation due to massive cervical tumor.
Case: An 18-year-old, G1P0, otherwise healthy woman presented with a fetus with a massive tumor with intrathoracic and extrathoracic extension compressing the distal trachea, heart, and lungs. EXIT was planned for 37 weeks EGA, but at 36 weeks 3 days EGA the fetus was noted with new-onset hydrops and the procedure was urgently performed. Obstetric and pediatric anesthesiology, maternal fetal medicine, pediatric general surgery, pediatric otolaryngology, neonatal ICU, and pediatric cardiology teams were assembled. Rapid sequence induction and endotracheal intubation were performed with video laryngoscopy. Large bore peripheral intravenous access (including rapid infusion catheter) and radial arterial line were established. Anesthesia was maintained with remifentanil infusion and high dose sevoflurane (2.5%-4.0%). Nitroglycerine infusion promoted uterine relaxation. Phenylephrine infusion maintained maternal MAP. A vertical incision and large hysterotomy were made. The fetal head, chest, and arm were delivered. Intramuscular atropine, fentanyl, and vecuronium were administered, pulse oximeter was applied, and IV access was established. Intermittent transthoracic echocardiography allowed for fetal cardiac monitoring. The mass was larger and more vascular than imaging suggested and was actively hemorrhaging. This led to fetal asystole requiring epinephrine, transfusion, CPR, and simultaneous tumor debridement and control of hemorrhage. ROSC was achieved. Debridement continued until the sternum was identified. Still on placental bypass, median sternotomy was performed, relieving airway and cardiac compression. Soon, the fetus again became asystolic; the placenta was found to be detached from the uterus. Intubation was performed via bronchoscopy. Fetal hemorrhage continued, so the fetus was delivered and taken to another operating room for continued debridement and control of hemorrhage. Owing to edema from massive transfusion, the baby was taken with open chest (though off vasopressors) to the NICU. The mother’s incision was closed uneventfully and she was extubated. Her requirement for vasopressors ceased when the sevoflurane and nitroglycerine were discontinued.
Discussion: EXIT to sternotomy for purely intrathoracic mass has been reported (Perry 2004), but we are unaware of a case of this complexity. This case illustrates a novel application of the EXIT procedure and highlights the unique anesthetic considers, including the necessity of an interdisciplinary approach and techniques to promote coordination between myriad specialist teams.
1. Liechty KW. Semin Fetal Neonatal Med. 2010:34-9.
2. Perry JA, et al. J Ped Surg. 2004:1408-1410.