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Anesthesia for Ex Utero Intrapartum Treatment (EXIT) procedure: A Case Series
Abstract Number: T2C-6
Abstract Type: Case Report/Case Series
Anesthesia for Ex Utero Intrapartum Treatment (EXIT) procedure: a case series
Introduction: The EXIT procedure is indicated for cases in which difficulty in establishing a neonatal airway is anticipated. The anesthestic plan involves three important stages: maintaining normal uterine tone up to hysterotomy, facilitating complete uterine atony at time of hysterotomy and neonatal intervention, and rapid return of uterine tone after fetal airway establishment and delivery.
Cases: Case 1 involved severe fetal micrognathia. Case 2 involved an extensive fetal neck mass. After an extensive literature search, both cases were performed using a similar anesthetic technique. Two large-bore peripheral IVs and arterial line were placed. Single-shot spinal anesthesia was performed with Fentanyl and Morphine. Maternal airway was secured via rapid-sequence intubation (RSI). Total intravenous anesthesia (TIVA) was initiated with Propofol and Remifentanil infusions. Vasoactive infusions were used to maintain mean arterial pressures (MAPs) greater than 65. Prior to hysterotomy, maintenance anesthesia was converted to Sevoflurane titrated to a mean alveolar concentration (MAC) of greater than 2, and a Nitroglycerin infusion was started simultaneously. Fetal head and shoulders were delivered and pediatric ENT secured the airway. Once the fetus was completely delivered, Sevoflurane and Nitroglycerin were stopped and TIVA was restarted. Oxytocin infusion and intra-muscular (IM) Methylergonivine were used in both cases for rapid return of uterine tone with additional IM Carboprost Tromethamine for Case 2 due to prolonged atony. The mothers were extubated at the end of procedure and had an uncomplicated post-operative course.
Discussion: Single-shot spinal anesthesia assisted with intra-operative and post-operative maternal analgesia. TIVA with Propofol and Remifentanil were used to maintain anesthesia with minimal effects on uterine tone. The Nitroglycerin infusion and Sevoflurane helped achieve complete uterine atony. Uterotonics were used to minimize maternal hemorrhage. This mixed anesthetic technique was used to provide ideal surgical conditions at different stages of the EXIT procedure.
Conclusion: Knowledge of the physiologic effects of different anesthetics on the parturient uterus is imperative for a successful and safe EXIT procedure.