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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Anesthetic Management of Ex Utero Intrapartum Treatment (EXIT) in a Catastrophically Difficult Fetal Airway

Abstract Number: T2C-8
Abstract Type: Case Report/Case Series

Anne Wanaselja M.D.1 ; Anne Wanaselja M.D.2; Andrew Gerughty M.D.3; David A Gutman M.D.4; Michael Marotta M.D.5

Introduction: The goal of the ex utero intrapartum treatment (EXIT) procedure is to intervene on a fetal anomaly while maintaining adequate uteroplacental perfusion. Anesthetic goals include uterine atony for the duration of the fetal intervention followed by the rapid return of uterine tone to decrease maternal hemorrhage.1 The anesthesiologist must balance optimal surgical conditions with cardiovascular support to maintain adequate circulation to the mother and fetus.

Case report: The indication for the EXIT procedure was a fetal neck mass. A single shot spinal containing Morphine and Fentanyl was placed followed by induction. A total intravenous anesthesia (TIVA) technique of Propofol and Remifentanil was used for maintenance. An arterial line and a second large bore IV were placed. Mean arterial pressure was kept within 10% of baseline via phenylephrine infusion. Two minutes prior to hysterotomy, maintenance of anesthesia was switched to an inhalational technique with 2 minimum alveolar concentration of Sevoflurane, and a Nitroglycerin infusion of 50 mcg/min was initiated. The fetal head and shoulder were delivered and the Nitroglycerin infusion was increased to 100 mcg/min to further facilitate time for intubation. The airway was secured by an ENT surgeon and the fetal body was delivered. Sevoflurane and Nitroglycerin were discontinued and the previous TIVA technique was restarted. Total time from hysterotomy to cord clamping was 4 minutes. Oxytocin infusion and intramuscular Methylergonovine and Carboprost Tromethamine were administered and uterine tone was soon deemed to be adequate by the surgical team. The patient was successfully extubated and had an uneventful postoperative course.

Discussion: Uterine atony was achieved with the use of inhalational volatile anesthetic and nitroglycerin just prior to hysterotomy. The use of TIVA prior to this point and following cord clamping allowed for adequate hemodynamic stability and rapid return of uterine tone. This technique along with single shot intrathecal narcotics allowed for adequate surgical and anesthetic conditions including maternal and fetal hemodynamic stability, minimal blood loss from atony, and post-operative maternal analgesia.

Conclusion: TIVA technique transitioned to inhalational anesthesia and Nitroglycerin infusion prior to hysterotomy followed by reinstatement of TIVA following cord clamping provides optimal surgical and anesthetic conditions for the EXIT procedure.

SOAP 2018