Anesthetic management of an ex utero intrapartum treatment procedure: a novel balanced approach

Braden, Adam; Maani, Christopher V.; Nagy, Christopher J.

doi:10.1016/j.jclinane.2015.12.010

Cited by 93 publications

(20 citation statements)

References 12 publications

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“…However, there remains potential for fetal complications related to the inability to secure the airway at the time of the EXIT procedure due to placental separation/abruption or fetal bradycardia from cord compression [6]. Furthermore, the potential advantage to the fetus must be weighed against increased maternal risks, including longer operating times, maternal hypotension requiring vasopressor support, pulmonary edema secondary to fluid overload, and postpartum hemorrhage from uterine atony induced by high concentrations of inhalational agents, and wound infections [3,6,8,9].…”

Section: Discussionmentioning

confidence: 99%

In utero Fetal Intubation for a Large Neck Mass: A Minimally Invasive EXIT Option

et al. 2018

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Fetuses with obstructive neck and orofacial lesions have been delivered via an ex utero intrapartum treatment (EXIT) procedure to facilitate securement of the airway while on placental circulation. Pregnancy-related cardiovascular changes and technical issues unique to an EXIT procedure increase fetal and maternal risks relative to a standard cesarean section. In order to circumvent such issues, fetal endoscopic intubation has been proposed. We report a case of a fetus with a large neck mass (mixed solid and multiloculated cystic lesion measuring 9.2 × 5.3 × 8.5 cm, neck hyperextension, protruding tongue, and serial gagging movements) that was successfully intubated in utero and delivered at 36 weeks and 0 days via standard cesarean section, thereby avoiding an EXIT procedure. The risks, benefits, and technical issues of in utero tracheal intubation are reviewed.

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Section: Discussionmentioning

confidence: 99%

In utero Fetal Intubation for a Large Neck Mass: A Minimally Invasive EXIT Option

et al. 2018

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“…Epidural was used in some cases as a form of post-operative pain relief 12,15 . General anaesthetic allows for the use of inhalation agents which cause tocolysis, described by Braden et al 2 as complete uterine relaxation. Tocolysis prevents placental separation, therefore is essential for the success of the EXIT procedure and, in turn, survival of the fetus 12 .…”

Section: The Proceduresmentioning

confidence: 99%

“…In addition to inhalational agents such as desflurane 2, 12 sevoflurane 1 and isoflurane 15 , nitroglycerine was reported by multiple authors as being used to maintain tocolysis 2,8,11,12 . Tocolytic agents may cause maternal hypotension, which in turn may interfere with the maintenance of placental circulation and fetal oxygenation 8 .…”

Section: The Proceduresmentioning

confidence: 99%

“…Ex utero intrapartum treatment (EXIT) procedure is performed when there is airway compromise in the fetus 1 . Braden et al 2 describe it as a modified caesarean birth, where the fetus is partially delivered in order to secure the airway or commence extra corporeal membrane oxygenation (ECMO) while oxygenation to the fetus is maintained via uteroplacental circulation. Resection of the mass and separation of conjoined twins may also occur during EXIT procedure; however, these are rare 3 .…”

Section: Introductionmentioning

confidence: 99%

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Ex utero intrapartum treatment (EXIT) procedure: Indications and procedural considerations

Silva¹

2019

Journal of Perioperative Nursing

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Problem identificationEx Utero Intrapartum Treatment (EXIT) has become the optimal delivery strategy in fetuses with airway compromise; however, it remains an extremely rare procedure. This review aims to provide perioperative nurses with an overview of EXIT procedure to enable them to be an effective member of the multidisciplinary team. Literature searchAn electronic search of the CINAHL, Medline and Scopus databases was undertaken yielding 19 articles for inclusion in this integrative review. The papers included were case studies, case series or retrospectives and describe 42 EXIT procedures with 43 babies. Data evaluation synthesisThe most common indication for the EXIT procedure is neck tumours, with other indications being congenital high airway obstruction syndrome (CHAOS), cardiac anomalies, extremely low birth weight (ELBW), micrognathia and congenital diaphragmatic hernia. Literature revealed 41 cases had successful establishment of an airway, with the procedure failing in two cases, both with diagnoses of CHAOS. Implications for perioperative nursing practice or researchThe role of the perioperative nurse within these cases needs to be explored further. Perioperative nurses need to have the skills and ability to participate as key members of the multidisciplinary team. This can be achieved through in-depth understanding of the topics within this review.

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“…[1–3] With maintenance of fetal oxygenation via uteroplacental circulation, sufficient time is provided to achieve airway access in a fetus through direct laryngoscopy, fiberoptic bronchoscopy, or tracheostomy. [4–7] However, it is very challenging to establish airway access during the EXIT procedure, even for anesthesiologists who are very skilled at airway management, because such a fetus has severe airway difficulty that necessitates the EXIT procedure and there is insufficient room for airway management within the surgical field.…”

Section: Introductionmentioning

confidence: 99%

Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft

Byun

Lee²,

Hong³

et al. 2016

Medicine

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Introduction:In fetuses who are predicted to be at risk of catastrophic airway obstruction at delivery, the ex utero intrapartum treatment (EXIT) procedure is useful for securing the fetal airway while maintaining fetal oxygenation via placental circulation. Factors, including poor posture of the fetus and physician, narrow visual field, and issues of contamination in the aseptic surgical field, make fetal intubation during the EXIT procedure difficult. Herein, we report our experience of the usefulness of the GlideScope video laryngoscope (GVL) for intubation during the EXIT procedure.Symptoms and clinical findings:A 28-year-old woman presented with a fetus having a cystic neck mass diagnosed on prenatal ultrasound at 25 weeks of gestation. We planned the EXIT procedure in conjunction with cesarean delivery at 38 weeks of gestation, as the mass enlarged to 4.9 cm × 3.2 cm, protruded externally at the neck, and subsequently resulted in polyhydramnios.Therapeutic intervention and outcomes:After induction of anesthesia using intravenous thiopental (300 mg), adequate uterine relaxation was achieved with sevoflurane (2.0–3.0 vol%) combined with continuous intravenous infusion of nitroglycerin (0.5–1.0 μg/kg/min) for maintaining uteroplacental circulation. After hysterotomy, the head and right upper limb of the fetus were partially delivered, and fetal heart tones were monitored with a sterile Doppler probe. After oropharyngeal suctioning to improve the visual field, the fetus was intubated successfully using a sterile GVL by an anesthesiologist, and the passage of the endotracheal tube beyond the vocal cords was confirmed on the screen of the GVL system. Immediately after the fetal airway was definitely secured, the fetus was fully delivered with umbilical cord clamping. After delivery, nitroglycerine administration was ceased and sevoflurane administration was reduced to 0.5 minimum alveolar concentration. Additionally, oxytocin (10 units) and carbetocin (100 μg) were administered for recovery of uterine contraction. Cesarean delivery was successfully performed without any problems, and the neonate successfully underwent surgery for removal of the neck mass under general anesthesia on the 7th day after delivery. The neonate is developing normally.Conclusion:The GVL approach may be a useful noninvasive approach for establishing a clear fetal airway during the EXIT procedure.

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Anesthetic management of an ex utero intrapartum treatment procedure: a novel balanced approach

Cited by 93 publications

References 12 publications

In utero Fetal Intubation for a Large Neck Mass: A Minimally Invasive EXIT Option

In utero Fetal Intubation for a Large Neck Mass: A Minimally Invasive EXIT Option

Ex utero intrapartum treatment (EXIT) procedure: Indications and procedural considerations

Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft

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