Error traps in anesthesia for fetal interventions

Ferschl, Marla B.; Rollins, Mark D.; Chatterjee, Debnath

doi:10.1111/pan.14120

Cited by 5 publications

(5 citation statements)

References 33 publications

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“…The use of maternal general anesthesia, particularly during open fetal surgery, allows for the transfer of anesthetics to the placental circulation, however, the need for higher doses of volatile anesthetic agents can have a substantial adverse impact on fetal hemodynamics and prolonged use raises concern of fetal neurotoxicity. Supplemental maternal intravenous anesthesia to reduce the dosage of volatile agents used during general anesthesia may lower this risk and allow adequate transplacental transfer ( 82 ). However, maternal anesthesia via local anesthetic infiltration or neuraxial blockade (ie.…”

Section: Fetal Responses To Noxious Stimulimentioning

confidence: 99%

The fetal pain paradox

Thill

2023

Front. Pain Res.

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Controversy exists as to when conscious pain perception in the fetus may begin. According to the hypothesis of cortical necessity, thalamocortical connections, which do not form until after 24–28 weeks gestation, are necessary for conscious pain perception. However, anesthesiologists and neonatologists treat age-matched neonates as both conscious and pain-capable due to observable and measurable behavioral, hormonal, and physiologic indicators of pain. In preterm infants, these multimodal indicators of pain are uncontroversial, and their presence, despite occurring prior to functional thalamocortical connections, has guided the use of analgesics in neonatology and fetal surgery for decades. However, some medical groups state that below 24 weeks gestation, there is no pain capacity. Thus, a paradox exists in the disparate acknowledgment of pain capability in overlapping patient populations. Brain networks vary by age. During the first and second trimesters, the cortical subplate, a unique structure that is present only during fetal and early neonatal development, forms the first cortical network. In the third trimester, the cortical plate assumes this function. According to the subplate modulation hypothesis, a network of connections to the subplate and subcortical structures is sufficient to facilitate conscious pain perception in the fetus and the preterm neonate prior to 24 weeks gestation. Therefore, similar to other fetal and neonatal systems that have a transitional phase (i.e., circulatory system), there is now strong evidence for transitional developmental phases of fetal and neonatal pain circuitry.

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Section: Fetal Responses To Noxious Stimulimentioning

confidence: 99%

The fetal pain paradox

Thill

2023

Front. Pain Res.

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“…Of these, levels III (subspecialty care) and IV (regional perinatal center) have boardcertified obstetricians, maternal-fetal medicine subspecialists, obstetric anesthesiologists, and adult subspecialists, with ICU facilities onsite that accept individuals who are pregnant or in the postpartum period; both levels III and IV allow access to the full range of expertise that may be necessary for any maternal or fetal intervention. [8][9][10][76][77][78] Onsite ICU care at a level IV center allows for primary or comanagement by a maternal-fetal medicine team with expertise in complex medical conditions and critically ill or unstable pregnant or postpartum patients.…”

Section: Maternal Levels Of Carementioning

confidence: 99%

Care Levels for Fetal Therapy Centers

Baschat¹,

Blackwell²,

Chatterjee³

et al. 2022

Obstetrics &Amp; Gynecology

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Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal, or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal, and neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight and monitoring of clinical performance and to facilitate multidisciplinary collaboration between the relevant specialties. Three care levels for fetal therapy centers are proposed to match the anticipated care complexity,

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“…The article in this issue by Ferschl et al 1 describing error traps in anesthesia for fetal interventions identifies a number of potential complications the anesthesiologist engaged in fetal intervention or surgery should be wary of. The traps range from complications involving the mother as well as those which involve the fetus.…”

mentioning

confidence: 99%

“…An essential aspect of those procedures that cannot be overstated is a multidisciplinary team to assess and ensure fetal well‐being. Some of these considerations are highlighted in the manuscript by Ferschl et al 1 For example, a fetal cardiologist or maternal‐fetal medicine specialist who is dedicated to monitoring fetal cardiac function intra‐procedure is imperative for in utero surgery. As emphasized in the manuscript, close communication between the anesthesiologist and each member of the team is also imperative to allow for successful surgery.…”

mentioning

confidence: 99%

“…While this information is not included in the typical curriculum of many pediatric or obstetric anesthesia fellowship training programs, anesthesiologists interested and committed to caring for these patients need to equip themselves with this knowledge to be adequately prepared for the unique challenges these cases may present. Some of these potential challenges are aptly referenced in the manuscript on Error traps In Fetal intervention by Ferschl et al 1 …”

mentioning

confidence: 99%

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