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(EXIT) Procedure: Anesthetic Implications

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(EXIT) Procedure: Anesthetic Implications International Journal of Obstetric Anesthesia (2004) 13, 178–182 Ó 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2004.01.007 CASE REPORT Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications G. Dahlgren, D. C. Tornberg,€ K. Pregner, L. Irestedt Department of Anesthesia and Intensive Care, Karolinska Hospital and Institute, SE 171 76 Stockholm, Sweden SUMMARY. The ex utero intrapartum treatment (EXIT) procedure is a method of maintaining utero-placental cir- culation during cesarean section to gain time to secure a potentially obstructed fetal airway. Four cases of the EXIT procedure are described with special reference to the maternal anesthetic technique. Deep volatile anesthesia (ap- proximately 2 MAC) with isoflurane or sevoflurane for a prolonged period of time, in three cases in combination with an intravenous nitroglycerin infusion, was used to ensure a fully relaxed uterus during the procedure. All mothers were maintained hemodynamically stable with preserved utero-placentary perfusion. It was possible to intubate the tracheas of two fetuses, whereas in the other two tracheostomies had to be performed. Fetal gas exchange was not negatively affected during the EXIT procedure as evidenced by normal blood gas values in the umbilical artery at the time of delivery. After reducing the concentration of volatile anesthetic, delivery of the neonate and administration of oxytocin, uterine contractility was promptly re-established and there were no signs of uterine atony in the post- operative period. All four neonates survived the procedure without complications. Ó 2004 Elsevier Ltd. All rights reserved. INTRODUCTION The EXIT procedure is performed in conjunction with an elective cesarean section. The fetus is only The ex utero intrapartum tracheoplasty procedure was partially delivered from the uterus with maintenance of originally developed for the fetus with severe congenital the utero-placental circulation allowing for diagnostic diaphragmatic hernia treated in utero with temporary and/or therapeutic procedures to the fetal airway. tracheal occlusion to enhance lung growth. With this Commonly, the fetus has been anesthetized and immo- technique utero-placental circulation could be main- bilized by the intramuscular route before the start of tained during removal of the tracheal clips immediately airway manipulations. When the airway is secured the followed by cesarean delivery.1 The technique has since fetus is delivered and the umbilical cord clamped. Main been used also for fetuses with giant neck masses and prerequisites during the EXIT procedure include com- other diseases with an increased risk for airway man- plete uterine relaxation and maintained uterine volume agement problems directly after delivery. It has for this and utero-placental circulation. Uterine relaxation has in reason been renamed ex utero intrapartum treatment most published cases been accomplished by deep vola- (EXIT) or operation on placental support (OOPS).2–4 tile anesthesia but other means of treatment are also After the first EXIT procedures were reported in the available.3;6 Uterine volume is preserved by the fact that mid-nineties many case reports and case reviews have the main part of the torso and the lower part of the fetus been published of which the review of 31 cases from the are retained in the uterus during the procedure. In many Children’s Hospital of Philadelphia is the largest.5 centers warmed Ringer’s lactate solution is also infused into the uterine cavity. In order to maintain the utero- placental blood flow, maternal cardiac output and blood ––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Accepted January 2004 pressure have to be kept at acceptable levels. Between 1998 and 2002 four EXIT procedures G. Dahlgren MD, PhD, Consultant Anesthetist; D.C. Tornberg€ MD, Consultant Anesthetist; K. Pregner, Nurse Anesthetist; have been performed at the Karolinska Hospital, L. Irestedt MD, PhD, Associate Professor, Chairman. Stockholm. Case number one has previously been published in detail.7 The aim of this case review is to Correspondence to: Dr. Gunnar Dahlgren, Department of Anesthesia and Intensive Care, Karolinska Hospital, SE 171 76 Stockholm, highlight the maternal anesthetic technique and also to Sweden; E-mail: [email protected] discuss possible implications for the use of volatile 178 Four cases of the ex utero intrapartum treatment (EXIT) procedure 179 anesthetics during general anesthesia for standard ce- direct laryngoscopy confirmed the diagnosis of lar- sarean section. yngeal atresia and a tracheostomy was performed. Manual ventilation was started and surfactant instilled into the tracheostomy tube after which the fetus was CASE PRESENTATIONS delivered and the cord clamped. ET isoflurane was re- duced to 0.9% and oxytocin 5 units was administered Relevant maternal and neonatal data are summarized in i.v. followed by slow infusion of 50 units. The recovery Tables 1 and 2. of uterine contractility was indeed very quick (within Case one was a healthy 28-year-old primigravida. In minutes) and there were no problems with uterine atony week 27 the fetus was found to have a laryngeal ste- postoperatively. Maternal hemodynamics remained sta- nosis/atresia. An EXIT procedure was performed at 35 ble throughout the procedure and blood loss was mod- weeks’ gestation. The patient was placed supine with erate. At four years of age the child is doing fine with a left lateral tilt to avoid aortocaval compression. General normal clinical and neurological status, although still anesthesia was then induced with thiopentone 400 mg, breathing via a tracheostomy. fentanyl 200 lg and succinylcholine 100 mg. After en- Case two was a healthy 29-year-old multiparous dotracheal intubation anesthesia was maintained with woman. In week 28 the fetus was found to have a large isoflurane and nitrous oxide in oxygen (50-50) com- oral cyst. An EXIT procedure was performed at 37 bined with additional doses of fentanyl and vecuronium weeks’ gestation. The patient was placed supine with for muscle relaxation. The nitrous oxide was discontin- left lateral tilt to avoid aortocaval compression. Gen- ued before uterine incision and the FiO2 was increased eral anesthesia was then induced with thiopentone 500 to 1.0. End-tidal (ET) isoflurane concentration was in- mg, fentanyl 100 lg and succinylcholine 100 mg. After creased to 2.2% during 10–15 min before uterine inci- intubation, anesthesia was maintained with sevoflurane sion. At the time of uterine incision the obstetrician in oxygen-air with FiO2 0.5. Vecuronium was admin- confirmed that the uterus was fully relaxed. During the istered for muscular relaxation together with additional EXIT procedure ET isoflurane concentration was kept small doses of fentanyl. The sevoflurane concentration between 1.8 and 2.2%. Bleeding was controlled by a was increased to 4.5% ET for 10 min to achieve full continuous suture around the uterotomy. The head, right uterine relaxation. Nitroglycerin 1 lg Á kgÀ1 minÀ1 was arm and part of the torso of the fetus were then deliv- infused i.v. beginning before uterine incision and run- ered. Based on the estimated fetal weight an intramus- ning until clamping of the cord. During the EXIT cular injection of fentanyl 10 lg/kg, vecuronium 0.2 procedure ET sevoflurane concentration was kept be- mg/kg and atropine 10 lg/kg was given to the fetus. A tween 2.8 and 4.5%. Bleeding was controlled by a sterile pulse oximetry probe was positioned on the right continuous suture around the uterotomy. The fetus was hand but a reliable reading could not be obtained. The anesthetized intramuscularly and monitored as in case fetal heart rate was monitored with ultrasonography. A 1. The fetus could be intubated nasally after aspiration Table 1. Maternal data Case 1 Case 2 Case 3 Case 4 Anesthetic agent Isoflurane Sevoflurane Sevoflurane Sevoflurane Additional tocolytic No Nitroglycerin Nitroglycerin Nitroglycerin Skin incision to uterotomy (min) 11 10 8 10 Blood loss (mL) 700 200 1700 2000 Post partum uterine atony No No No No Table 2. Neonatal data Case 1 Case 2 Case 3 Case 4 Diagnosis Laryngeal atresia Dermoid cyst Lymphangioma Lymphangioma Airway procedure Tracheostomy Intubation Tracheostomy Intubation Uterotomy to cord clamp time (min) 24 14 62a 29 Umbilical artery pH 7.30 7.30 7.16 7.22 Umbilical artery PO2 (kPa) 5.5 8.6 3.9 3.3 Umbilical artery PCO2 (kPa) 6.9 7.0 9.1 8.8 Umbilical artery base deficit (meq/L) 2.8 2.1 6.1 2.8 Umbilical artery lactate (mmol/L) Not analyzed 2.3 6.0 4.1 a See text Case three for comments. 180 International Journal of Obstetric Anesthesia of liquid contents from the sublingual cyst. After was a lymphangioma which was to be treated with in- clamping of the cord oxytocin 10 units was given i.v. jections of the sclerosing agent OK-432 (Picibanil). At followed by a slow infusion of 100 units. Prostinfenem one year of age the child was normally developed al- (15-metyl prostaglandin F2a) 0.25 mg was given into though still breathing through the tracheostomy. the uterine wall. Within a minute after clamping the Case four was a 24-year-old healthy nulliparous cord and reducing the ET sevoflurane concentration to woman with a history of three missed abortions. She was 1.4%, the uterus started to contract. Maternal hemo- pregnant in week 29 when the fetus was found to have a dynamics remained stable throughout the procedure tumor on the left side of the face and neck. At 31 weeks and bleeding was minimal. The sublingual cyst which the tumor measured 7 Â 8 cm. An EXIT procedure was turned out to be a dermoid cyst increased in size performed at 35 weeks’ gestation. The patient was postoperatively; it was marsupialised the day after de- placed supine with left lateral tilt to avoid aortocaval livery and resected surgically two months later.
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