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Jiang Q, Wang C, Gao Q, Wu Z, Zhao P. Multiple sevoflurane exposures during mid-trimester induce neurotoxicity in the developing brain initiated by 15LO2-Mediated ferroptosis. CNS Neurosci Ther 2023; 29:2972-2985. [PMID: 37287422 PMCID: PMC10493671 DOI: 10.1111/cns.14236] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 06/09/2023] Open
Abstract
AIMS Mid-gestational sevoflurane exposure may induce notable long-term neurocognitive impairment in offspring. This study was designed to investigate the role and potential mechanism of ferroptosis in developmental neurotoxicity induced by sevoflurane in the second trimester. METHODS Pregnant rats on day 13 of gestation (G13) were treated with or without 3.0% sevoflurane, Ferrostatin-1 (Fer-1), PD146176, or Ku55933 on three consecutive days. Mitochondrial morphology, ferroptosis-relative proteins, malondialdehyde (MDA) levels, total iron content, and glutathione peroxidase 4 (GPX4) activities were measured. Hippocampal neuronal development in offspring was also examined. Subsequently, 15-lipoxygenase 2 (15LO2)-phosphatidylethanolamine binding protein 1 (PEBP1) interaction and expression of Ataxia telangiectasia mutated (ATM) and its downstream proteins were also detected. Furthermore, Morris water maze (MWM) and Nissl's staining were applied to estimate the long-term neurotoxic effects of sevoflurane. RESULTS Ferroptosis mitochondria were observed after maternal sevoflurane exposures. Sevoflurane elevated MDA and iron levels while inhibiting GPX4 activity, and resultant long-term learning and memory dysfunction, which were alleviated by Fer-1, PD146176, and Ku55933. Sevoflurane could enhance 15LO2-PEBP1 interaction and activate ATM and its downstream P53/SAT1 pathway, which might be attributed to excessive p-ATM nuclear translocation. CONCLUSION This study proposes that 15LO2-mediated ferroptosis might contribute to neurotoxicity induced by maternal sevoflurane anesthesia during the mid-trimester in the offspring and its mechanism may be ascribed to hyperactivation of ATM and enhancement of 15LO2-PEBP1 interaction, indicating a potential therapeutic target for ameliorating sevoflurane-induced neurotoxicity.
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Affiliation(s)
- Qian Jiang
- Department of AnesthesiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Cong Wang
- Department of AnesthesiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Qiushi Gao
- Department of AnesthesiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Ziyi Wu
- Department of AnesthesiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Ping Zhao
- Department of AnesthesiologyShengjing Hospital of China Medical UniversityShenyangChina
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A Review of EXIT: Interventions for Neonatal Airway Rescue. CURRENT OTORHINOLARYNGOLOGY REPORTS 2023. [DOI: 10.1007/s40136-023-00442-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Duci M, Pulvirenti R, Fascetti Leon F, Capolupo I, Veronese P, Gamba P, Tognon C. Anesthesia for fetal operative procedures: A systematic review. FRONTIERS IN PAIN RESEARCH 2022; 3:935427. [PMID: 36246050 PMCID: PMC9554945 DOI: 10.3389/fpain.2022.935427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe anesthetic management of fetal operative procedures (FOP) is a highly debated topic. Literature on fetal pain perception and response to external stimuli is rapidly expanding. Nonetheless, there is no consensus on the fetal consciousness nor on the instruments to measure pain levels. As a result, no guidelines or clinical recommendations on anesthesia modality during FOP are available. This systematic literature review aimed to collect the available knowledge on the most common fetal interventions, and summarize the reported outcomes for each anesthetic approach. Additional aim was to provide an overall evaluation of the most commonly used anesthetic agents.MethodsTwo systematic literature searches were performed in Embase, Medline, Web of Science Core Collection and Cochrane Central Register of Controlled Trials up to December 2021. To best cover the available evidence, one literature search was mostly focused on fetal surgical procedures; while anesthesia during FOP was the main target for the second search. The following fetal procedures were included: fetal transfusion, laser ablation of placental anastomosis, twin-reversed arterial perfusion treatment, fetoscopic endoluminal tracheal occlusion, thoraco-amniotic shunt, vesico-amniotic shunt, myelomeningocele repair, resection of sacrococcygeal teratoma, ligation of amniotic bands, balloon valvuloplasty/septoplasty, ex-utero intrapartum treatment, and ovarian cyst resection/aspiration. Yielded articles were screened against the same inclusion criteria. Studies reporting anesthesia details and procedures’ outcomes were considered. Descriptive statistical analysis was performed and findings were reported in a narrative manner.ResultsThe literature searches yielded 1,679 articles, with 429 being selected for full-text evaluation. A total of 168 articles were included. Overall, no significant differences were found among procedures performed under maternal anesthesia or maternal-fetal anesthesia. Procedures requiring invasive fetal manipulation resulted to be more effective when performed under maternal anesthesia only. Based on the available data, a wide range of anesthetic agents are currently deployed and no consistency has been found neither between centers nor procedures.ConclusionsThis systematic review shows great variance in the anesthetic management during FOP. Further studies, systematically reporting intraoperative fetal monitoring and fetal hormonal responses to external stimuli, are necessary to identify the best anesthetic approach. Additional investigations on pain pathways and fetal pain perception are advisable.
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Affiliation(s)
- Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
- Correspondence: Francesco Fascetti Leon
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Veronese
- Maternal-fetal Medicine Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Costanza Tognon
- Anesthesiology Pediatric Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
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Novoa RH, Quintana W, Castillo-Urquiaga W, Ventura W. EXIT (ex utero intrapartum treatment) surgery for the management of fetal airway obstruction: A systematic review of the literature. J Pediatr Surg 2020; 55:1188-1195. [PMID: 32151401 DOI: 10.1016/j.jpedsurg.2020.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 11/24/2019] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To provide a comprehensive overview of the perinatal and maternal outcomes of fetuses undergoing EXIT surgery for the management of fetal airway obstruction secondary to cervical or oral tumors. METHODS A comprehensive search from inception to September 2018 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported an EXIT surgery in singleton were considered eligible. A descriptive analysis was performed. RESULTS Out of the 250 full-text study reports, 120 articles reporting 235 cases of EXIT surgery were included. EXIT surgery was performed at 35.1 weeks of gestation on average. The most frequent diagnosis was teratoma (46.4%, n = 109/235). There were 13 adverse maternal events, and the most frequent one was postpartum hemorrhage (4.7%, n = 11/235). No maternal death was reported. Fetal and neonatal death occurred in 17% (40/235) of the cases. There were 29 adverse fetal events (12.2%), and the most frequent one was the failure of intubation or tracheostomy (3.4%, n = 8/235). CONCLUSION EXIT surgery could be considered for the management of an oral or cervical tumor that's highly suspicious of blocking the fetal airway. This systematic review reports that EXIT surgery poses substantial risks of maternal and fetal adverse events, including neonatal death. LEVEL OF EVIDENCE IV case series with no comparison group.
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Affiliation(s)
- Rommy H Novoa
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Willy Quintana
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Walter Ventura
- Fetal Medicine Unit, Instituto Nacional Materno Perinatal, Lima, Peru; Fetal Medicine Unit, Clinica Delgado, Grupo AUNA, Lima, Peru.
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Takla M, Gratz I, Gourkanti B. Anesthesia for Ex-Utero Intra-Partum Procedures. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Taghavi K, Beasley S. The ex utero intrapartum treatment (EXIT) procedure: application of a new therapeutic paradigm. J Paediatr Child Health 2013; 49:E420-7. [PMID: 23662685 DOI: 10.1111/jpc.12223] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 12/15/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a term given to a technique that can transform a potentially fatal neonatal emergency to a controlled intervention with an improved outcome. It has revolutionised the care of prenatally diagnosed congenital malformations in which severe upper airway obstruction is anticipated. An extended period of utero-placental circulation can be utilised to avoid profound cardiopulmonary compromise. Its therapeutic applications have been broadened to include fetuses with congenital diaphragmatic hernia after tracheal plugging, high-risk intrathoracic masses, severe cardiac malformations and conjoined twins. It requires the co-ordination of a highly skilled and experienced multidisciplinary team. The recent enthusiasm for the EXIT procedure needs to be balanced against maternal morbidity. Specific indications and guidelines are likely to be refined as a consequence of ongoing advances in fetal intervention and antenatal imaging.
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Ex utero intrapartum treatment procedure for management of congenital high airway obstruction syndrome in a vertex/breech twin gestation. Int J Pediatr Otorhinolaryngol 2013; 77:439-42. [PMID: 23260572 DOI: 10.1016/j.ijporl.2012.11.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 11/10/2012] [Accepted: 11/17/2012] [Indexed: 11/20/2022]
Abstract
Congenital high airway obstruction syndrome (CHAOS) is one indication for the ex utero intrapartum treatment (EXIT), which is used to secure the fetal airway, while fetal oxygenation is maintained by uteroplacental circulation. We report a successful EXIT procedure in a twin gestation in which one child had CHAOS while the other was a healthy child without any congenital abnormalities. After version of Twin B to allow for delivery of Twin A, Twin B underwent airway evaluation and tracheostomy for laryngeal atresia prior to delivery.
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Abstract
Airway management plays a pivotal role in Paediatric Anaesthesia. Over the last two decades many improvements in this area have helped us to overcome this final frontier. From an era where intubation with a conventional laryngoscope or blind nasal intubation was the only tool for airway management, we have come a long way. Today supraglottic airway devices have pride of place in the Operating Room and are becoming important airway devices used in routine procedures. Direct and indirect fibreoptic laryngoscopes and transtracheal devices help us overcome difficult and previously impossible airway situations. These developments mean that we need to update our knowledge on these devices. Also much of our basic understanding of the physiology and anatomy of the paediatric airway has changed. This article attempts to shed light on some of the most important advances/opinions in paediatric airway management like, cuffed endotracheal tubes, supraglottic airway devices, video laryngoscopes, rapid sequence intubation, the newly proposed algorithm for difficult airway management and the role of Ex Utero Intrapartum Treatment (EXIT) procedure in the management of the neonatal airway.
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Affiliation(s)
- S Ramesh
- Department of Anaesthesia, Kanchi Kamkoti Child Trust Hospital, Chennai, Tamil Nadu, India
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Helfer DC, Clivatti J, Yamashita AM, Moron AF. Anesthesia for Ex Utero Intrapartum Treatment (EXIT procedure) in Fetus with Prenatal Diagnosis of Oral and Cervical Malformations: Case Reports. Braz J Anesthesiol 2012; 62:411-23. [DOI: 10.1016/s0034-7094(12)70141-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 08/03/2011] [Indexed: 11/15/2022] Open
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Stefini S, Bazzana T, Smussi C, Piccioni M, Frusca T, Taddei F, Tomasoni G, Recupero D, Cavazza A, Villani P, Nicolai P, Eivazi B, Wiegand S, Werner JA, Schmidt S, Maier RF, Torossian A. EXIT (Ex utero Intrapartum Treatment) in lymphatic malformations of the head and neck: discussion of three cases and proposal of an EXIT-TTP (Team Time Procedure) list. Int J Pediatr Otorhinolaryngol 2012; 76:20-7. [PMID: 22078744 DOI: 10.1016/j.ijporl.2011.09.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 09/14/2011] [Accepted: 09/19/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Ex utero Intrapartum Treatment (EXIT) is a technique to secure the fetal airway while oxygenation is maintained through utero-placental circulation. The aim of the study is to present three cases of fetal lymphatic malformation of the head and neck that required EXIT and to summarize EXIT details. METHODS The cases were studied before the delivery and EXIT was planned with a multidisciplinary team. The key factors of EXIT are considered and the type, stage and clinical score of the three lymphatic malformations are defined. RESULTS In the three cases of EXIT the time working on placental support to secure the airway was 9, 7, and 9 min, respectively (from the hysterotomy to clamping the umbilical cord). Procedures performed on the airway were laryngo-tracheo-bronchoscopy in the first case, laryngoscopy and intubation in the second one, laryngoscopy, drainage of the lymphatic macro-cyst, and intubation in the third case. A sketching to detail the EXIT steps are presented: EXIT-Team Time Procedure list (EXIT-TTP list). Lymphatic malformations were classified as mixed (micro/macro-cystic) in two cases, and macro-cystic in one. de Serres Stage was IV, V and II. Therapy varied in the three neonates (surgery alone, surgery+Picibanil+Nd-YAG, or Picibanil alone). CONCLUSIONS In case of prenatal suspicion of airway obstruction, EXIT should be planned with a multidisciplinary team. The EXIT-Team Time Procedure list (EXIT-TTP list), reviews the most critical phases of the procedure when different teams are working together. The type of lymphatic malformation, the anatomic location and the clinical score predict the outcome.
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Affiliation(s)
- Stefania Stefini
- Department of Otorhinolaryngology, University of Brescia - Spedali Civili of Brescia, Italy
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Lee H, Ryu JW, Kim DY, Lee GY. Anesthetic management of the ex utero intrapartum treatment (EXIT) procedure -A case report-. Korean J Anesthesiol 2010; 59 Suppl:S154-7. [PMID: 21286428 PMCID: PMC3030024 DOI: 10.4097/kjae.2010.59.s.s154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 05/24/2010] [Accepted: 06/05/2010] [Indexed: 11/10/2022] Open
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a very rare technique performed in cases of fetal congenital malformations. The EXIT procedure increases the rate of survival at delivery by maintaining the uteroplacental circulation until the airway of the fetus is secured. To maintain the uteroplacental circulation, a higher dose of inhalational anesthetics and/or intravenous nitroglycerin can be used as compared to conventional Cesarean section. The aim of this report is to share our anesthetic experience during the EXIT procedure with members of the Korean society of anesthesiology for the first time, and to highlight the maternal implications of the use of inhalational anesthetics and nitroglycerin during Cesarean section for the EXIT procedure.
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Affiliation(s)
- Heeseung Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
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12
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Abraham RJ, Sau A, Maxwell D. A review of the EXIT (Ex uteroIntrapartum Treatment) procedure. J OBSTET GYNAECOL 2010; 30:1-5. [DOI: 10.3109/01443610903281656] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ferrer L, Paredes P. Manejo Anestésico de paciente obstétrica sometida a EXIT. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2009. [DOI: 10.1016/s0120-3347(09)74004-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Comparison of the effects of sevoflurane and isoflurane anesthesia on the maternal-fetal unit in sheep. J Anesth 2009; 23:392-8. [DOI: 10.1007/s00540-009-0763-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Accepted: 03/09/2009] [Indexed: 10/20/2022]
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Hartnick CJ, Barth WH, Coté CJ, Albrecht MA, Grant PE, Geyer JT. Case records of the Massachusetts General Hospital. Case 7-2009. A pregnant woman with a large mass in the fetal oral cavity. N Engl J Med 2009; 360:913-21. [PMID: 19246364 DOI: 10.1056/nejmcpc0809061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ferrer L, Paredes P. Manejo Anestésico de paciente obstétrica sometida a EXIT. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2008. [DOI: 10.1016/s0120-3347(08)64010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Kuczkowski KM. Advances in obstetric anesthesia: anesthesia for fetal intrapartum operations on placental support. J Anesth 2007; 21:243-51. [PMID: 17458654 DOI: 10.1007/s00540-006-0502-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 01/13/2007] [Indexed: 12/17/2022]
Abstract
Fetal intrapartum operations on placental support (OOPS), also known as ex-utero intrapartum treatment (EXIT) procedures, are very rare (and often challenging) surgical techniques designed to allow partial delivery (cesarean section) of a fetus with a potentially difficult airway, with subsequent management of the neonatal airway (direct laryngoscopy, fiberoptic bronchoscopy, or tracheostomy) while oxygenation is continuously maintained via the placenta (on placental support). The peripartum management of pregnant women and their fetuses undergoing OOPS is very complex and multidisciplinary, and differs greatly from that of standard cesarean sections. The goal of this article is to review the current recommendations for the peripartum anesthetic management of pregnant women carrying fetuses with fetal congenital malformations undergoing OOPS.
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Affiliation(s)
- Krzysztof M Kuczkowski
- Department of Anesthesiology, University of California, San Diego, San Diego, California 92103-8770, USA
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George RB, Melnick AH, Rose EC, Habib AS. Case series: Combined spinal epidural anesthesia for Cesarean delivery and ex utero intrapartum treatment procedure. Can J Anaesth 2007; 54:218-22. [PMID: 17331934 DOI: 10.1007/bf03022643] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To report the use of regional anesthesia and iv nitroglycerin to provide anesthesia and uterine relaxation for three Cesarean deliveries (CD) involving ex utero intrapartum treatment (EXIT) of potentially life-threatening airway obstruction in the newborn. CLINICAL FEATURES Case 1--a 36-yr-old woman at 38 weeks' gestation was scheduled for an elective CD for fetal skeletal dysplasia and micrognathia. Case 2--a 34-yr-old woman at 35 weeks gestation had a fetal ultrasound revealing fixed neck flexion and micrognathia consistent with fetal arthrogryposis. Case 3--a 27-yr-old woman presented at 38 weeks gestation for CD for severe fetal micrognathia, with mandibular growth below the fifth percentile. For each case, a combined spinal epidural anesthetic was performed with 0.75% bupivacaine, fentanyl and morphine intrathecally followed by placement of a multiorifice epidural catheter. Prior to uterine incision patients received a loading dose followed by an iv infusion of nitroglycerin. Uterine relaxation was sufficient in all cases for delivery of the fetus, and allowed for evaluation by direct laryngoscopy and intubation while maintaining fetal-placental circulation. The surgical procedures were completed without incident. CONCLUSIONS Anesthesia and uterine relaxation for CD and EXIT procedures can be safely provided with regional anesthesia and iv nitroglycerin.
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Affiliation(s)
- Ronald B George
- Department of Anesthesiology, Women's Anesthesia and Critical Care, Box 3094, Duke University Medical Center, Durham, NC 27710, USA.
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Ducloy-Bouthors AS, Marciniak B, Vaast P, Fayoux P, Houfflin-Debarge V, Fily A, Rakza T. Anesthésie maternofœtale pour « ex utero intrapartum » traitement (EXIT) procédure : à propos de deux cas. ACTA ACUST UNITED AC 2006; 25:638-43. [PMID: 16698227 DOI: 10.1016/j.annfar.2006.02.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 02/23/2006] [Indexed: 11/23/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a surgical procedure maintaining utero-placental circulation during caesarean section. Anaesthetic implications are described: foetal transplacental anaesthesia to avoid first breathing and to permit surgical procedure on obstructed foetal airway, deep maternal haemodynamically stable anaesthesia to relax uterine smooth muscle during a long caesarean procedure but avoiding post-partum haemorrhage. Volatile anaesthesia with sevoflurane seems to be adequate for these aims. Two cases are described.
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Affiliation(s)
- A-S Ducloy-Bouthors
- Clinique d'Anesthésie-Réanimation, Hôpital Jeanne-de-Flandre, CHRU de Lille, 2 Avenue Oscar-Lambret, 59037 Lille Cedex, France.
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Kill C, Gebhardt B, Schmidt S, Werner JA, Maier RF, Wulf H. Die EXIT-Prozedur als anästhesiologische Herausforderung. Anaesthesist 2005; 54:1105-10. [PMID: 16021389 DOI: 10.1007/s00101-005-0898-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The ex-utero intra-partum (EXIT) procedure enables the surgeon to perform invasive procedures in an infant during cesarean section before clamping the umbilical cord. Specific anesthesiological concepts are necessary for ensuring sufficient umbilical perfusion. We report the case of a 33-year-old female undergoing cesarean section in the 36th week of pregnancy because of a large fetal cervical tumor. The EXIT procedure was performed in order to secure the infant's airway during delivery. The anesthesiological management and interdisciplinary tasks are discussed in the literature review.
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Affiliation(s)
- C Kill
- Klinik für Anästhesie und Intensivtherapie, Philipps-Universität, Marburg.
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Eschertzhuber S, Keller C, Mitterschiffthaler G, Jochberger S, Kühbacher G. Verifying Correct Endotracheal Intubation by Measurement of End-Tidal Carbon Dioxide During an Ex Utero Intrapartum Treatment Procedure. Anesth Analg 2005; 101:658-660. [PMID: 16115970 DOI: 10.1213/01.ane.0000175206.91231.77] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure provides time to secure the airway of the fetus while utero-placental circulation supplies the fetus with oxygen. We report the anesthetic management of a fetus with a large neck mass during an EXIT procedure in which the confirmation of correct endotracheal intubation was hampered by parts of the mass, blood, and other fluids. The use of a standard end-tidal carbon dioxide probe provided a reliable signal and proved the endotracheal position of the tube while utero-placental circulation was still intact.
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Affiliation(s)
- Stephan Eschertzhuber
- Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria
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Faria A, Fonseca C, Sampaio C, Abreu F, Tavares J. Ex utero intrapartum procedure for delivery of a fetus with a large cervical mass. Eur J Anaesthesiol 2005; 22:642-3. [PMID: 16119606 DOI: 10.1017/s0265021505251062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Good airway management technique is an essential skill for physicians in most specialties. This article begins with a review of basic airway anatomy and the physiology of the uninstrumented airway. This subject is of particular importance given the increasing use of procedural sedation and the increased recognition of sleep-disordered breathing in infants and children. A discussion of the various artificial airways and their advantages and disadvantages follows. The difficult airway is an important contributor to both patient morbidity and mortality. It is important to have a planned management approach available for the anticipated and, more importantly, the unanticipated difficult airway. The recommendations of the American Society of Anesthesiologists Taskforce on the Management of the Difficult Airway have good application for this important problem. The fetus with the prenatal diagnosis of a lesion that predicts a difficult airway presents a particular challenge. The utilization of an ex-utero intrapartum treatment method is presented as an important approach for the delivery and airway management of these infants. This section closes with a discussion of the prehospital airway management of the pediatric patient.
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Affiliation(s)
- William L McNiece
- Department of Anesthesia, Section of Pediatric Anesthesia, James Whitcomb Riley Hospital for Sick Children, Indiana University, Indianapolis 46202-5128, USA
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Zadra N, Giusti F, Midrio P. Ex utero intrapartum surgery (EXIT): indications and anaesthetic management. Best Pract Res Clin Anaesthesiol 2004; 18:259-71. [PMID: 15171503 DOI: 10.1016/j.bpa.2003.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a technique for safely managing airway obstruction at birth, in which placental support is maintained until the airway is evaluated and secured. In addition to the usual considerations of anaesthesia in obstetrics there are special considerations relating to the EXIT procedure: maintaining fetoplacental circulation by profound uterine relaxation and achieving fetal anaesthesia for airway manipulations. This chapter focuses on the key issues involved in managing this procedure: the indications, preoperative concerns, organization of a multidisciplinary team, problems of maternal and fetal anaesthesia, maintenance of the uterine relaxation and control of fetal airway.
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Affiliation(s)
- Nicola Zadra
- Department of Anaesthesiology and Intensive Care, University of Padova, Via C. Battisti 267, 35100 Padova, Italy.
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Abstract
Advances in prenatal diagnosis, combined with a better understanding of the natural history of prenatally diagnosed anomalies, are providing increasing opportunities to consider fetal intervention in selected cases of life-threatening malformations. Accurate prenatal diagnosis can now accurately identify fetal pathophysiology that poses an immediate threat to the life of the newborn infant on separation from the placental circulation. In this circumstance, the ex-utero intrapartum treatment (EXIT) procedure, which maintains intrapartum uteroplacental support, can be life saving. The most common indications for the EXIT procedure are fetal lesions causing extrinsic or intrinsic airway obstruction. However, fetuses with other anomalies that may compromise neonatal resuscitation can also benefit from this approach. The EXIT procedure differs significantly from a cesarean delivery, and caution must be taken to avoid maternal morbidity. As with all endeavors involving maternal-fetal intervention, a team approach is crucial to ensure accurate diagnosis and optimal perinatal management.
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Affiliation(s)
- Tippi C MacKenzie
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
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