1
|
Nallani R, Francis CL, Wagner AF, Brown JR. Management of Neonatal Airway Obstruction: A Point-Counterpoint Ethical Discussion. Otolaryngol Head Neck Surg 2024; 171:599-602. [PMID: 38482947 DOI: 10.1002/ohn.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/26/2024] [Accepted: 02/11/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Rohit Nallani
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Carrie L Francis
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
- Division of Pediatric Otolaryngology, Kansas City, Missouri, USA
| | | | - Jason R Brown
- Division of Pediatric Otolaryngology, Kansas City, Missouri, USA
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Powell E, Metodiev Y. Is it time for the 'OOPS' to 'EXIT'? Anaesth Rep 2023; 11:e12259. [PMID: 37937280 PMCID: PMC10626001 DOI: 10.1002/anr3.12259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/09/2023] Open
Affiliation(s)
- E. Powell
- Department of AnaesthesiaUniversity Hospital of WalesCardiffUK
| | - Y. Metodiev
- Department of AnaesthesiaUniversity Hospital of WalesCardiffUK
| |
Collapse
|
4
|
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]
|
5
|
Chung W, Lim C. Intraoperative management for ex-utero intrapartum treatment: focusing on the fetus. Anesth Pain Med (Seoul) 2022; 16:329-337. [PMID: 35139613 PMCID: PMC8828620 DOI: 10.17085/apm.21097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
Ex-utero intrapartum treatment (EXIT) is a method of securing the airway of a fetus while maintaining umbilical circulation for newborns who are experiencing life-threatening airway obstruction. Cesarean section is completed only after ensuring the neonate's safety. However, managing the airway of a neonate while maintaining umbilical circulation is a major challenge for anesthesiologists. Anesthesiologists must understand the physiology of both the mother and fetus, and extensive discussions with obstetricians, pediatricians, otolaryngologists, and nursing staff prior to the procedure are essential. This review provides an overview of the EXIT and details of airway management for neonates.
Collapse
Affiliation(s)
- Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Chaeseong Lim
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| |
Collapse
|
6
|
Mohammad S, Olutoye OA. Airway management for neonates requiring ex utero intrapartum treatment (EXIT). Paediatr Anaesth 2020; 30:248-256. [PMID: 31898837 DOI: 10.1111/pan.13818] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 12/30/2019] [Indexed: 12/19/2022]
Abstract
In utero congenital malformations in the fetus can occasionally lead to an obstructed airway at birth accompanied by hypoxic injury or peripartum demise, without intervention. Ex utero intrapartum treatment (EXIT) may help reduce morbidity and mortality associated with challenging airways by providing extra time on uteroplacental circulation to secure the airway. Meticulous preparation and planning are crucial for this procedure. Many different types of congenital malformations can result in a difficult airway, but there is no correlation between specific malformations and a required type of airway intervention. Based on our experience and literature review, an airway process flow diagram has been created to help assist teams in decision-making for airway intervention in a neonate during the EXIT procedure. The management of the airway in this scenario involves additional unique considerations that accompany handling a partially delivered newborn in the uterine environment. Extensive preparation and team rehearsal are essential to the success of this procedure.
Collapse
Affiliation(s)
- Shazia Mohammad
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Olutoyin A Olutoye
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
7
|
Patel D, Adler AC, Hassanpour A, Olutoye O, Chandrakantan A. Monitored Anesthesia Care versus General Anesthesia for Intrauterine Fetal Interventions: Analysis of Conversions and Complications for 480 Cases. Fetal Diagn Ther 2020; 47:597-603. [PMID: 31931502 DOI: 10.1159/000504978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Fetal intervention/surgery constitutes a relatively new field of maternal-fetal medicine in which monitored anesthesia care (MAC) or general anesthesia (GA) are utilized as anesthetic techniques when feasible. In this study, we sought to calculate the usage of MAC and GA in various fetal procedures as well as investigate any anesthetic complications and conversions from MAC to GA. METHODS All intrauterine fetal intervention cases performed at the Texas Children's Hospital Pavilion for Women from 2012 to 2016 were retrospectively analyzed and categorized by mode of anesthesia. Anesthetic complications, conversions to GA, preoperative patient physical status, average number of intraoperative medications required, and average duration of procedure were compared between the MAC and GA groups. RESULTS A total of 480 fetal interventions were performed with 432 under MAC (90%) and 37 under GA (7.7%). There were 11 conversions from MAC to GA (2.3%). These conversions were due to poor visualization with ultrasound and change of surgical approach to laparoscopic-assisted technique (n = 5), inability to lay flat due to back pain (n = 3), persistent vomiting (n = 2), and unresponsiveness after a spinal block (n = 1). One anesthetic complication occurred due to a medication administration error and did not require conversion to GA. The average preoperative American Society of Anesthesiologists (ASA) physical status classification was 1.97 for the MAC group and 1.87 for the GA group (p = 0.23). Duration of the interventions averaged 129 min under MAC and 138 min under GA (p = 0.23). An average of 7.8 different medications were administered during MAC cases compared to 13.1 during GA cases (p < 0.0001). DISCUSSION This analysis suggests that MAC is the most commonly used anesthetic option for fetal interventions with a low complication rate and minimal conversion rates to GA. It is therefore preferable to use MAC when feasible due to the low complication rate and decreased drug exposure.
Collapse
Affiliation(s)
- Deep Patel
- Baylor College of Medicine, Houston, Texas, USA
| | - Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Ali Hassanpour
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Olutoyin Olutoye
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA,
| |
Collapse
|
8
|
Kornacki J, Szydłowski J, Skrzypczak J, Szczepańska M, Rajewski M, Koziołek A, Gaca M, Wender-Ożegowska E. Use of ex utero intrapartum treatment procedure in fetal neck and high airway anomalies - report of four clinical cases. J Matern Fetal Neonatal Med 2017; 32:870-874. [PMID: 28992728 DOI: 10.1080/14767058.2017.1390740] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To present antenatal management and use of ex utero intrapartum treatment (EXIT) in different fetal neck and high airway anomalies. MATERIAL AND METHODS We have presented four different cases of fetal neck or airway pathology which were indications for EXIT, at our department. RESULTS In three cases of fetal neck tumors, the primary precise antenatal diagnoses of tumors were confirmed after birth. The airways of all three fetuses were properly secured during EXIT by laryngologist. All these newborns survived. In the fourth case, a primary, antenatal diagnosis of congenital high airway obstruction syndrome due to severe trachea obstruction was not confirmed after birth. Finally, due to complete trachea dysgenesis, neither tracheoscopy nor tracheostomy was done during EXIT and the baby died. CONCLUSION Despite a failure of intrapartum treatment in the fourth case, we strongly recommend this procedure for deliveries of fetuses with a suspicion of airway obstruction.
Collapse
Affiliation(s)
- Jakub Kornacki
- a Division of Reproduction , Poznan University of Medical Sciences , Poznań , Poland
| | - Jarosław Szydłowski
- b Department of Pediatric Otorhinolaryngology , Poznan University of Medical Sciences , Poznań , Poland
| | - Jana Skrzypczak
- a Division of Reproduction , Poznan University of Medical Sciences , Poznań , Poland
| | | | - Marcin Rajewski
- a Division of Reproduction , Poznan University of Medical Sciences , Poznań , Poland
| | - Agnieszka Koziołek
- c Department of Anesthesiology in Obstetrics and Gynaecology , Poznan University of Medical Sciences , Poznań , Poland
| | - Michał Gaca
- c Department of Anesthesiology in Obstetrics and Gynaecology , Poznan University of Medical Sciences , Poznań , Poland
| | - Ewa Wender-Ożegowska
- a Division of Reproduction , Poznan University of Medical Sciences , Poznań , Poland
| |
Collapse
|
9
|
de Oliveira GH, Svetliza J, Vaz-Oliani DCM, Liedtke H, Oliani AH, Pedreira DAL. Novel multidisciplinary approach to monitor and treat fetuses with gastroschisis using the Svetliza Reducibility Index and the EXIT-like procedure. EINSTEIN-SAO PAULO 2017; 15:395-402. [PMID: 29364360 PMCID: PMC5875150 DOI: 10.1590/s1679-45082017ao3979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 08/15/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To describe our initial experience with a novel approach to follow-up and treat gastroschisis in "zero minute" using the EXITlike procedure. METHODS Eleven fetuses with prenatal diagnosis of gastroschisis were evaluated. The Svetliza Reductibility Index was used to prospectively evaluate five cases, and six cases were used as historical controls. The Svetliza Reductibility Index consisted in dividing the real abdominal wall defect diameter by the larger intestinal loop to be fitted in such space. The EXIT-like procedure consists in planned cesarean section, fetal analgesia and return of the herniated viscera to the abdominal cavity before the baby can fill the intestines with air. No general anesthesia or uterine relaxation is needed. Exteriorized viscera reduction is performed while umbilical cord circulation is maintained. RESULTS Four of the five cases were performed with the EXIT-like procedure. Successful complete closure was achieved in three infants. The other cases were planned deliveries at term and treated by construction of a Silo. The average time to return the viscera in EXIT-like Group was 5.0 minutes, and, in all cases, oximetry was maintained within normal ranges. In the perinatal period, there were significant statistical differences in ventilation days required (p = 0.0169), duration of parenteral nutrition (p=0.0104) and duration of enteral feed (p=0.0294). CONCLUSION The Svetliza Reductibility Index and EXIT-like procedure could be new options to follow and treat gastroschisis, with significantly improved neonatal outcome in our unit. Further randomized studies are needed to evaluate this novel approach.
Collapse
Affiliation(s)
| | - Javier Svetliza
- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | | | - Humberto Liedtke
- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | - Antonio Helio Oliani
- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | | |
Collapse
|
10
|
Zhao C, Anicete R, Tan H. Management of airway obstruction in two cases of head and neck teratoma. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.pedex.2016.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
11
|
Walz PC, Schroeder JW. Prenatal diagnosis of obstructive head and neck masses and perinatal airway management: the ex utero intrapartum treatment procedure. Otolaryngol Clin North Am 2014; 48:191-207. [PMID: 25442130 DOI: 10.1016/j.otc.2014.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Advances in prenatal imaging in the last 20 years have enabled prenatal diagnosis of obstructive head and neck masses. These advances, coupled with improvements in maternal-fetal anesthesia, have made possible the development of the ex utero intrapartum treatment (EXIT) procedure for management of obstructive head and neck masses, during which the airway is managed in a controlled fashion while maintaining fetal circulation for oxygenation. This review addresses the preoperative and perioperative assessment and management of patients with prenatally diagnosed airway obstruction, indications and contraindications for the EXIT procedure, technical details of the procedure, and outcomes.
Collapse
Affiliation(s)
- Patrick C Walz
- Department of Pediatric Otolaryngology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611-2991, USA
| | | |
Collapse
|
12
|
Abstract
The scope of obstetric anesthesia practice ranges far beyond the delivery of care to women for vaginal and cesarean deliveries. Increasingly, obstetric anesthesiologists are involved in the management of anesthetics for new procedures and for new indications. Anesthesia is frequently needed for maternal procedures, as well as fetal procedures, and at varying times in the intrapartum period. Maternal-specific procedures include cerclage, external cephalic version (ECV), postpartum bilateral tubal ligation (BTL), and dilation and evacuation (D and E). Fetus-specific procedures include fetoscopic laser photocoagulation and ex-utero intrapartum treatment (EXIT). This review will not include discussion of the anesthetic management of non-obstetric surgery during pregnancy, such as appendectomy or cholecystectomy.
Collapse
Affiliation(s)
- Jaime Aaronson
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Columbia University, 630 W 168th St, P & S Box 46, New York, NY, 10032
| | - Stephanie Goodman
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Columbia University, 630 W 168th St, P & S Box 46, New York, NY, 10032.
| |
Collapse
|
13
|
Bamberg C, Hinkson L, Longardt AC, Rothe K, Horn D, Henrich W. Three-dimensional ultrasound of massive macroglossia in a fetus with Beckwith-Wiedemann syndrome. CASE REPORTS IN PERINATAL MEDICINE 2014. [DOI: 10.1515/crpm-2013-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
We present the prenatal ultrasound findings of massive macroglossia in a fetus with prenatally diagnosed Beckwith-Wiedemann syndrome. Three-dimensional surface mode ultrasound was utilized for enhanced visualization of the macroglossia.
Collapse
Affiliation(s)
- Christian Bamberg
- Department of Obstetrics, Charité-University Medical Center, Berlin, Germany
| | - Larry Hinkson
- Department of Obstetrics, Charité-University Medical Center, Berlin, Germany
| | | | - Karin Rothe
- Department of Pediatric Surgery, Charité-University Medical Center, Berlin, Germany
| | - Denise Horn
- Department of Human Genetics, Charité-University Medical Center, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité-University Medical Center, Berlin, Germany
| |
Collapse
|