Perioperative Maternal-Fetal Outcomes in the Setting of Minimally Invasive Fetal Therapy for Complex Monochorionic Pregnancies with Monitored Anesthesia Care

INTRODUCTION

Fetoscopic selective laser photocoagulation (FSLPC) and selective cord occlusion with radiofrequency ablation (RFA) can improve fetal outcomes when vascular anastomoses between fetuses cause twin-to-twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR) in multiple gestation pregnancies with monochorionic placentation. This study analyzed perioperative maternal-fetal complications and anesthetic management in a high-volume fetal therapy center over a 4-year period.

METHODS

Included patients received MAC for minimally invasive fetal procedures for complex multiple gestation pregnancies between January 1, 2015, and September 20, 2019. Maternal and fetal complications, intraoperative maternal hemodynamics, medication usage, and reasons for conversion to general anesthesia, if applicable, were analyzed.

RESULTS

A total of 203 (59%) patients underwent FSLPC and 141 (41%) had RFA. Four patients (2%; rate 95% CI: 0.00039, 0.03901) undergoing FSLPC had conversion to general anesthesia. No conversions to general anesthesia occurred in the RFA group. The incidence of maternal complications was higher in those who underwent FSLPC. No aspiration or postoperative pneumonia events were observed. Medication usage was similar in FSLPC and RFA groups.

CONCLUSION

A low rate of conversion to general anesthesia and no serious adverse maternal events were observed in patients receiving MAC.

New Trends in Fetal Anesthesia

Fetal anesthesia teams must understand the pathophysiology and rationale for the treatment of each disease process. Treatment can range from minimally invasive procedures to maternal laparotomy, hysterotomy, and major fetal surgery. Timing may be in early, mid-, or late gestation. Techniques continue to be refined, and the anesthetic plans must evolve to meet the needs of the procedures. Anesthetic plans range from moderate sedation to general anesthesia that includes monitoring of 2 patients simultaneously, fluid restriction, invasive blood pressure monitoring, vasopressor administration, and advanced medication choices to optimize fetal cardiac function.

0168 Effects of School Night Sleep Duration and Circadian Preference on Student Tardiness: An Investigation in a Middle-School Aged Sample

Introduction

Sleep and circadian factors play an important role in school attendance, academic performance, and daytime behaviors among adolescents. This investigation assessed school night sleep duration (SNSD) and circadian preference (CP) association with first period tardies (FPT) using a middle-aged sample from the Madison (Wisconsin) Metropolitan School District (MMSD), prior to implementation of a planned district-wide delay in middle school start times.

Methods

4,175 middle-school aged students from 12 MMSD schools completed a sleep survey, which included SNSD and a validated 4-level measure of CP. Self-reported SNSD between 4-and-12 hours served as final sample inclusion criterion. Mixed effects modeling was employed with students nested within school. Linear regression determined SNSD and CP effect on student tardiness. Individual, year-long FPT served as outcome variable. Inclusion of SNSD quadratic term was not statistically indicated. Full model covariates included age, sex, race, parent educational level, homelessness, free and reduced lunch, and special education status.

Results

Final sample included 3,860 students. Univariate regression determined a significant CP association with FPT [β=1.20, 95% CI (0.54, 1.86), F(1,10.41)=13.7, p=0.004), but not SNSD [β=-0.31, 95% CI (-0.70, -0.09), F(1,10.21)=2.5, p=0.14]. SNSD and CP interaction was not significant. CP significance was maintained in the full model [β=1.24, 95% CI (-0.70, -0.09), F(1,11.21)=13.7, p=0.004]. Evening preference associated with 3.72 more FPT, relative to morning preference.

Conclusion

Results suggest evening preference is associated with increased risk of tardiness among middle school students. Future research that examines the relationships between delayed school start times, circadian preference, and impact on school tardiness is indicated.

Support

This research was generously supported by a grant from the Madison Education Partnership (MEP).

0267 School Night Sleep Duration Effect on Risk for In-and-Out of School Suspensions: An Investigation in a Middle-School Aged Sample

Introduction

Sleep plays an important role in adolescent education and development. Sleep impacts student school attendance, academic performance, and daytime behaviors. There has been limited investigation into the impact on sleep duration (SD) on school suspension risk. Given the growing public health and policy focus on altering school start times to increase SD, this study assessed SD association with school suspension risk using a middle-school aged sample from the Madison (Wisconsin) Metropolitan School District (MMSD), prior to implementation of a planned district-wide delay in middle school start times.

Methods

4,175 middle-school aged students from 12 MMSD schools completed a sleep survey, which included school-night SD (SNSD). Self-reported SNSD between 4-and-12 hours served as criterion for inclusion in final sample. Mixed effects modeling was employed with students nested within school. Logistic regression determined SNSD association with in-school (ISS) and out-of-school (OSS) suspensions. ISS and OSS were dichotomized (No ISS/OSS = 0; nonzero ISS/OSS = 1) to serve as outcome variables. Full model covariates included age, sex, race, circadian preference, parent educational level, homelessness, free and reduced lunch, and special education status.

Results

Final sample included 3,860 students. Shorter SNSD associated with greater likelihood of OSS [OR = 0.83, 95% CI (-0.28, -0.09), X2 = 16.1, p < 0.0001], but not ISS [OR = 0.97, 95% CI (-0.14, -0.070), X2 = 0.44, p = 0.51]. Significance between SNSD and OSS was maintained in the full model [OR = 0.84, 95% CI (-0.27, -0.08), X2 = 13.2, p = 0.0003]. Each additional hour of sleep associated with 16% lower risk of OSS.

Conclusion

These results suggest that students with shorter SD are at increased risk for OSS, which further highlights the potential deleterious impact of short SD on adolescent educational experience.

Support

This research was generously supported by a grant from the Madison Education Partnership (MEP).

Management of neonatal difficult airway emergencies in the delivery room

Neonatal airway emergencies in the delivery room are associated with significant morbidity and mortality. Etiologies vary, but often predispose the neonate to life threatening airway obstruction. With the recent expansion of fetal medicine programs, pediatric anesthesiologists are increasingly being asked to care for these patients. In this review, we discuss common etiologies of difficult airway at delivery, management tools and techniques, and surgical approaches.

Risk factors for perioperative mortality and transfusion in sacrococcygeal teratoma resections

BACKGROUND

Sacrococcygeal teratomas are a common congenital tumor. Surgical resection can occur in utero, in the neonatal period, or in the postneonatal period.

AIMS

We describe patient and tumor factors associated with mortality and transfusion in this population.

METHODS

We did a retrospective chart review of patients who underwent sacrococcygeal teratoma resection between January 1998 and March 2016. Demographic data, transfusion data, and tumor characteristics were collected. Descriptive statistics were calculated, and univariate comparisons were performed with chi-square test and Fisher's exact test. Variables significant at univariate level were used in multivariate logistic regression and negative binomial regression.

RESULTS

Of the 112 cases, 6 were in utero repairs, 73 were neonatal repairs, and 33 were repairs at >30 days of life. There was 17%, 1%, and 0% intraoperative mortality and 33%, 5%, and 0% 30-day mortality in the in utero, neonatal, and >30 days of life repairs, respectively. All six patients who died within the first 30 days of life had a postmenstrual age of <32 weeks at time of surgery. All six patients who died had noncystic tumors. Patients with noncystic tumors were more likely to be born prior to 30-week gestation (23/65 vs 6/47; χ² = 7.3; P = 0.007). Gestational age >30 weeks was associated with decreased intraoperative death (0% vs 10%; modified maximum likelihood estimate of OR 0.05; 95% CI 0.002-0.96; P = 0.02). Gestational age >30 weeks (2.4% vs 13.8%; OR 0.15; 95% CI 0.03-0.89; P = 0.04) and cystic morphology (0% vs 9.2%; modified maximum likelihood estimate of OR 0.1; CI 0.01-1.75; P = 0.04) were associated with decreased 30-day mortality and emergent surgery (17.9% vs 1.2%; OR 18; 95% CI 2-162.2; P = 0.004) was associated with increased 30-day mortality. Gestational age >30 weeks (33.7% vs 62.1%; OR 0.27; 95% CI 0.09-0.79; P = 0.02) and Altman class 3-4 (12.1% vs 52.7%; OR 0.1; 95% CI 0.03-0.34; P = 0.0002) were associated with decreased need for transfusion and noncystic tumor was associated with increased transfusion volume (131.6 ml·kg^-1 [95% CI 94-184] vs 63 ml·kg^-1 [95% CI 40-100.1]; P = 0.01).

CONCLUSIONS

Prematurity is associated with increased intraoperative and 30-day mortality. Noncystic tumor morphology was the only significant factor associated with transfusion volume and all six patients who died had transfusion volumes of 240 ml·kg^-1 or greater. In these patients at high risk of mortality due to blood loss, the anesthesia team should be prepared to manage massive transfusion and coagulopathy with blood components and pharmacologic measures.

The role of echocardiography in the intraoperative management of the fetus undergoing myelomeningocele repair

INTRODUCTION

Fetal surgery for myelomeningocele (MMC) results in better outcomes compared to postnatal treatment. However, risks are present. We describe our experience with intraoperative fetal echocardiography during repair of MMC and report on the management of serious cardiovascular events.

MATERIAL AND METHODS

The subjects included fetuses with intent to repair MMC from January 2011 to February 2014. The protocol involved continuous echocardiography in a looping, sequential manner of systolic function, heart rate and tricuspid and mitral valve regurgitation.

RESULTS

A total of 101 cases intended fetal MMC repair; 100 completed surgery. Intraoperative ventricular dysfunction was present in 60% (20 mild, 25 moderate, 15 severe). Heart rate <100 bpm was noted in 11 cases. Tricuspid valve regurgitation was present in 35% (26 mild, 7 moderate, 2 severe); mitral valve regurgitation was present in 19% (15 mild, 4 moderate). Serious cardiovascular events were experienced in 7 cases, which affected the conduct of surgery and/or outcome. In 4 of these, medications were given via the umbilical vein and external cardiac compressions were performed. Fetal echocardiography was used to gauge the efficacy of compressions and to guide resuscitation.

DISCUSSION

Cardiovascular compromise is common during fetal surgery for MMC. Intraoperative fetal echocardiography is recommended as a growing number of centers contemplate offering this form of novel, but potentially risky, therapy.

Anesthesia for fetal surgery

Fetal surgery pushes the limits of knowledge and therapy beyond conventional paradigms by treating the developing fetus as a patient. Providing anesthesia for fetal surgery is challenging for many reasons. It requires integration of both obstetric and pediatric anesthesia practice. Two patients must be anesthetized for the benefit of one, and there is little margin for error. Many disciplines are involved, and communication must be effective among all of them. Conducting anesthetic research with vulnerable populations, such as the pregnant woman carrying a fetus with a birth defect is difficult, and many questions remain to be answered. Work is needed to study possible neurotoxicity caused by exposure of the developing brain to anesthetic agents. The effects of stress on the developing fetus also must be further delineated. Anesthetic techniques vary by institution, and prospective studies to determine optimal anesthetic regimens are warranted.

Anesthesia for fetal surgery

Fetal surgery pushes the limits of knowledge and therapy beyond conventional paradigms by treating the developing fetus as a patient. Providing anesthesia for fetal surgery is challenging for many reasons. It requires integration of both obstetric and pediatric anesthesia practice. Two patients must be anesthetized for the benefit of one, and there is little margin for error. Many disciplines are involved, and communication must be effective. Conducting anesthetic research with vulnerable populations, such as pregnant women and their fetuses, is difficult, and many questions remain unanswered. Work must be done in the study of possible neurotoxicity caused by exposure of developing brain to anesthetic agents. The effects of stress on the developing fetus must also be further examined. Optimal anesthetic regimens remain to be determined.

Emergent excision of a prenatally diagnosed sacrococcygeal teratoma

Prenatally diagnosed sacrococcygeal teratomas (SCT) have higher mortality rates than those diagnosed in the neonatal period. Natural history of SCT varies, and management depends on pathophysiology. Treatment may be minimally invasive or require open surgery. Intervention may take place in the prenatal period, or it may occur within minutes to days after birth. Optimal care requires close follow up and communication between members of a multidisciplinary team. We present a case of prenatally diagnosed SCT and address the evaluation, anesthetic considerations, and mechanisms needed to care for this high risk population.

Intraarticular Bupivacaine-Clonidine-Morphine Versus Femoral-Sciatic Nerve Block in Pediatric Patients Undergoing Anterior Cruciate Ligament Reconstruction

We hypothesized that combined femoral-sciatic nerve block (FSNB) offers better analgesia with fewer side effects than intraarticular infiltration (IA) in children undergoing anterior cruciate ligament (ACL) reconstruction. Thirty-six children undergoing ACL reconstruction were randomized to FSNB or IA. FSNB patients had FSNB with bupivacaine (0.125%)-clonidine (2 microg/kg), whereas IA patients received bupivacaine (0.25%)-clonidine (1 microg/kg)-morphine (5 mg). Postoperatively, analgesia was provided with patient-controlled analgesia and rescue morphine. Patient demographics were similar. FSNB patients required less intraoperative fentanyl (50 +/- 40 microg versus 80 +/- 50 microg; P = 0.04). Visual analog scale score for FSNB was smaller than IA in the recovery room (1.8 +/- 3 versus 5.4 +/- 3; P = 0.0002) and during the first 24 h (1.6 +/- 1 versus 2.9 +/- 2; P = 0.01)). FSNB morphine use in the first 18 h was less (7 +/- 13 mg versus 21 +/- 21 mg; P = 0.03). Fewer FSNB patients vomited (11% versus 50%; P = 0.03). IA patients required morphine patient-controlled analgesia sooner. After ACL reconstruction in children, FSNB with bupivacaine-clonidine provides better analgesia with fewer side effects than IA with bupivacaine-clonidine-morphine.

Comparison of lower extremity cutaneous temperature changes in patients receiving lumbar sympathetic ganglion blocks versus epidural anesthesia

STUDY OBJECTIVE

To investigate if paravertebral lumbar sympathetic ganglion block and lumbar epidural anesthesia result in comparable cutaneous temperature changes in the lower extremity.

DESIGN

Nonrandomized comparison study.

SETTING

Operating rooms and pain clinic procedure rooms in a tertiary care hospital.

PATIENTS AND INTERVENTIONS

18 patients undergoing lumbar sympathetic ganglion blocks for the diagnosis and/or treatment of chronic pain, and 13 patients undergoing lumbar epidural anesthesia for radical prostatectomy.

MEASUREMENTS

Cutaneous temperatures were measured over the great toe, calf, and thigh in all patients. Mean maximum temperature (Tmax), rate of change of skin temperature (from 5% to 95% of maximum temperature change), and mean time to 1 degrees C increase, and 50% and 95% of maximum temperature change for each group were compared. Temperature changes for the epidural and lumbar sympathetic block patients were compared.

MAIN RESULTS

Epidural and lumbar sympathetic block resulted in similar Tmax (34.1 +/- 0.2 and 33.8 +/- 0.9 degrees C, respectively, mean +/- SEM; p = 0.18) and rate of temperature change (0.64 +/- 0.09 and 0.49 +/- 0.07 degrees C/min; p = 0.2) in the great toe. The onset of cutaneous temperature change after lumbar sympathetic block was slower than after epidural anesthesia (1 degrees C increase: 17 and 11 min, respectively, 50% of Tmax: 25 and 17 min, respectively, and 95% of Tmax: 40 and 31 min, respectively; p < 0.05 for each).

CONCLUSIONS

The similar rate and magnitude of cutaneous temperature change in the distal lower extremity suggests the degree of sympathetic blockade is similar with lumbar sympathetic blockade and epidural anesthesia. Either technique should provide adequate sympathectomy for treating sympathetically maintained pain once the diagnosis has been confirmed using selective sympathetic blockade.

In-person vs telephone-administered multiple-pass 24-hour recalls in women: validation with doubly labeled water

OBJECTIVE

To determine the accuracy of energy intakes estimated with the multiple-pass 24-hour recall method in women by conducting in-person and telephone interviews. Doubly labeled water measurements of total energy expenditure were used for validation.

SUBJECTS

Thirty-five weight-stable women (mean age = 30 years, range = 19 to 46 years) participated.

DESIGN

Total energy expenditure was measured over a 14-day period using the doubly labeled water method. During this time, 4 multiple-pass 24-hour recalls were obtained from the women (2 in-person, 2 by telephone) who were provided 2-dimensional food models to estimate portion sizes. The Food Intake Analysis System was used to analyze recall data.

STATISTICAL ANALYSES

Paired t tests were conducted to examine differences between energy intake estimated from the telephone and in-person interviews. Agreement between the energy intake estimates from the telephone recalls and the in-person recalls was assessed using the technique of Bland and Altman. Paired t tests were used to compare energy intake estimated from the telephone and in-person recalls to total energy expenditure.

RESULTS

No significant difference in mean daily energy intake was found between the telephone (2,253 +/- 688 kcal) and in-person (2,173 +/- 656 kcal) interviews (P = .36). However, the mean energy intake from each interview method was significantly lower than total energy expenditure (2,644 +/- 503 kcal) (P = .006 and .001, respectively).

APPLICATIONS/CONCLUSIONS

Underreporting of energy intake was widespread in the sample. Although the multiple-pass 24-hour recall method did not generate a group measure of energy intake that was accurate or unbiased, the telephone-administered multiple-pass 24-hour recall was just as effective in estimating energy intake as the recall administered in-person. Dietetics professionals should be aware of the pervasive and serious problem of under-reporting of self-reported food intakes.

Warmed humidified inspired oxygen accelerates postoperative rewarming

STUDY OBJECTIVE

To investigate the efficacy of warmed, humidified inspired oxygen (O(2)) for the treatment of mildly hypothermic postoperative patients.

DESIGN

Prospective, randomized, unblinded clinical trial.

SETTING

Postanesthesia care unit in a tertiary care hospital.

PATIENTS AND INTERVENTIONS

30 ASA physical status I, II, and III patients following intraabdominal surgical procedures were randomly assigned to receive either routine O(2) therapy (control group, n = 15), or warmed (42 degrees C) humidified O(2) (treatment group, n = 15) for the initial 90 postoperative minutes.

MEASUREMENTS

Core (tympanic) temperature, dry mouth score and shivering score.

MAIN RESULTS

Tympanic temperature was similar in both groups on admission ( approximately 35.8 degrees C). Rewarming rate in the first postoperative hour was greater in the treatment group (0.7 +/- 0.1 degrees C. hr(-1)) compared to the control group (0.4 +/- 0.1 degrees C. hr(-1)) (p = 0.03). Patients receiving the warmed, humidified O(2) had a lower incidence of dry mouth compared to the control group (p = 0.03). The incidence of shivering was low and similar in both groups.

CONCLUSIONS

Warming and humidifying inspired O(2) hastens recovery from hypothermia in postoperative patients.

Lumbar sympathetic block for sympathetically maintained pain: changes in cutaneous temperatures and pain perception

Lumbar sympathetic block (LSB) is used in the management of sympathetically maintained pain states. We characterized cutaneous temperature changes over the lower extremities after LSB. Additionally, we examined the effects of iohexol, a radio-opaque contrast medium, on temperature changes and pain relief. After institutional review board approval and written, informed consent, 28 LSBs were studied in 17 patients. Iohexol or normal saline was injected in a randomized, double-blinded fashion before bupivacaine. Lower extremity cutaneous temperatures were measured. Pain, allodynia, interference with daily function, and perceived pain relief were reported in a subset of 15 LSBs for 1 wk after the block. The distal lower extremity ipsilateral to the LSB had the greatest magnitude (8.7 degrees +/- 0.8 degrees C) and rate (1.1 degrees +/- 0.2 degrees C/min) of temperature change. The great toe temperature was within 3 degrees C of core temperature within 35 min after LSB. There were no differences in temperature change between the groups. The iohexol group had greater relief of pain until the morning of the first postblock day (P = 0.002) and longer perceived relief of pain (P = 0.01). The maximum temperature of the great toe correlated with allodynia relief (P = 0.0007). Thus clinicians should expect ipsilateral toe temperatures to increase to within approximately 3 degrees C of core temperature. Iohexol does not alter the efficacy of LSB and may improve relief of symptoms. The magnitude of temperature change may predict relief of allodynia.

IMPLICATIONS

Cutaneous toe temperatures approaching core temperature provide a useful monitor of lumbar sympathetic block and may predict relief of sympathetically maintained pain. Iohexol will not compromise temperature changes or pain relief.

The accuracy and precision of body temperature monitoring methods during regional and general anesthesia

We tested the hypotheses that accuracy and precision of available temperature monitoring methods are different between spinal anesthesia (SA) and general anesthesia (GA), and that patients receiving SA are at equal risk for hypothermia as those receiving GA. Patients scheduled for radical retropubic prostatectomy were enrolled. Either GA (n = 16) or SA (n = 16) was given according to patient and clinician preference. Temperatures were monitored with thermocouple probes at the tympanic membrane, axilla, rectum, and forehead skin surface. Tympanic temperatures were also measured with an infrared device, and forehead skin temperatures were monitored with two brands of liquid crystal thermometer strips. Accuracy and precision of these monitoring methods were determined by using tympanic membrane temperature, measured by thermocouple, as the reference core temperature (T(c)). At the end of surgery, T(c) was similar between SA (35.0 +/- 0.1 degrees C) and GA (35.2 +/- 0.1 degrees C) (P = 0.44). Accuracy and precision of each temperature monitoring method were similar between SA and GA. Rectal temperature monitoring offered the greatest combination of accuracy and precision. All other methods underestimated T(c). These findings suggest that patients receiving SA or GA are at equal and significant risk for hypothermia, and should have their temperatures carefully monitored, recognizing that most monitoring methods underestimate T(c).

IMPLICATIONS

Body temperature should be monitored during spinal anesthesia because patients are at significant risk for hypothermia. Rectal temperature is a valid method of measuring core temperature, whereas other methods tend to underestimate true core temperature.