Canadian Journal of Anesthesia 53:1117 (2006)
© Canadian Anesthesiologists' Society, 2006
Obstetrical and Pediatric Anesthesia
Images in Anesthesia: Ex utero intrapartum treatment (exit procedure): fetal airway management
Krzysztof M. Kuczkowski, MD
University of California San Diego, San Diego, USA, E-mail: kkuczkowski{at}ucsd.edu
Recent advances in prenatal diagnosis of fetal congenital malformations (including the airway) have led to the development of ex utero intrapartum treatment (EXIT) procedures on the fetus (including management of the potentially difficult fetal airway) before severing the umbilical cord.1 These very rare procedures are also known as fetal intrapartum operations on placental support (OOPS).2 The EXIT procedures are performed in conjunction with elective Cesarean delivery.
The anesthetic management (general anesthesia) of parturients undergoing EXIT procedures is very different from standard Cesarean deliveries. First, unlike a standard Cesarean delivery, there is no need to limit induction of anesthesia to delivery time. Second, deep inhalational anesthesia (exceeding 2 MAC end-tidal concentration) with sevoflurane or isoflurane (often in combination with continuous iv infusion of nitroglycerine) is required to maintain full uterine relaxation. Third, maintenance of maternal intraoperative blood pressure and cardiac output might at times necessitate continuous iv infusions of dopamine. The fetus is only partially delivered from the uterus with maintenance of placental support for the duration of time needed to establish the fetal airway.
At the University of California, San Diego we recently performed an EXIT procedure on a healthy parturient carrying a fetus with Treacher Collins syndrome. The fetal airway was established with orotracheal intubation while on placental support (Figure
, Panels A and B).
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FIGURE Management of the potentially difficult fetal air way on placental support during the EXIT procedure; Panel A (laryngoscopy), and Panel B (endotracheal intubation). Consent for publication of these photographs was obtained in accordance with institutional guidelines at the University of California, San Diego.
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Footnotes
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Accepted for publication August 14, 2006.
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References
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1 Ducloy-Bouthors AS, Marciniak B, Vaast P, et al. Maternal and foetal anaesthesia for ex utero intrapartum treatment (EXIT) procedure (French). Ann Fr Anesth Reanim 2006; 25: 638–43.[Medline]2 Kill C, Gebhardt B, Schmidt S, Werner JA, Maier RF, Wulf H. Anesthesiological management of the EXIT procedure. Case report and literature review (German). Anaesthesist 2005; 54: 1105–10.[Medline]
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