Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942006000300008
Brazilian Journal of Anesthesiology
Clinical Information

Anestesia para tratamento intraparto extra-útero em feto com diagnóstico pré-natal de higroma na região cervical: relato de caso

Anesthesia for ex utero intrapartum treatment of fetus with prenatal diagnosis of cervical hygroma: case report

Angélica de Fátima de Assunção Braga; José Aristeu F. Frias; Franklin S. da Silva Braga; Monique Sampaio Rousselet; Ricardo Barini; Lourenço Sbragia; Juliana Guarize; Larissa C.C. Gil

http://dx.doi.org/10.1590/S0034-70942006000300008 Braz J Anesthesiol, vol.56, n3, p.278-286, 2006
PDF Português
PDF English
Downloads: 0
Views: 1099

Resumo

JUSTIFICATIVA E OBJETIVOS: O tratamento intraparto extra-útero (EXIT) constitui procedimento realizado durante a cesariana, com preservação da circulação feto-placentária, que permite manuseio seguro da via aérea do feto, com risco de obstrução das vias aéreas. O objetivo deste relato foi apresentar um caso de anestesia para EXIT, em feto com higroma cístico na região cervical. RELATO DO CASO: Paciente com 22 anos, 37 semanas de idade gestacional, sem antecedentes anestésicos, estado físico ASA I, submetida ao EXIT para manuseio de via aérea e intubação traqueal em feto com risco para obstrução de vias aéreas. O procedimento foi realizado sob anestesia geral associada a peridural contínua; no pré-operatório foram utilizados metoclopramida (10 mg) e ranitidina (50 mg), por via venosa. No espaço peridural administrou-se bupivacaína a 0,25% com adrenalina (30 mg) associada a fentanil (100 µg), seguida de passagem de cateter cefálico, para analgesia pós-operatória. O útero foi deslocado para a esquerda. A indução anestésica foi feita em seqüência rápida, com fentanil, propofol e rocurônio e a manutenção com isoflurano 2,5% a 3%, em O2 e N2O (50%). Após histerotomia, procedeu-se à liberação parcial do feto, assegurando-se a circulação útero-placentária, seguindo-se as manobras de laringoscopia e intubação traqueal fetal. A seguir, foi realizada liberação total do feto, com pinçamento de cordão umbilical, administração de ocitocina (20 UI) em infusão venosa contínua seguida de metil-ergonovina (0,2 mg) por via venosa. Durante o procedimento, a pressão arterial sistólica materna foi mantida acima de 100 mmHg, com efedrina em bolus (5 mg) e cristalóide (3.000 mL). A concentração do isoflurano foi diminuída gradativamente durante o fechamento uterino. Ao final da intervenção cirúrgica o bloqueio neuromuscular foi revertido e injetou-se morfina (2 mg) pelo cateter peridural para analgesia pós-operatória. CONCLUSÕES: As principais recomendações para a realização do EXIT são segurança materno-fetal, relaxamento uterino para manutenção do seu volume, da circulação útero-placentária e imobilidade fetal para facilitar o manuseio das vias aéreas.

Palavras-chave

ANESTESIA, Obstétrica, CIRURGIA, Obstétrica, COMPLICAÇÕES, COMPLICAÇÕES, TÉCNICAS ANESTÉSICAS, Geral, Regional

Abstract

BACKGROUND AND OBJECTIVES: Ex utero intrapartum treatment (EXIT) is a procedure performed during Cesarean section with preservation of fetal-placental circulation, which allows the safe handling of fetal airways with risk of airways obstruction. This report aimed at describing a case of anesthesia for EXIT in a fetus with cervical cystic hygroma. CASE REPORT: Female patient, 22 years old, 37 weeks gestation without anesthetic background, physical status ASA I, submitted to EXIT for airway handling and tracheal intubation of fetus at risk for airway obstruction. Procedure was performed under general anesthesia associated to continuous epidural anesthesia. Patient was premedicated with intravenous metoclopramide (10 mg) and ranitidine (50 mg). Epidural 0.25% bupivacaine with epinephrine (30 mg) associated to fentanyl (100 mg) was administered, followed by cephalic catheter for postoperative analgesia. Uterus was displaced to the left. Anesthesia was induced in rapid sequence with fentanyl, propofol and rocuronium and was maintained with isoflurane in 2.5 at 3% in O2 and N2O (50%). After hysterotomy, fetus was partially released assuring uterus-placental circulation, followed by fetal laryngoscopy and tracheal intubation. Then fetus was totally released with umbilical cord clamping, administration of oxytocin (20 UI) in continuous infusion, followed by intravenous methyl-ergonovine (0.2 mg). Maternal systolic pressure was maintained above 100 mmHg during the procedure with bolus ephedrine (5 mg) and crystalloids (3000 mL). Isoflurane concentration was gradually decreased during uterine closure. At surgery completion neuromuscular block was reversed and morphine (2 mg) was injected through the epidural catheter for postoperative analgesia. CONCLUSIONS: Major recommendations for EXIT are maternal-fetal safety, uterine relaxation to maintain uterine volume and uterus-placental circulation, and fetal immobility to help airway handling.

Keywords

ANESTHESIA, Obstetric, ANESTHETIC TECHNIQUES, General, Regional, COMPLICATIONS, COMPLICATIONS, SURGERY, Obstetric, SURGERY, Obstetric

References

Myers LB, Cohen D, Galinkin J. Anaesthesia for fetal surgery. Paediatr Anaesth. 2002;12:569-578.

Zadra N, Giusti F, Midrio P. Ex utero intrapartum surgery (EXIT): indications and anaesthetic management. Best Pract Res Clin Anaesthesiol. 2004;18:259-271.

Stevens GH, Schoot BC, Smets MJ. The ex utero intrapartum treatment (EXIT) procedure in fetal neck masses: a case report and review of the literature. Eur J Obstet Gynecol Reprod Biol. 2002;100:246-250.

Shah SI, Holterman AX, Licameli GR. Congenital cervical teratoma: airway management and complications. Otolaryngol Head Neck Surg. 2001;124:53-55.

De Backer A, Madern GC, van de Ven CP. Strategy for management of newborns with cervical teratoma. J Perinat Med. 2004;32:500-508.

Mychaliska GB, Bealer JF, Graf JL. Operating on placental support: the ex utero intrapartum treatment procedure. J Pediatr Surg. 1997;32:227-231.

Clark KD, Viscomi CM, Lowell J. Nitroglycerin for relaxation to establish a fetal airway (EXIT procedure). Obstet Gynecol. 2004;103:1113-1115.

Hasiotou M, Vakaki M, Pitsoulakis G. Congenital cervical teratomas. Int J Pediatr Otorhinolaryngol. 2004;68:1133-1139.

Davies D, Rogers M. Morphology of lymphatic malformations: a pictorial review. Australas J Dermatol. 2000;41:1-5.

Dahlgren G, Tornberg DC, Pregner K. Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications. Int J Obstet Anesth. 2004;13:178-182.

Bouchard S, Johnson MP, Flake AW. The EXIT procedure: experience and outcome in 31 cases. J Pediatr Surg. 2002;37:418-426.

Rosen MA. Anesthesia for fetal procedures and surgery. Yonsei Med J. 2001;42:669-680.

Schwarz U, Galinkin JL. Anesthesia for fetal surgery. Semin Pediatr Surg. 2003;12:196- 201.

Gaiser RR, Kurth CD. Anesthetic considerations for fetal surgery. Semin Perinatol. 1999;23:507-514.

Farrell PT. Prenatal diagnosis and intrapartum management of neck masses causing airway obstruction. Paediatr Anaesth. 2004;14:48-5.

Braga AFA, Rousselet MS, Zambelli H. Anestesia para correção intra-útero de mielomeningocele: Relato de caso. Rev Bras Anestesiol. 2005;55:329-335.

Datta S, Ostheimer GW, Weiss JB. Neonatal effect of prolonged anesthetic induction for cesarean section. Obstet Gynecol. 1981;58:331-335.

Fan SZ, Susetio L, Tsai MC. Neuromuscular blockade of the fetus with pancuronium or pipecuronium for intra-uterine procedures. Anaesthesia. 1994;49:284-286.

Matsuda Y, Kinouchi K, Kagawa K. Anesthetic management of the ex-utero intrapartum treatment (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS). Masui. 2005;54:530-534.

Bui TH, Grunewald C, Frenckner B. Successful EXIT (ex utero intrapartum treatment) procedure in a fetus diagnosed prenatally with congenital high-airway obstruction syndrome due to laryngeal atresia. Eur J Pediatr Surg. 2000;10:328-333.

Anand KJ, Sippell WG, Aynsley-Green A. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: effects on the stress response. Lancet. 1987;1:62-66.

Cauldwell CB. Anesthesia for fetal surgery. Anesthesiol Clin North America. 2002;20:211-226.

Turner RJ, Lambrost M, Holmes C. The effects of sevoflurane on isolated gravid human myometrium. Anaesth Intensive Care. 2002;30:591-596.

Riley ET. Editorial I: Spinal anaesthesia for Caesarean delivery: keep the pressure up and don't spare the vasoconstrictors. Br J Anaesth. 2004;92:459-461.

5dd42ffe0e88251b3ac63493 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections