Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942012000300013
Brazilian Journal of Anesthesiology
Clinical Information

Anestesia para tratamento intraparto extraútero (EXIT) em fetos com diagnóstico pré-natal de malformações cervical e oral: relato de casos

Anesthesia for ex utero intrapartum treatment (EXIT procedure) in fetus with prenatal diagnosis of oral and cervical malformations: case reports

Daniel Corrêa Helfer; Jefferson Clivatti; Américo Massafuni Yamashita; Antonio Fernades Moron

http://dx.doi.org/10.1590/S0034-70942012000300013 Braz J Anesthesiol, vol.62, n3, p.417-423, 2012
PDF Português
PDF English
Downloads: 1
Views: 1146

Resumo

JUSTIFICATIVA E OBJETIVOS: O feto com diagnóstico pré-natal de massa cervical, ou qualquer outra doença que obstrua as vias aéreas, não deve ser abordado de forma convencional por apresentar dois desafios ao médico assistente logo após o parto: o tempo limitado para se estabelecer o acesso a vias aéreas potencialmente difíceis e a ausência de anestesia do neonato caso seja necessária instrumentação das vias aéreas. O procedimento EXIT (ex utero intrapartum treatment - EXIT procedure) consiste em manter a circulação fetoplacentária durante a cesariana até que as vias aéreas do feto estejam asseguradas. RELATO DOS CASOS: Mulher de 37 anos, G3P2, 38 semanas de gestação, apresentando polidrâmnio e feto com grande massa cervical diagnosticada por ultrassonografia pré-natal. A cesariana foi realizada com procedimento EXIT para possibilitar o acesso seguro das vias aéreas. Após a histerotomia, o feto foi intubado sob laringoscopia direta. O concepto foi transferido imediatamente para outra sala de cirurgia, onde foi realizada a ressecção do tumor cervical e a traqueostomia, ambos com sucesso. Mulher de 27 anos, G3P1A1, idade gestacional de 32 semanas, cujo feto tinha diagnóstico pré-natal de grande tumor em região oral. O tumor obstruía as vias aéreas do feto e foi programada traqueostomia com técnica EXIT, no entanto, foi possível intubar o recém-nascido sob laringoscopia direta, sendo então submetido à ressecção do tumor e encaminhado à UTI neonatal. CONCLUSÕES: Os relatos descrevem o uso bem sucedido de anestesia geral com isoflurano para a realização de cesariana seguida de procedimento EXIT em fetos com tumores obstruindo as vias aéreas.

Palavras-chave

cirurgia, cesárea, doenças, congênita, neoplasias, voláteis, isoflurano

Abstract

BACKGROUND AND OBJECTIVES: Fetus prenatally diagnosed with neck tumors, or with any other disease that obstructs the airways, should not be treated conventionally, as the assistant physician has to face two challenges right after the infant's delivery: the limited time to establish the access to the potentially difficult airways and the lack of anesthesia of the neonate in case of instrumentation of the airways. The ex utero intrapartum treatment, i.e., the EXIT procedure consists of maintaining the fetoplacental circulation during the cesarean section, until the airways of the fetus be secured. CASE REPORTS: Female patient, 37 years old, G3P2, 38 weeks pregnant, having polyhydramnios and fetus diagnosed with large cervical masses by prenatal ultrasound. A cesarean section was performed using the EXIT procedure to enable safe access to the infant's airways. After hysterotomy, the fetus was intubated by direct laryngoscopy. The neonate was immediately transferred to another operating room, where cervical tumor resection of the neck tumor and tracheostomy were successfully performed. Female patient, 27 years old, G3P1A1, 32 weeks pregnant, whose fetus was prenatally diagnosed with a large oral tumor. As the tumor obstructed the fetus' airways, a tracheostomy was performed when the fetus underwent EXIT procedure. It was then possible to use direct laryngoscopy for neonate intubation. The fetus underwent tumor resection and was sent to the Neonatal Intensive Care Unit. CONCLUSIONS: Reports describe the successful use of general anesthesia with isoflurane for cesarean delivery followed by the EXIT procedure in fetus diagnosed with tumors obstructing the airways.

Keywords

cesarean section, congenital, hereditary, and neonatal diseases and abnormalities, fetal therapies, isoflurane, prenatal diagnosis

References

Tanaka M, Sato S, Naito H. Anesthetic management of a neonate with prenatally diagnosed cervical tumor and upper airway-obstruction. Can J Anaesth. 1994;41:236-240.

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

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

Gaiser RR, Cheek TG, Kurth CD. Anesthetic management of cesarean delivery complicated by ex utero intrapartum treatment of the fetus. Anesth Analg. 1997;84:1150-1153.

Shih GH, Boyd GL, Vincent RD. The EXIT procedure facilitates delivery of an infant with a pretracheal teratoma. Anesthesiology. 1998;89:1573-1575.

Schwartz DA, Moriarty KP, Tashjian DB. Anesthetic management of the EXIT (ex utero intrapartum treatment) procedure. J Clin Anesth. 2001;13:387-391.

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

Gogarten W, Van Aken H, Marcus MA. Fetal surgery: general or regional anaesthesia?. Curr Opin Anaesthesiol. 2000;13:277-281.

Cox PB, Gogarten W, Strumper D. Fetal surgery, anaesthesiological considerations. Curr Opin Anaesthesiol. 2004;17:235-240.

Courtier J, Poder L, Wang ZJ. Fetal tracheolaryngeal airway obstruction: prenatal evaluation by sonography and MRI. Pediatr Radiol. 2010;40:1800-1805.

Stevens GH, Schoot BC, Smets MJW. 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.

Botto HA, Boailchuk ID, Garcia C. Ex utero intrapartum treatment: Management of neonatal congenital high airway obstruction syndrome. Case report. Arch Argent Pediatr. 2010;108:E92-E95.

Schwartz MZ, Silver H, Schulman S. Maintenance of the placental circulation to evaluate and treat an infant with massive head and neck hemangioma. J Pediatr. 1993;28:520-522.

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

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.

George RB, Melnick AH, Rose EC. Case series: Combined spinal epidural anesthesia for Cesarean delivery and ex utero intrapartum treatment procedure. Can J Anaesth. 2007;54:218-222.

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

Biehl DR, Yarnell R, Wade JG. The uptake of isoflurane by the foetal lamb in utero: effect on regional blood flow. Can Anaesth Soc J. 1983;30:581-586.

Dwyer R, Fee JPH, Moore J. Uptake of halothane and isoflurane by mother and baby during cesarean-section. Br J Anaesth. 1995;74:379-383.

Reynolds LM, Lau M, Brown R. Intramuscular rocuronium in infants and children: Dose-ranging and tracheal intubating conditions. Anesthesiology. 1996;85:231-239.

Giannakoulopoulos X, Sepulveda W, Kourtis P. Fetal plasma-cortisol and beta-endorphin response to intrauterine needling. Lancet. 1994;344:77-81.

Braga A FA, Frias JAF, Braga FSS. Anestesia para tratamento intraparto extra-útero em feto com diagnóstico pré-natal de higroma na região cervical. Rev Bras Anestesiol. 2006;58:278-286.

Tame JD, Abrams LM, Ding XY. Level of postoperative analgesia is a critical factor in regulation of myometrial contractility after laparotomy in the pregnant baboon: Implications for human fetal surgery. Am J Obstet Gynecol. 1999;180:1196-1201.

Fauza DO, Berde CB, Fishman SJ. Prolonged local myometrial blockade prevents preterm labor after fetal surgery in a leporine model. J Pediatr Surg. 1999;34:540-542.

Ramanathan S, Gandhi S, Arismendy J. Oxygen-transfer from mother to fetus during cesarean-section under epidural-anesthesia. Anesth Analg. 1982;61:576-581.

Eschertzhuber S, Keller C, Mitterschiffthaler 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.

Abraham RJ, Sau A, Maxwell D. A review of the EXIT (ex utero intrapartum treatment) procedure. J Obstet Gynaecol. 2010;30:1-5.

Dick WF. Anesthesia for cesarean-section (epidural and general): effects on the neonate. Eur J Obstet Gynecol Reprod Biol. 1995;59:S61-S67.

Gaiser RR, Kurth CD, Cohen D. The cesarean delivery of a twin gestation under 2 minimum alveolar anesthetic concentration isoflurane: one normal and one with a large neck mass. Anesth Analg. 1999;88:584-586.

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.

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

Palahniuk RJ, Schnider SM. Maternal and fetal cardiovascular and acid-base changes during halothane and isoflurane anesthesia in the pregnant ewe. Aneshtesiology. 1974;41:462-472.

Rosen MA, Andreae MH, Cameron AG. Nitroglycerin for fetal surgery: fetoscopy and Ex Utero intrapartum Treatment Procedure with Malignat Hypertermia Precautions. Anesth Anag. 2003;96:698-700.

Yamashita AM, Moron AF. Anestesia para cirurgia fetal. Anestesia em Obstetrícia. 2007:347-355.

5dd2e3e70e8825f526c63493 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