Abstract
Purpose: We propose that using remifentanil in ex utero intrapartum treatment (EXIT) procedures reduces the need for maternal exposure to general anesthesia. Using remifentanil along with spinal anesthesia eliminates the fetal and maternal risks associated with inhalational general anesthesia, allows the mother to be awake, and obviates the need for and costs associated with general anesthesia and a second anesthesia team. Materials and Methods: We performed a retrospective review of all sequential patients undergoing ex utero intrapartum treatment procedure at our hospital from 1/1/2009 to 11/1/2010. All procedures were performed under regional neuraxial analgesia, using nitroglycerine as a tocolytic agent and remifentanil for analgesia. Variables included indication, time to secured fetal airway, complications, estimated blood loss, need for additional anesthetics, participating personnel, and survival. Results: All five of our ex utero intrapartum treatment procedures were successfully completed with combined spinal epidural remifentanil anesthetic. No patient was required additional alternative anesthetic. There were no complications with mother or fetus. Indications for procedure were arthyrogryposis (n = 3), fetal goiter, and micrognathia. Average time to secured airway was 10.25 minutes. Average estimated blood loss was 1010 ml. All five mothers were conscious during their procedure. Conclusions: We report the largest series of ex utero intrapartum treatment procedures performed with remifentanil regional anesthesia. We found that the combined use of nitroglycerin and regional remifentanil anesthesia is a safe alternative to the pediatric otolaryngologist for performing ex utero intrapartum treatment procedures without the risks of general anesthesia, allowing the mother to be awake for the delivery, and reducing the cost of providing care.
Highlights
Ex utero intrapartum treatment (EXIT) procedures are effective means for evaluating and securing the fetal airway in prenatally identified head and neck anomalies
We propose that using remifentanil in ex utero intrapartum treatment (EXIT) procedures reduces the need for maternal exposure to general anesthesia
We found that the combined use of nitroglycerin and regional remifentanil anesthesia is a safe alternative to the pediatric otolaryngologist for performing ex utero intrapartum treatment procedures without the risks of general anesthesia, allowing the mother to be awake for the delivery, and reducing the cost of providing care
Summary
Ex utero intrapartum treatment (EXIT) procedures are effective means for evaluating and securing the fetal airway in prenatally identified head and neck anomalies. It involves obstetrics partially delivering the infant while maintaining uteroplacental circulation, so that the pediatric otolaryngologist can evaluate and secure a threatened airway. Most centers use general anesthesia for both the mother and the fetus, relying on inhaled halogenated anesthetic agents for uterine relaxation. This potentially exposes the mother to the risks associated with general anesthesia, requires the mother to be asleep for the procedure, and can require two anesthesia teams with their associated costs. Our series examines the surgical outcomes of EXIT procedures performed at Duke University Hospital using combined neuraxial regional anesthesia with remifentanil, thereby avoiding general inhalational anesthetics
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