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Similar to Airway Management for the Unborn Patient by Dr. Corey Iqbal, Chief, Section of Fetal Surgery, Children's Mercy Kansas City, Assistant Professor of Surgery, UMKC
Similar to Airway Management for the Unborn Patient by Dr. Corey Iqbal, Chief, Section of Fetal Surgery, Children's Mercy Kansas City, Assistant Professor of Surgery, UMKC (20)
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Airway Management for the Unborn Patient by Dr. Corey Iqbal, Chief, Section of Fetal Surgery, Children's Mercy Kansas City, Assistant Professor of Surgery, UMKC
- 1. Airway Management for the Unborn Patient Corey W. Iqbal, MD, FAAP
- 2. Objectives • What is an EXIT procedure • Indications • Procedural considerations – Preoperative – Intraoperative – Postoperative
- 3. • Not that important Fetal Airway
- 6. History of Fetal Surgery • Michael R. Harrison – 1981 “Father of Fetal Surgery” • Bladder Obstruction • CDH Pulmonary Hypoplasia
- 7. CDH • 70% survival – Pulm hypoplasia – Pulm HTN
- 8. CHAOS
- 10. OOPS!!! • Operation On Placental Support • Ex-utero Intra-partum Therapy (EXIT)
- 11. NOT A CESAREAN SECTION EXIT • Placental Circulation – Placenta as bypass pump • Uterine atony – Deep general anesthesia – Tocolytics • Hemorrhage risk* Cesarean • Uterine contraction • No placental circulation • Regional anesthesia • “Slash & Dash”
- 12. Indications • Any anomaly where cardiopulmonary collapse off placental/fetal circulation – Airway • Fetal neck mass • CHAOS • Micrognathia – Thoracic lesions • Lung lesions • CDH – Congenital heart disease – SCT
- 13. EXIT-to-??? • EXIT-to-airway – Oral endotracheal – Trachesotomy • EXIT-to-resection • EXIT-to-ECMO
- 14. Fetal Considerations – Pain – fetal cocktail – Monitoring • US • Pulse Oximetry • Temperature – Venous access
- 15. Maternal Considerations • DVT risk • Position – right side up • Epidural • DEEP general anesthesia – Uterine atony • Tocolytics – Nitroglycerin – Terbutaline • Hemorrhage risk
- 16. Preoperative • Patient selection • Fetal Neck Mass – Obtain MRI – repeat between 30-34 weeks – TEDI score >12 – Teratoma – Polyhydramnios Cass et al. JPS. 2012;47:46-50
- 17. Fetal Neck Mass • Survival without EXIT – 0-20% • Survival with EXIT – 83% • ALL EXITs – UCSF survival 71% Iqbal et al. In Submission
- 18. Fetal Neck Mass • 36 year old
- 19. Fetal MRI
- 20. Aerodigestive Compression Deviated Trachea Small Stomach
- 21. Intraoperative • Low transverse incision to expose uterus • Placental mapping by ultrasound • Hysterotomy • Tocolytics – Nitro – Terbutaline
- 22. Intraoperative
- 23. Intraoperative • Fetal cocktail – Fentanyl + rocuronium • Pulse oximetry – HR – SpO2 • Temp probe • +/-Fetal IV access – Pressors: epi, atropine – Fluid resuscitation
- 24. Intraoperative
- 25. Other Indications • CDH – Boston data does not support – EXIT-to-ECMO: 33% vs 50% survival • Lung lesions – 100% survival; discharge at 10 days – 71% survival without EXIT Buchmiller et al. JPS. 2012;47:1053-1057 Lee et al. JPS. 2013;48:138-144
- 26. Other Indications • Congenital Heart Disease – HLHS with in tact septum – Delivery in OR with immediate cath • Other neoplasms – SCT – Little data to support
- 28. Delivery • Secure airway – paralytics on board • Clamp chord and deliver – Obtain chord blood gas • Anesthesia – Reduce inhalation – Administer pitocin • Now becomes a Cesarean
- 29. Crowd Control
- 30. Postoperative • Mom C-sxn – Pain control – ADAT – 4 days • Baby – Work-up – Definitive treatment
- 31. Other Scenarios • CHAOS – Fetoscopy
- 33. Questions