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Anaesthesia for foetal surgery

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An overview of foetal surgical procedures and the anaesthetic techniques used. …

An overview of foetal surgical procedures and the anaesthetic techniques used.
Discussion about the need for foetal analgesia.

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  • 1. Anaesthesia for foetal surgery Dr. F. De Buck Anaesthesiology University Clinics Leuven Belgium. 11 feb 2011
  • 2. Indications for foetal surgery Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
  • 3. Open foetal surgery
    • Major risks for mother and foetus
      • Invasive monitoring / intensive care
      • Blood loss
    • Laparotomy + hysterotomy
    • Foetal monitoring
    • Experimental technique
      • CCAM
      • Myelomeningocoele
  • 4. Open foetal surgery
    • Anaesthesia vapour
      • Transplacentar passage
      • High concentrations for uterine relaxation
    • Foetal medication : IV or IM
      • Muscle relaxant (pancuronium 0,3 mg/kg)
      • Opioid (fentanyl 10 µg/kg – sufentanil 1 µg/kg)
    • Postoperative analgesia : PCEA
      • Uterine contractility postop
  • 5. EXIT procedure
    • Securing airway before clamping of cord
      • Endotracheal intubation / tracheostomy
      • ECMO
    • During C-section
    • Uterine relaxation
      • Placental perfusion
      • Volatiles > 2 MAC
      • Nitroglycerine IV
      • > Blood loss
    • GA or CSE
  • 6. EXIT procedure
  • 7. Foetoscopic interventions
    • Interventions on the foetus
      • Congenital diaphragmatic hernia
      • Vesico-amniotic shunt
    • Interventions on placenta, cord & membranes
      • TTTS
      • Cord occlusion – selective foeticide
  • 8. Congenital diaphragmatic hernia
    • Pulmonary hypoplasia
      • Pressure from abdominal organs
      • Ventilatory insufficiency
      • Persistent pulmonary hypertension
    • Prediction of poor outcome : LHR
      • LHR 0.4-0.5 : extreme : no survival
      • LHR < 1.0 : severe : survival +/- 15%
      • LHR > 1.0 : survival > 60%
    • Position of liver
  • 9. Fetoscopic Endoluminal Tracheal Occlusion Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
  • 10. FETO
    • Obstruction of lung liquid flow
      • Stretch-induced growth
        • Airways and vessels
      • Gradual repositioning of abdominal organs
        • No kinking of liver vessels
    • Balloon removed prenatally (34 weeks)
      • Fetoscopic / puncture
      • Maturation Type 2 pneumocytes -> surfactant
    • Delivery with balloon -> EXIT procedure
  • 11. Isolated congenital diaphragmatic hernia Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
  • 12. Twin to Twin Transfusion Syndrome
    • 5 – 10 % of monochorionic twins
      • Imbalance in shared placental circulation
    • “ Donor” twin
      • Hypovolaemia & anemia
      • Oliguria -> oligohydramnios (“stuck”)
    • “ Receptor” twin
      • Hypervolaemia, volume overload
      • Polyuria -> polyhydramnios
      • Cardiac failure -> hydrops
  • 13. TTTS
    • Polyhydramnios -> preterm ROM
    • R/ repetitive amniodrainages
      • 61 % survival
      • Preterm delivery (28 wks GA) -> morbidity
    • Fetoscopic ablation of anastomoses
      • Bichorionisation of placenta
      • 1% risk for placental abruption
      • PROM within 4 weeks : 6-9 %
  • 14. Laser ablation for TTTS Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
  • 15. Laser ablation for TTTS Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
  • 16. Cord occlusion – selective feticide
    • Monochorionic twins
      • 1 twin with severe abnormalities
      • Protection of viable co-twin
    • Twin Reversed Arterial Perfusion sequence
      • TRAP – foetus acardiacus
      • Perfusion by “pump” twin
      • Cardiac failure of “pump” twin
      • Feto-fetal haemorrhage
    • Fetoscopic or ultrasound guided bipolar cord coagulation
  • 17. Anaesthesia for fetoscopic surgery
    • Maternal
      • Local anaesthesia +/- sedation (remifentanil)
      • High risk for urgent C-section : CSE
        • Viable foetus
        • Contractile uterus
    • Foetal anaesthesia ?
  • 18. Foetal anaesthesia Does the foetus feel pain ? Responses to noxious stimuli
  • 19. Pain : 2 components
    • Nociception :
      • Detection, transmission and modulation of a noxious stimulus by the nervous system
      • “ Objective”
    • Emotional reaction :
      • Where nociception meets consciousness.
      • “ Subjective”
  • 20. History of neonatal pain
    • The early days :
      • It was believed that (preterm) neonates did not have a completely developed pain system
      • 1980's : beter outcome with Fentanyl for closure of open ductus arteriosus in preterm neonates
      • Evidence for neonatal stress response
    • Neonates on intensive care :
      • Better outcome with adequate analgesia during invasive procedures
      • Better neural development on long term
    Anand KJS. Biol Neonate 1998 vol. 73 (1) pp. 1-9
  • 21. foetus or neonate ? Both have the same gestational age !
  • 22. Foetal nociceptive system
    • Anatomical development of nociceptive pathways
    • Neurophysiology
    • Behaviour of the foetus
    • foetal stress response
  • 23. Anatomical pathways 0: Peripheral receptors 1: Afferent fibres 2: Spino-thalamic fibres 3: Thalamus 4,5: Thalamo-cortical fibres 6: Inhibitory efferent fibres Lowery et al. Sem Perinatol 2007; 31, 275.
  • 24. Development of nociceptive pathways
    • Peripheral receptors
      • Perioral from 7 weeks
      • Spread over body by 20 weeks
    • Afferent system
      • Receptors -> spinal cord : 8 wks
      • Substantia gelatinosa : 13 wks
      • Spino-thalamic fibres : 16 – 20 wks
      • Thalamo-cortical fibres : 17 – 24 wks
    • Efferent inhibitory system
      • Develops after birth...
  • 25. Neurophysiology
    • EEG
      • Detectable from 19 weeks
      • Sustained from 22 weeks
      • SSEP's from 24 weeks
      • Structured EEG from 26 weeks
      • Sleep/wake patterns : 28 – 30 weeks
    • fMRI
      • Response on auditive and visual stimuli
    Glover and Fisk. Brit J Obstet Gynecol 1999; 106, 881-886. Fulford J, Human brain mapping 2003 vol. 20 (4) pp. 239-45.
  • 26. Behaviour
    • Movement to external stimuli : 8 weeks
    • Reaction to sound : 20 weeks
    • Behavioural response to painful stimuli : 22 weeks (preterm infants)
    • Differentiation of sound : 28 weeks
    Prechtl. Early Hum Dev 1985; 12, 91 - 98. De Vries. Early Hum Dev 1985; 12, 301 – 322.
  • 27. foetal stress response
    • Measurement of stress hormones
      • Cortisol
      • β-endorphin
      • Noradrenalin
    • Regional foetal blood flow
    Giannakoulopoulos et al. The Lancet 1994; 344, 77-81.
  • 28. Cortisol levels IHV PCI Giannakoulopoulos et al. The Lancet 1994; 344, 77-81.
  • 29. Noradrenalin Giannakoulopoulos et al. Ped Res 1999; 45, 494 - 499.
  • 30. Regional blood flow
    • Reduction in foetal cerebral vascular resistance
    • Redistribution of blood to the brain (and other vital organs)
    Teixeira et al. The Lancet 1996; 347, 624.
  • 31. Long term effects
    • Early exposure to noxious stimulation
      • Effect on neural development
    • Neonatal ritual circumcision
      • With / without EMLA analgesia
      • Stronger reactions to vaccination at 2 months
    • Vulnerability to stress disorders
      • Ex-preterm neonates : noxious stimulation on NICU
  • 32. Long term implications Taddio et al. The Lancet 1997; 349, 599 - 603. Hyperalgesia after circumcision
  • 33. Nerve sprouting Reynolds et al. J Comp Neur 1995; 358, 487 - 498.
    • Neonatal rats
      • Skin wound on different ages
      • Staining for nerves
    • Greatest effect when wounded earlier in life
      • Effect up to 3 – 4 weeks later
    • Also 50% drop in mechanical thresholds
  • 34. Pain stimulus in utero
    • Pregnant rats, d18
    • Injection of foetuses
      • CFA (pain stimulus)
      • Placebo
      • Nothing (control)
    • Birth
    • Hot plate test
      • Age 7 days
      • Age 28 days
  • 35. Pain stimulus in utero De Buck et al. IJOA 2009; S1.
  • 36. foetal pain perception Does the foetus feel pain ? Foetal analgesia ?
  • 37. Foetal opioids Fisk et al. Anesthesiology 2001; 95, 828 – 835.
  • 38. Fentanyl decreases foetal stress response Fisk et al. Anesthesiology 2001; 95, 828 – 835.
  • 39. foetoscopic foetal surgery
    • Maternal anaesthesia
      • Local or locoregional
      • +/- sedation
    • Foetal anaesthesia
      • IV or IM
        • Opioids
        • Atropine
        • Muscle relaxant
      • Additional risk
  • 40. foetoscopic surgery on membranes, cord and placenta
    • Maternal anaesthesia
      • Local / regional
    • Foetal anaesthesia
      • IV / IM
      • IV maternal sedation
    • -> Foetal immobilisation
  • 41. Without sedation...
  • 42. Maternal IV remifentanil
    • Easy to titrate
    • Short acting IV opioid
    • Succesfull immobilisation of the foetus
    • Excellent transplacental passage
  • 43. Safety of foetal analgesia
    • Behavioural teratogenic effect of analgesia / anaestesia
      • CNS sensitivity during period of myelination
    • Intrauterine exposure to halothane -> effect on postnatal learning behaviour in rats
    • Both GABA-ergic drugs and NMDA antagonists
      • Neuronal apoptosis in rats during synaptogenesis
      • Quid opioids ?
    • Relevance for humans ?
      • Rat experiments : prolonged periods of administration, large doses
      • Quid control of circulation, oxygenation during experiments ?
    • Foetal analgesia without nociceptive stimulation ?
  • 44. Conclusions
    • The foetus reacts to noxious stimulation
    • Noxious stimuli most likely produce long term effects
    • Foetal analgesia decreases stress response
    • Different options are available, depending on the type of surgery and the extent of foetal stress and trauma
    • Maternal hemodynamic stability is crucial
    • Potential harmful effects of foetal anaesthesia / analgesia -> correct indications
  • 45. Thank you

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