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Anaesthesia for foetal surgery
 

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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    Anaesthesia for foetal surgery Anaesthesia for foetal surgery Presentation Transcript

    • Anaesthesia for foetal surgery Dr. F. De Buck Anaesthesiology University Clinics Leuven Belgium. 11 feb 2011
    • Indications for foetal surgery Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
    • Open foetal surgery
      • Major risks for mother and foetus
        • Invasive monitoring / intensive care
        • Blood loss
      • Laparotomy + hysterotomy
      • Foetal monitoring
      • Experimental technique
        • CCAM
        • Myelomeningocoele
    • 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
    • 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
    • EXIT procedure
    • Foetoscopic interventions
      • Interventions on the foetus
        • Congenital diaphragmatic hernia
        • Vesico-amniotic shunt
      • Interventions on placenta, cord & membranes
        • TTTS
        • Cord occlusion – selective foeticide
    • 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
    • Fetoscopic Endoluminal Tracheal Occlusion Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
    • 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
    • Isolated congenital diaphragmatic hernia Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
    • 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
    • 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 %
    • Laser ablation for TTTS Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
    • Laser ablation for TTTS Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
    • 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
    • Anaesthesia for fetoscopic surgery
      • Maternal
        • Local anaesthesia +/- sedation (remifentanil)
        • High risk for urgent C-section : CSE
          • Viable foetus
          • Contractile uterus
      • Foetal anaesthesia ?
    • Foetal anaesthesia Does the foetus feel pain ? Responses to noxious stimuli
    • Pain : 2 components
      • Nociception :
        • Detection, transmission and modulation of a noxious stimulus by the nervous system
        • “ Objective”
      • Emotional reaction :
        • Where nociception meets consciousness.
        • “ Subjective”
    • 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
    • foetus or neonate ? Both have the same gestational age !
    • Foetal nociceptive system
      • Anatomical development of nociceptive pathways
      • Neurophysiology
      • Behaviour of the foetus
      • foetal stress response
    • 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.
    • 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...
    • 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.
    • 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.
    • foetal stress response
      • Measurement of stress hormones
        • Cortisol
        • β-endorphin
        • Noradrenalin
      • Regional foetal blood flow
      Giannakoulopoulos et al. The Lancet 1994; 344, 77-81.
    • Cortisol levels IHV PCI Giannakoulopoulos et al. The Lancet 1994; 344, 77-81.
    • Noradrenalin Giannakoulopoulos et al. Ped Res 1999; 45, 494 - 499.
    • 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.
    • 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
    • Long term implications Taddio et al. The Lancet 1997; 349, 599 - 603. Hyperalgesia after circumcision
    • 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
    • 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
    • Pain stimulus in utero De Buck et al. IJOA 2009; S1.
    • foetal pain perception Does the foetus feel pain ? Foetal analgesia ?
    • Foetal opioids Fisk et al. Anesthesiology 2001; 95, 828 – 835.
    • Fentanyl decreases foetal stress response Fisk et al. Anesthesiology 2001; 95, 828 – 835.
    • foetoscopic foetal surgery
      • Maternal anaesthesia
        • Local or locoregional
        • +/- sedation
      • Foetal anaesthesia
        • IV or IM
          • Opioids
          • Atropine
          • Muscle relaxant
        • Additional risk
    • foetoscopic surgery on membranes, cord and placenta
      • Maternal anaesthesia
        • Local / regional
      • Foetal anaesthesia
        • IV / IM
        • IV maternal sedation
      • -> Foetal immobilisation
    • Without sedation...
    • Maternal IV remifentanil
      • Easy to titrate
      • Short acting IV opioid
      • Succesfull immobilisation of the foetus
      • Excellent transplacental passage
    • 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 ?
    • 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
    • Thank you