Geburtshilfe: Anästhesie bei EXIT-Prozedur

Zusammenfassung

Die Ex-utero-Intrapartum-Treatment-(EXIT-)Prozedur wird im Rahmen einer erweiterten Sectio caesarea beispielsweise bei fetaler Atemwegsanomalie durchgeführt. Dazu ist die Aufrechterhaltung der uteroplazentaren Versorgung des Feten bei optimaler Uterusrelaxation erforderlich. Eine „balancierte“ Anästhesie, Tokolyse und maternale arterielle Blutdruckeinstellung in engen Grenzen wird empfohlen. Das fetale Standardmonitoring umfasst dabei die Pulsoxymetrie und Echokardiografie. Es werden die physiologischen Besonderheiten und anästhesiologischen Ziele der EXIT-Prozedur und Möglichkeiten der Anästhesieführung dargestellt sowie ein Ausblick auf mögliche Neuerungen gegeben.

Abstract

The ex utero intrapartum treatment (EXIT) procedure is performed as a part of an extended caesarean section for example to treat fetal airway disorders. For treatment, optimal uterine relaxation is necessary, however utero-placental supply of the fetus has to be guaranteed as well. “Balanced” anesthesia, tocolysis and tight maternal arterial blood pressure control are recommended. Standard fetal monitoring comprises pulse oxymetry and echocardiography. The article describes the physiology and anesthestic goals of the EXIT procedure, discusses alternative anesthesia techniques and gives an outlook on emerging progress.

Kernaussagen

• Die EXIT-Prozedur (= Ex Utero Intrapartum Treatment) wird im Rahmen einer erweiterten Sectio caesarea beispielsweise bei fetaler Atemwegsanomalie durchgeführt. Dazu ist die Aufrechterhaltung der uteroplazentaren Versorgung des Feten bei optimaler Uterusrelaxation erforderlich. Eine „balancierte“ Anästhesie, Tokolyse und maternale arterielle Blutdruckeinstellung in engen Grenzen wird empfohlen. Das fetale Standardmonitoring umfasst dabei die Pulsoxymetrie und Echokardiografie.

• Ziele während der EXIT-Prozedur sind:

  • Aufrechterhaltung der uteroplazentaren Zirkulation

  • kontrollierte uterine Hypotension (komplette Relaxation)

  • kontinuierliches fetales Monitoring

  • Aufrechterhaltung des uterinen Volumens

Schlüsselwörter

EXIT Prozedur - uteroplazentarer Blutfluss - Anästhesieführung bei EXIT - fetales Monitoring

Key words

EXIT procedure - utero-placental blood flow - anesthesia for EXIT - fetal monitoring

• Literatur

• 1 Norris MC, Joseph J, Leighton BL. Anesthesia for perinatal surgery. Am J Perinatal 1989; 6: 39-40
• 2 Mychaliska GB, Bealer JF, Graf JL. et al. Operating on placental support: the ex utero intrapartum treatment procedure. J Pediatr Surg 1997; 32: 227-230 discussion 230–231
• 3 Bouchard S, Johnson MP, Flake AW. et al. The EXIT procedure: experience and outcome in 31 cases. J Pediatr Surg 2002; 37: 418-426
• 4 Hirose S, Farmer DL, Lee H. et al. The ex utero intrapartum treatment procedure: Looking back at the EXIT. J Ped Surg 2004; 39: 375-380
• 5 Kill C, Gebhardt B, Schmidt S. et al. Die EXIT-Prozedur als anästhesiologische Herausforderung. Anaesthesist 2005; 54: 1105-1110
• 6 Gaiser RR, Kurth CD. Anesthetic considerations for fetal surgery. Semin Perinatol 1999; 23: 507-514
• 7 Okutomi T, Whittington RA, Stein DJ. et al. Comparison of the effects of sevoflurane and isoflurane anesthesia on the maternal-fetal unit in sheep. J Anesth 2009; 23: 392-398
• 8 Palahniuk RJ, Shnider SM. Maternal and fetal cardiovascular and acid-base changes during halothane and isoflurane anesthesia in the ewe. Anesthesiology 1974; 41: 462-472
• 9 Braden A, Maani C, Nagy C. Anesthetic management of an ex utero intrapartum treatment: a novel balanced approach. J Clin Anesth 2016; 31: 60-63
• 10 Van de Velde M, Teunkens A, Kuypers M. et al. General anesthesia with target controlled infusion of propofol for planned caesarean section: maternal and neonatal effects of a remifentanil-based technique. Int J Obstet Anesth 2004; 13: 153-158
• 11 Thind AS, Turner RJ. In vitro effects of propofol on gravid human myometrium. Anaesth Intensive Care 2008; 36: 802-806
• 12 Boat A, Mahmoud M, Michelfelder EC. et al. Supplementing desflurane with intravenous anesthesia reduces fetal cardiac dysfunction during open fetal surgery. Paediatr Anaesth 2010; 20: 748-756
• 13 Soares de Moura R, Silva GA, Tano T. et al. Effect of propofol on human fetal placental circulation. Int J Obstet Anesth 2010; 19: 71-76
• 14 Rosen MA, Andreae MH, Cameron AG. Nitroglycerin for fetal surgery: fetoscopy and ex utero intrapartum treatment procedure with malignant hyperthermia precautions. Anesth Analg 2003; 96: 698-700
• 15 Fink RJ, Allen TK, Habib AS. Remifentanil for fetal immobilization and analgesia during the ex utero intrapartum treatment procedure under combined spinal-epidural anaesthesia. Br J Anaesth 2011; 106: 851-855
• 16 Erkinaro T, Makikallio K, Kavasmaa T. et al. Effects of ephedrine and phenylephrine on uterine and placental circulations and fetal outcome following fetal hypoxaemia and epidural-induced hypotension in a sheep model. Br J Anaesth 2004; 93: 825-832
• 17 Ngan Kee WD, Khaw KS, Lau TK. et al. Randomised double-blinded comparison of phenylephrine vs. ephedrine for maintaining blood pressure during spinal anaesthesia for non-elective Caesarean section. Anaesthesia 2008; 63: 1319-1326
• 18 Golombeck K, Ball RH, Lee H. et al. Maternal morbidity after maternal-fetal surgery. Am J Obstet Gynecol 2006; 194: 834-839
• 19 De Heus R, Mol BW, Erwich JJ. et al. Adverse drug reactions to tocolytic treatment for preterm labour: prospective cohort study. BMJ 2009; 338: b744
• 20 Gitau R, Fisk NM, Teixeira JM. et al. Fetal hypothalamic-pituitary-adrenal stress responses to invasive procedures are independent of maternal responses. J Clin Endocrinol Metab 2001; 86: 104-109
• 21 Van de Velde M, Jani J, De Buck F. et al. Fetal pain perception and pain management. Semin Fetal Neonatal Med 2006; 11: 232-236
• 22 Van de Velde M, De Buck F. Fetal and maternal analgesia/anesthesia for fetal procedures. Fetal Diagn Ther 2012; 31: 201-209
• 23 Nijland R, Jongsma HW, Nijhuis JG. et al. Accuracy of fetal pulse oximetry and pitfalls in measurement. Eur J Obstet Gynecol Reprod Biol 1997; 72: S21-S27
• 24 Ross MG, Gala R. Use of umbilical artery base excess: algorithm for the timing of hypoxic injury. Am J Obstet Gynecol 2002; 187: 1-9
• 25 Giliberti P, Mondi V, Conforti A. et al. Near infrared spectroscopy in newborns with surgical disease. J Matern Fetal Neonat 2011; 24: S56-S58
• 26 Reed CA, Baker RS, Lam CT. et al. Application of near-infrared spectroscopy during fetal cardiac surgery. J Surg Res 2011; 171: 159-163
• 27 Stefini S, Bazzana T, Smussi C. et al. EXIT (Ex utero Intrapartum Treatment) in lymphatic malformations of the head and neck: discussion of three cases and proposal of an EXIT-TTP (Team Time Procedure) list. Int J Pediatr Otorhinolaryngol 2012; 76: 20-27