EXIT procedures

[sevoflurane]

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I have a good pedi friend go through an EXIT procedure not too long ago.

This may be one of the most difficult, sphincter squeezing cases out there.... and it's all about the airway. 😀

Post your experience if you've been lucky enough to be involved in one of these.

The EXIT procedure (EX utero Intrapartum Treatment) encompasses a multidisciplinary approach to situations in which airway obstruction is anticipated. Uteroplacental circulation is maintained to avoid neonatal hypoxemia while intubation is attempted. Not only is it useful in congenital diaphragmatic hernia with intrauterine tracheal occlusion, but new indications have been proposed. We present two cases in which EXIT procedure was adopted (huge cervical mass with tracheal compression and a highly vascularized cephalocervical mass) for the same purpose on different grounds. Our two cases stress once more the importance of combining fetal ultrasound and magnetic resonance imaging in the characterization of cervical masses and its usefulness in programming the procedure with a multidisciplinary team.

http://www.ncbi.nlm.nih.gov/pubmed/17135754

 

[rsgillmd]

I have a good pedi friend go through an EXIT procedure not too long ago.

This may be one of the most difficult, sphincter squeezing cases out there.... and it's all about the airway. 😀

Post your experience if you've been lucky enough to be involved in one of these.

The EXIT procedure (EX utero Intrapartum Treatment) encompasses a multidisciplinary approach to situations in which airway obstruction is anticipated. Uteroplacental circulation is maintained to avoid neonatal hypoxemia while intubation is attempted. Not only is it useful in congenital diaphragmatic hernia with intrauterine tracheal occlusion, but new indications have been proposed. We present two cases in which EXIT procedure was adopted (huge cervical mass with tracheal compression and a highly vascularized cephalocervical mass) for the same purpose on different grounds. Our two cases stress once more the importance of combining fetal ultrasound and magnetic resonance imaging in the characterization of cervical masses and its usefulness in programming the procedure with a multidisciplinary team.

http://www.ncbi.nlm.nih.gov/pubmed/17135754

I've been involved with two -- one directly and one indirectly (was involved in the planning but it showed up early emergently).

These are mostly done under GA and about 2 MAC inhalational anesthetic to keep the uterus relaxed. Prepare for blood loss secondary to the potential for development of uterine atony. Assuming this is taking place at a planned time, Peds ENT will be there and have their equipment set up. NICU needs to be on-board also, especially if you are in a facility without peds surgery. They will help stabilize the baby initially and prepare it for transport. If immediate surgery on the baby is planned it makes sense to schedule the mom's surgery and have the Peds OR ready to go.

The one I was involved in directly we did under regional (CSE), gave a nitroglycerin bolus about 30-45 seconds before uterine incision, followed by a nitroglycerin infusion for uterine relaxation. This technique has been described before. I think the case series was out of Duke. We did regional because the patient was refusing general anesthesia, and she didn't have the most inviting airway either. The Peds ENT surgeon was skeptical, but he saw my point of view (it also helped that an older attending he knew supported me). Everything went great. Shortly after shutting off the infusion the placenta was delivered and the uterus contracted nicely.

Besides making sure that the anesthesia, NICU, ENT, and OB teams are on the same page, it also becomes important to control the amount of people in the room. You don't want people tripping over each other to get things done/get equipment.

I'm sure I've probably left out something and others will chime it. It is all about coordination.

 

[sevoflurane]

I've been involved with two -- one directly and one indirectly (was involved in the planning but it showed up early emergently).

These are mostly done under GA and about 2 MAC inhalational anesthetic to keep the uterus relaxed. Prepare for blood loss secondary to the potential for development of uterine atony. Assuming this is taking place at a planned time, Peds ENT will be there and have their equipment set up. NICU needs to be on-board also, especially if you are in a facility without peds surgery. They will help stabilize the baby initially and prepare it for transport. If immediate surgery on the baby is planned it makes sense to schedule the mom's surgery and have the Peds OR ready to go.

The one I was involved in directly we did under regional (CSE), gave a nitroglycerin bolus about 30-45 seconds before uterine incision, followed by a nitroglycerin infusion for uterine relaxation. This technique has been described before. I think the case series was out of Duke. We did regional because the patient was refusing general anesthesia, and she didn't have the most inviting airway either. The Peds ENT surgeon was skeptical, but he saw my point of view (it also helped that an older attending he knew supported me). Everything went great. Shortly after shutting off the infusion the placenta was delivered and the uterus contracted nicely.

Besides making sure that the anesthesia, NICU, ENT, and OB teams are on the same page, it also becomes important to control the amount of people in the room. You don't want people tripping over each other to get things done/get equipment.

I'm sure I've probably left out something and others will chime it. It is all about coordination.

Thx for sharing. Great case to have gone thorugh. Those cystic hygromas or big masses around the AW are serious issues. If unrecognized in utero, usually death follows. As you mentioned, coordination with the different teams seems to be key. The case my pedi anesthesia buddy went through had 2 seperate anesthesia teams. One for the mother and a pedi team for the fetus/neonate. ENT couldn't secure the AW and a trach was going to be VERY difficult because of the giant mass around the AW.
In this case, the pedi anesthesia team ultimately got ETCO2 back... but it wasn't easy. I wonder if there is a pedi heart team on standby during these cases. Amazing stuff.

Look at where that trach is in the first picture.... Isn't that carotid artery/IJ land? 😱

This one is down right scary.

Amazing stuff.

 

[IlDestriero]

I've done a few.
We set up two rooms. One for mom and the C/S and one next door for the baby if they can't secure the airway on the field and have to deliver or need to compete/clean up a trach that was placed on placental circulation.
Two teams, one for mom one for baby. Baby's team is attending and a fellow.
Mom gets aline for bp monitoring, epidural and GA. The epidural is really just for duramorph post op and some bupi for a nice wake up. Blood is checked and ready for mother and baby, hot lines, etc etc.
Mother gets 12-18% des with a Neo infusion.
Kids gets partially delivered, iv in hand, pulse ox monitor from transport monitor on mayo stand at the head of the bed. surgeon secures airway or does surgical airway. If lucky, the end. High fives all around. If not, plan B.
Plan B can be very unsatisfying. More so when it's emergent at 2 am. 🙁

I think we do 6 or 7 year and we have a well established feeder system. Very rare.


Edit: Forgot to mention the kid gets some atropine and vec.

 

[jwk]

I've done a few.
We set up two rooms. One for mom and the C/S and one next door for the baby if they can't secure the airway on the field and have to deliver or need to compete/clean up a trach that was placed on placental circulation.
Two teams, one for mom one for baby. Baby's team is attending and a fellow.
Mom gets aline for bp monitoring, epidural and GA. The epidural is really just for duramorph post op and some bupi for a nice wake up. Blood is checked and ready for mother and baby, hot lines, etc etc.
Mother gets 12-18% des with a Neo infusion.
Kids gets partially delivered, iv in hand, pulse ox monitor from transport monitor on mayo stand at the head of the bed. surgeon secures airway or does surgical airway. If lucky, the end. High fives all around. If not, plan B.
Plan B can be very unsatisfying. More so when it's emergent at 2 am. 🙁

I think we do 6 or 7 year and we have a well established feeder system. Very rare.


Edit: Forgot to mention the kid gets some atropine and vec.

This is very similar to our experience as well - 1/2 dozen or so a year, always a major pucker case. We do all of ours with GA. The two-room setup is a must. And you're right - plan B sucks. Sadly, these do not always end on a happy note.

One thing we do - despite much planning for the "experienced EXIT staff" and pre-scheduling, premature labor is always a possibility, and we've had more than one of our scheduled EXIT procedures show up in the middle of the night on a weeked. Every time we have a scheduled EXIT procedure, we send out an advisory email within our group that an EXIT procedure has been scheduled, give any details that we might have as to what fetal anomalies or maternal conditions might be expected, and a brief listing of how we usually do these procedures - GA, NTG, etc., just in case they show up at an unexpected time.

 

[michigangirl]

I've done two, both for massive cystic hygromas just like the first picture in sevo's post. Technique is exactly as IlDes described. Did the first one as a fellow, my job was to put the pulse ox on. Getting a pulse ox on that slippery bugger is no joke when like sixty pairs of eyes are on you! Wrap it in gauze, if IV doesn't get in give meds IM (this is what we did), ENT takes a look, tries to get an ETT- in both cases they did, but after a LOT of manipulation. As described above, the anesthetic technique for mother is pretty cool.

 

[RT2MD]

😱😱

Wow... that's all I can say.

That. Looks. Intense.

 

[sevoflurane]

You peds dudes are the bomb! Believe it or not... I like the challange of peripheral access on those michelein kids... central lines are butter compared to some of those 4mo. olds. Wish I did more as it's such a great skill to have.

Regarding EXIT procedures, is there a role for a pedi heart team if an AW can not be achieved? Are they on standby? Is this what you guys are referring to as plan B?

The ex-utero intrapartum treatment (EXIT) procedure transitions a newborn directly onto cardiopulmonary bypass when oxygenation and ventilation by intubation and mechanical ventilation are either not expected to be possible, or are likely to exacerbate pulmonary barotrauma.

http://www.ncbi.nlm.nih.gov/pubmed/20301533

Either way, real cool stuff guys (and girls).... 👍

 

[IlDestriero]

You peds dudes are the bomb! Believe it or not... I like the challange of peripheral access on those michelein kids... central lines are butter compared to some of those 4mo. olds. Wish I did more as it's such a great skill to have.

Regarding EXIT procedures, is there a role for a pedi heart team if an AW can not be achieved? Are they on standby? Is this what you guys are referring to as plan B?

The ex-utero intrapartum treatment (EXIT) procedure transitions a newborn directly onto cardiopulmonary bypass when oxygenation and ventilation by intubation and mechanical ventilation are either not expected to be possible, or are likely to exacerbate pulmonary barotrauma.

http://www.ncbi.nlm.nih.gov/pubmed/20301533

Either way, real cool stuff guys (and girls).... 👍

I've never heard of an exit to bypass, but we've done exit to ecmo. Though I have not.
I've done many IMPACTs (IMmediate Postnatal Access to Cardiac Therapies). You do the C/S in the cardiac suite and immediately hand the kid over to the cardiac anesthesia team (and peds cardiologist, neonatologist, cardiac surgeon, etc) who perform a Cath, cardiac surgery, etc. immediately after birth. It gives some kids who would have certainly died a chance. Obviously it requires a lot of coordination. Now imagine this happening urgently at 1 am when some woman scheduled for an IMPACT comes in laboring.

"Plan B" is when you have to abort the exit procedure because the baby is not tolerating it or the mother has uncontrollable bleeding, etc. You deliver the baby and deal with the aftermath. As in no airway in one of the kids above. Sucks, BAD.😱 😱
I've been there once at my old Hospital. ENT Hail Mary'd a rigid bronch through a "little bubble" way lateral and found a trachea.😎 That happened on the side table where they pushed some instruments out of the way to make room for the kid. Very unsatisfying. It was well planned but poorly executed, and when mama unexpectedly tried to exsanguinate and they had to abruptly abort everyone was running, including the OB anesthesia team who activated the massive transfusion protocol. They were about to go cutting on his neck, fishing for a trach. Remember this kid is 30 seconds old with massively distorted anatomy, unventable, and has a whopping single tenuous hand 24g.
Even with good MRI imaging of the kids airway inutero, things are not always as expected, and the cystic lesions can change in size and further distort the anatomy.

 

[sevoflurane]

Now imagine this happening urgently at 1 am when some woman scheduled for an IMPACT comes in laboring.

Oh... boy. Mobilize the troops... stat. 😱

I've kinda been there... for a restrictive cor triatrium that went in the middle of the night emergently on day of life # 2. Good number of schduled transpositions, TAPVR, TOF's, PA's, etc.

Never an EXIT or true IMPACT... throwing in the "middle of the night" curve ball sounds potentially very exhausting. 😉

 

[IlDestriero]

One other cleverly named procedure that we do with some frequency is the "section to resection". We do a (hopefully planned) c/section and take the kid immediately into a second OR for a resection of something or other. Usually a large sacrococcygeal teratoma or an intrathoracic mass. Lots of fun physiology to consider when anesthetizing the truly "newborn".👍
One more pain in the tuckus thing that can wreck your night at 2 am at the Children's Hospital.

 

[Arch Guillotti]

😱😱

Wow... that's all I can say.

That. Looks. Intense.

It depends on what your role is. I was involved in a couple of these in residency and there were always way too many people around. If you are just responsible for mom then it can be very straightforward. pent, sux, tube, 1.5 MAC or so.

The baby is the hard part but normally the airway would be secured by ENT/peds surgery. IM roc for the baby if needed. I never saw a transition to ECMO but I am sure it could be done.

 

[IlDestriero]

It depends on what your role is. I was involved in a couple of these in residency and there were always way too many people around. If you are just responsible for mom then it can be very straightforward. pent, sux, tube, 1.5 MAC or so.

The baby is the hard part but normally the airway would be secured by ENT/peds surgery. IM roc for the baby if needed. I never saw a transition to ECMO but I am sure it could be done.

It's all fun and games until everyone's trying to die.
We actually don't involve ENT, just OB, one or two of the fetal surgeons and us. And the NICU team next door, waiting. Apparently, years ago, they had ENT standing by for all of them and never used them. Of course that means if all hell breaks loose, it's on our 2nd team to try to secure the airway. If it's horrendous they usually just trach anyway. There was one where plan B included sternotomy. They just popped it in from above. I'm surprised we don't have ECMO standby for more. Tradition can be a real pain in the *****.