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EXIT procedures at Westmead Hospital, Sydney - 10 years experience
Agnes K Molnar1, Peter RJ Gibson2,3, Michael G Cooper3, Jane L Brown2
1Registrar, Department of Anaesthesia, Westmead Hospital Sydney, Australia
2Staff Specialist, Department of Anaesthesia, Westmead Hospital Sydney, Australia
3Staff Specialist, Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, Australia
Background: The EXIT procedure (Ex Utero Intrapartum Treatment) was developed in the 1990's to allow safe neonatal airway intubation during a modified Caesarean section birth, when antenatal investigation identified a potential or actual airway obstruction in the fetus. The neonate's upper body is partially delivered to provide access for the paediatric anaesthetist or ENT specialist to intubate. The placental circulation is maintained during this procedure by fully relaxing the uterus and keeping the uterine perfusion pressure, as measured by the mean arterial pressure, above 75 mmHg. Once the airway is secured, the baby is delivered, and the Caesarean section completed.
Results: The retrospective chart review revealed that the combination of deep volatile general anaesthetic for the mother with a nitroglycerin infusion of 1 mcg/kg/min provides excellent uterine relaxation, and prevents early placental separation. A remifentanil infusion of 1 mcg/kg/min aids the volatile anaesthetic effect on the baby, keeping it anaesthetised for airway manipulation. Over the last 10 years there were eight elective and two emergency procedures, nine general and one elective epidural anesthesia for eight cephalic and two breech presentations. Neonatal pathology included four cystic hygromas, an Aicardi syndrome with a large neck teratoma, a congenital epulis, a congenital goitre, a neck teratoma, a congenital cystic adenoma of the right upper lobe of the lung and a Treacher-Collins syndrome. Nine neonates survived, one with the Aicardi syndrome died on day 12, three required long term tracheostomy.
Conclusion: An EXIT procedure requires detailed planning by a multidisciplinary team with a clear plan for securing the neonatal airway using a variety of techniques including rigid bronchoscopy with the provision for tracheostomy as a fallback position.