Anesthetic Considerations for Uncommon Obstetrical

Procedures: The PUBS and EXIT Procedures

Adam Flowe, CRNA, MSNChief CRNA, Duke University Medical Center

November 2016NCANA Annual Meeting -- Asheville

None

Financial disclosures:

Subtitle: Wild things we get up to at Medical Centers

1. Please know that this presentation today is meant entirely to be informative… and only that.

2. The content presented here is in no way intended to pass judgment on any mother or child who should need these procedures.

3. The content presented here is in no way intended to credit or discredit any religious or cultural belief.

Personal disclosures:

1. You will be able to identify the key features of the PUBS procedure and its anesthetic considerations.

2. You will be able to identify the key features of the EXIT procedure and its anesthetic considerations.

Primary Objectives

Secondary Objectives1. You will think about cultural, popular, and

historical concepts and images and their relationship to scientific advances.

2. You will consider an operational definition of love.

Science fiction?

“Any sufficiently advanced technology is indistinguishable from magic.”

-Arthur C. Clarke, 1974

Let’s set the mood.

So, which came first?

Hmmm...

“The Jetsons,” Hanna-Barbera, 1963

Apple, 2015!

Part 1 -- the PUBS

The PUBS procedure

Percutaneous Umbilical Blood Sampling-also called cordocentesis-can be done purely as a diagnostic-but more interesting when done

therapeutically

PUBS -- What is it?It is using sonography to guide a needle into the umbilical vessels to sample for genetic assays or for other blood tests (i.e. hematocrit).

For this presentation, the focus is on the therapeutic PUBS used for the treatment of maternal-fetal Rh-incompatibility

Brief background1) Fetal-maternal Rh incompatibility occurs when the Rh-

mother forms antibodies to her Rh+ fetus (another damnable behavior of the father)

2) The mother’s antibodies will then attack the antigenic fetal blood.

3) This is a problematic situation that typically affects subsequent pregnancies.

More background (USNLM, 1995; NIH, 2013)

4) Maternal antibodies attack fetal blood cells, potentially resulting in a fetus with

hemolytic anemia, hyperbilirubinemia, IUGR,possible neurologic impairment,and frequent IUFD (%??).

Treatment options (Berry, 2013)

1) Exchange Transfusion (after delivery)2) Apheresis (maternal vs. pediatric)3) RhoGAM injections (immunoglobulins)

4) the therapeutic PUBS!

The candidateTherapeutic PUBS treatment is indicated for :

1. A. Rh-, non-primigravida mother,2. whose fetus is showing signs of IUGR,3. with the fetus having attained an developmental age of viability (25 wks???)

The candidate (continued)Historical features include:

1. A prior pregnancy with an Rh+ fatheror other Rh+ blood exposure?

2. Often poor peri-natal care (missed receiving RhoGam),

3. Often history of multiple losses/stillbirths

The PUBS Gestalt1. Performed in the OR with anesthesia and

surgical teams present2. Preparation is made for a possible c-

section3. Ultrasound (+/- technician) is brought to

OR4. Irradiated RBCs are brought to OR

The therapeutic PUBSThe mother is prepared as if for surgery, but hopefully will only receive an amniocentesis-type event.

An epidural is placed and dosed to ascertain if acceptable for surgical conditions.

The therapeutic PUBSThe mother is prepped and draped.

Ultrasound is used with sterile cover to assess the baby.

An amniocentesis needle is introduced.

The Therapeutic PUBSTypically, at this point, the baby is paralyzed with IM injection of paralytic.

The proceduralist then cannulates the umbilical vein and draws out 1-3 ml sample to assess hematocrit.

PARALYZED?Remember the fetus is on “placental bypass.”

The proceduralist injects the fetal rump or leg… trying to avoid head and vitals...

PARALYZED? Are you sure?Pancuronium, vecuronium and rocuronium have all been used.

The anesthetist prepares a non-dilute solution and delivers it to sterile cup on surgical field.

Paralytic comparison (Reynolds, et al. 1996)

Paralytic Dosing IM Pros Cons

Vecuronium 1 mg/kg ? Bradycardia?

Pancuronium 1 mg/kg Increased fetal HR

Benzyl alcohol?

Rocuronium 1 mg/kg Long-lasting, small volumes

?

Small volumes needed; best dosing unclear….

Why paralyze?The moving fetus is a problem:

1) Needle is easily decannulated.

2) Increased potential for injury with unexpected movement

Why paralyze?Procedure is challenging if the placenta is posteriorly implanted.

The Fetus is in the way!

Anterior vs. PosteriorPlacentation

What is good for a PUBSis less desirable for a C-Section!

Fetal transfusionThe event proceeds as follows:

1. Serial withdrawal of blood samples (1-3ml), 2. Assessment of hematocrit,3. Administration of PRBCs,4. Reassessment of hematocrit and repeat.

Fetal transfusion1. Blood administration tubing will be passed off sterile

field to anesthetist

2. Irradiated PRBC should be sent through fluid warmer

without dilution by saline (avoid excessive volumes)

3. Blood will be given in small aliquots dictated by

proceduralist and hematocrit-driven algorithm

Why irradiated blood?1. Irradiation eliminates donor antibodies (and is a standard precaution

in fetal, neonatal, and certain immunocompromised/cancer patients) (Chestnutt, 2014)

2. Should be made available before procedure begins

3. Request small divided amounts be prepared (due to potential for intra-procedure expiration)

Pull up a chairThe procedure may last 3-8 hours…depending on technical difficulty and/or need for transfusion...

(At this point, challenge patient to best 3-out-of-5 at Risk... offer to read New York Times aloud... discuss World Cup of Cricket highlights)

Anesthetic Concerns -- Review1. Need for epidural (tested and then hopefully not used)

2. Need for paralytics (prepared and delivered to sterile field for administration by proceduralist)

3. Need for fetal transfusion (warmed, undiluted, irradiated blood)

What could go wrong?1.Emergency c-section -- fetal distress and/or

procedural injury (single umbilical artery?)

2.Failure to cannulate -- failed procedure

3.Maternal discomfort -- bruised back and/or psychosocial stress

QUESTIONS?

The Gestalt? The Archetype?The Cultural Legacy?

A contained, besieged being receives life-sustaining aid from without/above?

A seemingly-doomed being is immersed in a hostile environment that requires intervention to survive?

Science Fiction?“Science fiction guesses at sciences before they are sprung out of the brows of thinking [wo]men… then we try to guess at how mankind will react to these machines, how use them, how grow with them, how be destroyed by them…”

Ray Bradbury, 1974

Popular images? Yes...

Warner Brothers/Roadshow Entertainment, 1999

X-Men Origins: Wolverine, 20th Century Fox, 2009

The Empire Strikes Back,20th Century Fox,Lucasfilm, 1980

Alien,20th Century Fox,Brandywine Productions,1979

The Sigourney is more important than the destination!!

“The past is never dead. It’s not even past.”

-William Faulkner, 1951

Historic iterationsMoses in his basket,unattributed

Noah’s Ark,Sainte Chappelle,Paris

Odysseus, Arnold Bocklin, 1896

Perseus and his mother set adrift to die,Arthur Rackham,1903

Romulus and Remus,The Childhood of RomeLouise Lamprey,Little, Brown and Co1920

The Capitoline Wolf,Piazza Campidoglio,5th century BCE,Rome

The InterventionDeus ex Machina or“Machine of the Gods”

Image from Greek Urn,possibly Medea,3rd century BCE

Deus ex Machinain ancient theatre,a crane was used to introduce the godly intervention(as coming from above)

from Google images

A constant theme?

The Wizard of Oz,MGM, 1939

Ingrained?

E.T. the Extra-Terrestrial,Universal Pictures,1982

Commonplace?

Toy Story 3,Disney/Pixar,2010

The Claaww!

Toy Story 3,Disney/Pixar,2010

An extraordinary intervention (from above?) that rescues the tethered or trapped innocent from a hostile and doomed scenario!

Part 2 -- the EXIT

Ex Utero Intrapartum Treatment

So, in essence, out of the uterus but during the birth…

It is a fetal procedure performed during c-section!

The EXIT procedure Gestalt

What is it?

A c-section is started…The fetus is half-delivered…An intervention takes place…Delivery is then completed.

Half-delivered?The hallmark feature for fetal safety with the EXIT is that placental perfusion is maintained during the intervention!

Who is the EXIT for?The Fetus has a condition that is incompatible with separation from mother (birth) that is treatable with a direct, “fairly short” intervention:

1.Airway establishment/creation2.Airway mass resection3.ECMO bridge

Who needs an EXIT?

Most common type is “the EXIT-to-airway.”

(Garcia, 2011)

Also for floppy or stiff babiesIn addition to the airway and cardiac concerns listed before…

Multiple case reports for Arthrogryposis (Benonis &

Habib, 2009; Fink, 2011)

Arthrogryposis

(Holloway, 2010)(Jeanty, 1999)

Operational Definition of Love

“Asserting the value of someone’s life… or something's existence.” (Flowe, 2016, just now)

This is really what it looks like...Obstetrical team,Surgical team,Cardiology teams,Pediatric team,Anesthesia (x1-2),Nursing, and auxiliary staff

No chairs this time!

And this....

(Filipchuk, 2009)

No large retrospective study, but there are multiple case reports

The best is an excellent overview from thisAnesthesiology, June 2011…

“Case Scenario: Anesthesia for Maternal-Fetal Surgery: The EXIT procedure”by Garcia, et al

Anesthetic Considerations1. Maternal anesthesia

2. Fetal anesthesia

3. Uterine relaxation

4. Prolonged hysterotomy

Maternal AnesthesiaThe EXIT is a deluxe c-section event… So most of us would select a regional anesthetic… out of concern for maternal safety…

Due to time concerns, a CSE is advisable. (George, et al, 2007)

Maternal AnesthesiaA review of case studies shows that many centers have elected for GETA...

Their rationale is for the next two anesthetic concerns: fetal anesthesia and uterine relaxation (Marwan, 2006)

Fetal AnesthesiaAll reports showed some attention to fetal anesthesia…

Two basic approaches described for anesthesia delivery:

1. Delivered directly to the fetus2. Delivered via the maternal anesthetic

Fetal AnesthesiaSome procedures have involved establishing IV access on the partly-delivered fetus.

Fetal AnesthesiaMore commonly, anesthesia is delivered via the mother

General anesthetics readily cross the placental membrane and enter fetal circulation(typically higher MACs are used)…

Fetal AnesthesiaIn the case of regional anesthesia, narcotic infusions have been given to the mother and titrated to maintain maternal respiratory effort and consciousness.

Remifentanil (.05-.2 mcg/kg/min) has been used for its rapid titratability and metabolism (Fink, 2011).

Uterine Relaxation

Surgeons (both obstetrical and pediatric) require a greater than normal uterine relaxation for positioning and interventional access.

Uterine relaxationGas anesthetics have a dose-dependent uterine relaxant effect (Yoo, 2006)… resulting in use of high MACs and likely need for vasopressors.

Regional cases have used IV nitroglycerin boluses and infusions to accomplish the relaxation. (Clark, et al, 2004)

Prolonged hysterotomyThe uterus is not closed promptly.

The parturient is already at a greater risk for DIC, PE, coagulopathy. (Chestnutt, 2014)

There is concern for increased blood loss (documented) and risk of amniotic fluid embolism (undemonstrated)(Marwan, 2006)

Prolonged hysterotomyBe prepared to transfuse…

• T&S/T&C (possibly will need for fetus too)

• Good IV access• +/- arterial line• +/- cardiac output monitor (non-

invasive?)

“EXIT strategy”?

General vs. Regional → Unclear (Gaiser, et al, 1997)

QUESTIONS?

The Gestalt? The Archetype?The Cultural Legacy? A vulnerable being must straddle two worlds (planes of existence) in order to overcome a test of survival?

A being-within-a-being must be brought forth (and altered? with violence?) in order to be released?

A being (perhaps a monster (in the teratogenic sense of the word)) must be physically or artificially altered before he/she is ready to survive/become independent?

Popular images? Indeed...

Alien,20th Century Fox,Brandywine Productions,1979

Popular images? Yep.Total Recall,Carolco Pictures,1990

“Kuato!”

Have these images had influence?

On scientists? I don’t know.

(SNL, April 2007)

Who’s a scientist anyway?

Popular images?Spaceballs,Brooksfilms/MSM,1987

(original title =“Planet Moron”)

Everyday? You bet...

The Hangover,Warner Brothers,2009

Existence on multiple planes?

Star Trek, 1966Superman,1978Thriller, 1982Company of Wolves, 1984

Religious multi-dimensionality?

Some Word Origins

Teratogens / TeratogenicityA agent that leads to malformation of the fetus (of vital importance to the anesthetist)

From the Greek…teras (monster) + genein (making)... (OED, 2015)

Monsters? What? Careful now….Monster from the Latin monstrum -- to show or warn (as in demonstrate)

The word took off in history hinging on its sense of showing, as in being distinctive, disruptive, or disastrous.

Monsters? Rude.The 3rd definition for “monster” in the OED

“a fetus, neonate, or individual with a gross congenital malformation, usually of a degree incompatible with life. Cf. MONSTROSITY n. 1a. (Now rare because of its pejorative associations.)” (OED, 2015)

Monster? What century are you from?

1752 W. SMELLIE Treat. Midwifery I. 122 When two children are distinct, they are called twins; and monsters when they are joined together.

1840 E. A. POE. 1002nd Tale, I. 141 The term ‘monster’ is equally applicable to small abnormal things and to great.

1897 T. C. ALLBUTT et al. Syst. Med. IV. 528. It [sc. congenital absence of spleen] has been noted in monsters.

1968 Brit. Jrnl. Plastic Surg. 21, 411. As the child was thought to be a mentally defective monster, unlikely to survive infancy, he was kept in the local hospital for 16 months.

1996 European Jrnl. Obstetr. & Gynecol, 65, 245. An acardiac acephalic monster following in-utero anti-epileptic drug exposure…

A doomed being (a monster?) is altered to survive?

As it turns out, there are many stories of:

a doomed (with a time limit)being-within-a-being,who receives an intervention,and is saved….

Fiona takes “true love’s form.”

Shrek,Dreamworks,2001

The frog princeFrog receiving monstrous treatment!

Arthur Rackham,1913

Love as an intervertion?

Beauty and the Beast,Disney,1991

A vulnerable being-within-a-being (a clinical monster?) receives a critical intervention to survive

University of Wisconsin, YouTube Channel, 2009

ReferencesBenonis JG, Habib AS. Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita, using continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation. Int J Obstet Anesth 2008 Jan 23;17(1):53-6. Epub 2007 Apr 23.

Berry SM, Stone J, Norton ME, Johnson D, Berghella V. Fetal blood sampling. Am J Obstet Gynecol. 2013 Sep;209(3):170-80.

Chestnut HD, Wong C., Chestnut's Obstetric Anesthesia: Principles and Practice. Saunders; 5th edition. 2014.

Clark KD, Visconi CM,Lowell J, Chien EK. Nitroglycerin for uterine relaxation to establish a fetal airway. Obstet Gynecol 2004: 103, 1113-5.

Fink RJ, Allen TK, Habib AS. Case series: remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined

spinal-epidural anesthesia. Br J Anesth 2011: 106, 851-8.

Gaiser HR, Cheek TG, Kurth CD. Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus. Anesth Analg 1997:

84, 1150-3.

ReferencesGeorge Rb, Melnick AH, Ros EC, Habib AS. Case series: comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure.

Can J Anesth 2007: 54, 218-22.Holloway, S. Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound. Ultrasound, February 2010; vol. 18, 1: pp. 25-27.

Marwan A. The EXIT procedure: principles, pitfalls, and progress. Semin Pediatr Surg 2006: 15, 107-15.

Reynolds LM1, Lau M, Brown R, Luks A, Fisher DM. Intramuscular rocuronium in infants and children. Dose-ranging and tracheal intubating conditions. Anesthesiology. 1996 Aug;85(2):231-9.

Steiner EA1, Judd WJ, Oberman HA, Hayashi RH, Nugent C. Percutaneous umbilical blood sampling and umbilical vein transfusions. Rapid serologic differentiation of fetal blood from maternal blood.Transfusion. 1990 Feb;30(2):104-8.

Yoo K, Lee JC, Yoon MH, et al. The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle: a comparison among sevoflurane, desflurane, isoflurane and halothane. Anesth Analg 2006: 103, 443-7.

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