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Fetal Surgery...Part II


Anesthetic Plan...

Fetal surgical cases require team work.
These include: pediatric general surgery, obstetrics, pediatric anaesthesia, obstetric anaesthesia, cardiology, radiology, neonatology, neonatal nursing and operating room nursing.

Preoperative preparation
Standard anesthtic history, physical examination and history of symptoms of aortocaval compression or gastroesphageal reflux.
Cross-matched blood for the mother.
O-negative blood for the fetus.
Maternal antibodies to blood antigens can cross the placenta.
Specific fetal information as location of the placenta, fetal weight, the actual disease process and pathophysiology.


Anesthesia for minimally invasive
These cases are the most variable in need for maternal analgesia and anesthesia and in
the need for fetal analgesia or immobility.
An anesthestic plan can range from local infiltration to sedation to neuroaxial to general anesthesia.
The current practice include maternal fasting, IV catheter, aspiration prophylaxis and
tocolysis with preoperative indomethacin, light sedation to provide maternal comfort
and decrease fetal movement, e.g. remifentanil for fetal immobilization
(0.1 μg/kg/min). Postoperative magnesium infusion and intravenous fluid restriction

Anesthesia for open mid-gestation
This surgery requires significant uterine relaxation.
General endotracheal anesthesia with high-dose volatile (2 times MAC), desflurane is the agent chosen for its low solubility, allows the rapid emergence from deep anesthesia. Intravenous nitroglycerine used for uterine relaxation for easier fetal manipulation and decrease the initiation of labor from uterine surgical manipulation.

Anesthesia for EX-utero Intrapartum Therapy (EXIT)
Uterine relaxation is only needed intraopertively.
Two operatiing rooms and resuscitation area for the neonatal team are needed. Once the airway is secured or lesion resected, surfactant to the premature fetus and the lungs are ventilated after the umbilical cord is divided.

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