Anesth Pain Med.  2021 Oct;16(4):329-337. 10.17085/apm.21097.

Intraoperative management for ex-utero intrapartum treatment: focusing on the fetus

• Chung W
• Lim C

• KMID: 2524444
• DOI: http://doi.org/10.17085/apm.21097

Abstract

Ex-utero intrapartum treatment (EXIT) is a method of securing the airway of a fetus while maintaining umbilical circulation for newborns who are experiencing life-threatening airway obstruction. Cesarean section is completed only after ensuring the neonate’s safety. However, managing the airway of a neonate while maintaining umbilical circulation is a major challenge for anesthesiologists. Anesthesiologists must understand the physiology of both the mother and fetus, and extensive discussions with obstetricians, pediatricians, otolaryngologists, and nursing staff prior to the procedure are essential. This review provides an overview of the EXIT and details of airway management for neonates.

Keyword

Airway management; Anesthesia; Ex-utero intrapartum treatment; Fetus; Neonate

Figure

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  Fig. 1. Preoperative evaluation of the fetal airway. (A) Schematic describing how to calculate the tracheoesophageal displacement index (TEDI). (B) Transverse magnetic resonance imaging (MRI) of a fetus with a huge neck mass inside the uterus. The airway of the fetus is compromised, although the bilateral lung volume and tracheal patency are relatively preserved. The TEDI is 17 based on the sum of the lateral (L = 0) and ventral (V = 17) displacements of the tracheoesophageal complex (T) from the ventral aspect of the cervical spine (S). (C) Sagittal MRI scan before ex-utero intrapartum treatment; the green arrow indicates a trachea filled with fluid. (D) MRI scan of neonate at 1 day after birth. LPH: left posterior head, RPF: right posterior foot. Modified from the article (Fig. 1) of Lazar et al. (J Pediatr Surg 2012; 47: 46-50) [6] with original copyright owner's permission.

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  Fig. 2. Flow chart for airway management of a fetus requiring ex-utero intrapartum treatment (EXIT). FOI: fiberoptic intubation, LMA: Laryngeal mask airways, ECMO: extracorporeal membrane oxygenation.

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  Fig. 3. Example of an operating room layout for EXIT. EXIT: ex-utero intrapartum treatment, ECMO: extracorporeal membrane oxygenation.

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