NCANA Annual 2016

1. Anesthetic Considerations for
Uncommon Obstetrical
Procedures:
The PUBS and EXIT Procedures
Adam Flowe, CRNA, MSN
Chief CRNA, Duke University Medical Center
November 2016
NCANA Annual Meeting -- Asheville

2. None
Financial disclosures:

3. Subtitle: Wild things we get up to at
Medical Centers

4. 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:

5. 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

6. Secondary Objectives
1. 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.

7. Science fiction?
“Any sufficiently advanced technology is
indistinguishable from magic.”
-Arthur C. Clarke, 1974

8. Let’s set the mood.

9. So, which came first?

10. Hmmm...
“The Jetsons,” Hanna-Barbera, 1963
Apple, 2015!

11. Part 1 -- the PUBS

12. The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a diagnostic
-but more interesting when done
therapeutically

13. 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

14. Brief background
1) 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.

15. 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 (%??).

16. Treatment options (Berry, 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs. pediatric)
3) RhoGAM injections (immunoglobulins)
4) the therapeutic PUBS!

17. The candidate
Therapeutic 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???)

18. The candidate (continued)
Historical features include:
1. A prior pregnancy with an Rh+ father
or other Rh+ blood exposure?
2. Often poor peri-natal care (missed receiving
RhoGam),
3. Often history of multiple losses/stillbirths

19. The PUBS Gestalt
1. Performed in the OR with anesthesia and
surgical teams present
2. Preparation is made for a possible c-
section
3. Ultrasound (+/- technician) is brought to
OR
4. Irradiated RBCs are brought to OR

20. The therapeutic PUBS
The 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.

21. The therapeutic PUBS
The mother is prepped and draped.
Ultrasound is used with sterile cover to assess
the baby.
An amniocentesis needle is introduced.

22. The Therapeutic PUBS
Typically, 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.

23. PARALYZED?
Remember the fetus is on “placental bypass.”
The proceduralist injects the fetal rump or leg…
trying to avoid head and vitals...

24. 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.

25. 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….

26. Why paralyze?
The moving fetus is a problem:
1) Needle is easily decannulated.
2) Increased potential for injury with
unexpected movement

27. Why paralyze?
Procedure is challenging
if the placenta is
posteriorly implanted.
The Fetus is in the way!

28. Anterior vs.
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section!

29. Fetal transfusion
The 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.

30. Fetal transfusion
1. 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

31. Why irradiated blood?
1. Irradiation eliminates donor antibodies (and is a standard precaution
in fetal, neonatal, and certain immunocompromised/cancer patients) (Chestnutt, 2014)
1. Should be made available before procedure begins
1. Request small divided amounts be prepared (due to
potential for intra-procedure expiration)

32. Pull up a chair
The 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)

33. Anesthetic Concerns -- Review
1. Need for epidural (tested and then hopefully not used)
1. Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1. Need for fetal transfusion (warmed, undiluted, irradiated
blood)

34. What could go wrong?
1.Emergency c-section -- fetal distress and/or
procedural injury (single umbilical artery?)
1.Failure to cannulate -- failed procedure
1.Maternal discomfort -- bruised back and/or
psychosocial stress

35. QUESTIONS?

36. 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?

37. 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

38. Popular images? Yes...
Warner Brothers/
Roadshow Entertainment, 1999

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

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

41. Alien,
20th Century Fox,
Brandywine Productions,
1979
The Sigourney is
more important
than the destination!!

42. “The past is never dead.
It’s not even past.”
-William Faulkner, 1951

43. Historic iterations
Moses
in his basket,
unattributed

44. Noah’s Ark,
Sainte Chappelle,
Paris

45. Odysseus, Arnold Bocklin, 1896

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

47. Romulus and Remus,
The Childhood of Rome
Louise Lamprey,
Little, Brown and Co
1920

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

49. The Intervention
Deus ex Machina or
“Machine of the Gods”
Image from Greek Urn,
possibly Medea,
3rd century BCE

50. Deus ex Machina
in ancient theatre,
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images

51. A constant theme?
The Wizard of Oz,
MGM,
1939

52. Ingrained?
E.T. the Extra-Terrestrial,
Universal Pictures,
1982

53. Commonplace?
Toy Story 3,
Disney/Pixar,
2010

54. The Claaww!
Toy Story 3,
Disney/Pixar,
2010

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

56. Part 2 -- the EXIT

57. Ex Utero Intrapartum Treatment
So, in essence, out of the uterus but during the
birth…
It is a fetal procedure performed
during c-section!

58. 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.

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

60. 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/creation
2.Airway mass resection
3.ECMO bridge

61. Who needs
an EXIT?
Most common type is
“the EXIT-to-airway.”
(Garcia, 2011)

62. Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed before…
Multiple case reports for Arthrogryposis (Benonis &
Habib, 2009; Fink, 2011)

63. Arthrogryposis
(Holloway, 2010)
(Jeanty, 1999)

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

65. 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!

66. And this....
(Filipchuk, 2009)

67. No large retrospective study,
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology, June 2011…
“Case Scenario: Anesthesia for
Maternal-Fetal Surgery: The EXIT procedure”
by Garcia, et al

68. Anesthetic Considerations
1. Maternal anesthesia
1. Fetal anesthesia
1. Uterine relaxation
1. Prolonged hysterotomy

69. Maternal Anesthesia
The 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)

70. Maternal Anesthesia
A 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)

71. Fetal Anesthesia
All reports showed some attention to fetal
anesthesia…
Two basic approaches described for
anesthesia delivery:
1. Delivered directly to the fetus
2. Delivered via the maternal anesthetic

72. Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus.

73. Fetal Anesthesia
More commonly, anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically higher MACs are used)…

74. Fetal Anesthesia
In 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).

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

76. Uterine relaxation
Gas 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)

77. Prolonged hysterotomy
The 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)

78. Prolonged hysterotomy
Be prepared to transfuse…
• T&S/T&C (possibly will need for fetus too)
• Good IV access
• +/- arterial line
• +/- cardiac output monitor (non-invasive?)

79. “EXIT strategy”?
General vs. Regional → Unclear (Gaiser, et al, 1997)

80. QUESTIONS?

81. 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?

82. Popular images?
Indeed...
Alien,
20th Century Fox,
Brandywine Productions,
1979

83. Popular images? Yep.
Total Recall,
Carolco Pictures,
1990
“Kuato!”

84. Have these images had influence?

85. On scientists? I don’t know.
(SNL, April 2007)

86. Who’s a scientist anyway?

87. Popular images?
Spaceballs,
Brooksfilms/MSM,
1987
(original title =
“Planet Moron”)

88. Everyday? You bet...
The Hangover,
Warner
Brothers,
2009

89. Existence on multiple planes?
Star Trek, 1966
Superman,1978
Thriller, 1982
Company of Wolves,
1984

90. Religious multi-dimensionality?

91. Some Word Origins

92. Teratogens / Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greek…
teras (monster) + genein (making)... (OED, 2015)

93. 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.

94. 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)

95. 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…

96. 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….

97. Fiona takes
“true love’s
form.”
Shrek,
Dreamworks,
2001

98. The frog prince
Frog receiving
monstrous treatment!
Arthur Rackham,
1913

99. Love as an
intervertion?
Beauty and the Beast,
Disney,
1991

100. A vulnerable being-within-a-being (a clinical monster?)
receives a critical intervention to survive
University of Wisconsin, YouTube Channel, 2009

101. References
Benonis 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.

102. References
George 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.

103. Come talk to me…