Special Topics in Anesthesia: Pediatrics

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Anesthetic Management for Percutaneous Minimally Invasive Fetoscopic Surgery of Spina Bifida Aperta: A Retrospective, Descriptive Report of Clinical Experience.

Author(s): Arens C, et al.
Journal: Anesth Analg. 2017;125(1):219-222. 10 references.
Reprint: Dept of Anesthesiology and Intensive Care Medicine, University Hospital of Giessen and Marburg, 35392 Giessen, Germany. E-mail: Rainer.Schuerg@chiru.med.uni-giessen.de
Faculty Disclosure: Abstracted by L Easley, who has nothing to disclose.
Objective: Describe clinical experience with modified protocol in consecutive patients undergoing fetoscopic surgery for spina bifida aperta (SBA).

The intraoperative development of maternal pulmonary edema was observed in approximately one-fourth of cases when the minimally invasive fetoscopic approach (MIFA) for closure of fetal SBA was introduced. The authors describe clinical experience with a modified protocol in consecutive patients undergoing fetoscopic surgery for SBA.

Patients undergoing percutaneous minimally invasive fetoscopic closure of SBA in their fetuses were included in this study. Parameters measured during the procedure included uterine insufflation pressure, the total volume administered for both lactated Ringer and hydroxyethyl starch solutions, the total dosages of epinephrine and remifentanil, and the durations of anesthesia and the surgical procedure. Values of blood gas analysis as well as continuous cardiac output index and extravascular lung water index (EVLWI), and temperature were measured.

Sixty-one cases underwent therapy of SBA by the MIFA. Duration of anesthesia and surgery both decreased as experience with the technique increased. Adequate fetal anesthesia was also uniformly achieved. Uterine relaxation was uniformly sufficient to allow the surgeons to complete the intervention with complete absence of intraoperative uterine contractions. No patient developed intraoperative pulmonary edema, and there were no maternal or acute fetal deaths, placental abruption, or evidence of spontaneous labor.

When combined with preoperative atosiban (an inhibitor of oxytocin and vasopressin) for tocolysis and remifentanil infusion, anesthetic maintenance with <1 minimum alveolar concentration (MAC) of desflurane was sufficient to achieve both adequate fetal and maternal anesthesia and uterine relaxation. The combination of reduced volatile anesthesia and goal-directed fluid and vasopressor therapy guided by the Pulse Contour Cardiac Output system ensured stable perioperative hemodynamics and mitigated the risk of pulmonary edema.

Important Points:
The authors found, “No patients developed intraoperative pulmonary edema, and only 15% of patients experienced increased EVLWI.The modified Hering-Kohl protocol provides a guide for safe general anesthesia during complex minimally invasive fetoscopic interventions.”

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