anesthesia for fetal surgery: what to expect –what’s · 2014. 6. 15. · marc van de velde, md,...
TRANSCRIPT
Marc Van de Velde, MD, PhD
Professor of Anaesthesia, Catholic University Leuven (KUL)
Chair Department of Anaesthesiology, University Hospitals Leuven (UZL)
Leuven, Belgium
Anesthesia for fetal surgery: what to expect – what’s
expected.
Conflict of Interest
• Holder of the “Baxter UZ Leuven Anaesthesia Research Chair 2012 – 2014”
• Holder of the “Noble Gas research fund” supported by Air Liquide.
• Received financial support of the following companies for either research,
consulting or lectures:
– AstraZeneca.
– Glaxo Smith Kline.
– Air Liquide.
– BBraun.
– Baxter.
– Abbott.
– Smiths Medical.
– Nordic Pharma.
– Sintetica.
• Currently involved in multicenter trials initiated by the following pharmaceutical
companies:
– MSD; Air Liquide
Outline.
• Types of surgery: what to expect ?
• Anesthesia for fetal surgery: techniques and
what is expected from us ?
• Fetal pain perception !
• EXIT procedure.
Criteria for fetal surgery.
• Accurate diagnosis possible, no associated anomalies.
• Natural history documented and prognosis established.
• No effective postnatal therapy.
• In utero surgery effective in animals.
• Interventions performed in specialized multdisciplinary
centers, approval of local ethics committee and consent
of parents.
Open surgery Keyhole surgery
FETAL SURGERY
Most important complication:
PPROM and Preterm labour
Fetus or PlacentaFetus
Diemert et al. Dtschl Arzeblt Int 2012; 109, 603 - 608.
TTTS: laser ablation for twin to twin transfusion syndrome
Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
Diemert et al. Dtschl Arzeblt Int 2012; 109, 603 - 608.
Senat et al. NEJM 2004; 351, 136 - 144.
GRADE I evidence
Diemert et al. Dtschl Arzeblt Int 2012; 109, 603 - 608.
Deprest, Nikolaides and Gratacos. Fetal Diagn Ther 2010; 29, 6 - 17.
Isolated congenital diaphragmatic hernia.
Isolated congenital diaphragmatic hernia.
Deprest, Nikolaides and Gratacos. Fetal Diagn Ther 2010; 29, 6 - 17.
Isolated congenital diaphragmatic hernia.
Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
Deprest, Nikolaides and Gratacos. Fetal Diagn Ther 2010; 29, 6 - 17.
Isolated congenital diaphragmatic hernia.
Isolated congenital diaphragmatic hernia.
Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
Diemert et al. Dtschl Arzeblt Int 2012; 109, 603 - 608.
Adzick J Ped Surg 2012; 47, 273 - 281.
Adzick et al. NEJM 2011; 364, 993 - 1004.
Adzick et al. NEJM 2011; 364, 993 - 1004.
Adzick et al. NEJM 2011; 364, 993 - 1004.
Lower birthweight
Adzick et al. NEJM 2011; 364, 993 - 1004.
Less
intracranial
pathology
postnatal
Adzick et al. NEJM 2011; 364, 993 - 1004.
Better
psychomotor
development
Iatrogenic rupture of membranes.
Deprest et al. Prenatal Diagnosis 2011; 31, 661 - 666.
Deprest et al. Prenatal Diagnosis 2011; 31, 661 - 666.
29 / 48
> 30 weeks
Outline.
• Types of surgery: what to expect ?
• Anesthesia for fetal surgery: techniques and
what is expected from us ?
• Fetal pain perception !
• EXIT procedure.
Maternal IV remifentanil.
• Easy to titrate.
• Short acting IV opioid.
• Successful immobilization of the
fetus.
• Excellent transplacental passage.
Van de Velde et al. Anesth Analg 2005; 101, 251 - 258.
Van de Velde et al. Anesth Analg 2005; 101, 251 - 258.
General Anaesthesia.
• General anaesthesia:
– Rapid sequence induction.
– Maintenance with inhalational
anaesthetics.
– Once baby delivered: propofol and
opioids + epidural anaesthesia.
• Epidural catheter for postoperative
analgesia.
Maternal monitoring / installation.
• Epidural catheter.
• Arterial and CVP lines.
• Good IV access.
• Blood and IV fluid heating.
• Standard monitoring: ECG, etCO2
and saturation.
Open surgery – EXIT: issues.
• Maintain normal uteroplacental
perfusion.
• Monitoring of fetus.
• Blood loss.
• Uterine relaxation.
Outline.
• Types of surgery: what to expect ?
• Anesthesia for fetal surgery: techniques and
what is expected from us ?
• Fetal pain perception !
• EXIT procedure.
The New York Times Magazine 2008
Does the fetus feel pain ?
Indications and strategies to treat
fetal pain.
Does the fetus experience pain ?
Anatomy Neurophysiology
Behavior Stress response
Anatomical pathways 1. Peripheral receptors:
7-20 weeks.
2. Afferent fibers: C-fibers
8-30 weeks.
3. Spino-thalamic fibers:
16-20 weeks.
4. Thalamo-cortical fibers:
17-24 weeks.
5. Efferent-inhibitory
fibers after birth.
Fitzgerald M. Pain Res Clin Management 1993; 3, 19 - 36.
Lowery et al. Sem Perinatol 2007; 31, 275.
Anatomical pathways
Lowery et al. Sem Perinatol 2007; 31, 275.
Neuro-physiological data
• Primitive EEG: 19 weeks.
• Sustained EEG: 22 weeks.
• Somato-sensory evoked
potentials: 24 weeks.
• Structured EEG: 26 weeks
• EEG with sleep-awake
patterns: 28 – 30 weeks.
• => nociceptive systems
functional from 24 weeks.
Glover and Fisk. Brit J Obstet Gynecol 1999; 106, 881-886.
Klimach and Cooke. Develop Med Chil Neurol 1988; 30, 208 – 214.
Behavior
• Movement to external stimuli: 8
weeks.
• Reaction to sound: 20 weeks.
• Behavioral response to painful
stimuli: 22 weeks (premature
infants).
• Differentiation of sound: 28 weeks.
Prechtl. Early Hum Dev 1985; 12, 91 - 98.
De Vries. Early Hum Dev 1985; 12, 301 – 322.
Fetal Stress Response
• Measurement of
stress hormones:
– Cortisol.
– β – endorphin.
– Noradrenaline.
• Regional fetal blood
flow.
Giannakoulopoulos et al. The Lancet 1994; 344, 77-81.
β-endorphin and cortisol.
Giannakoulopoulos et al. The Lancet 1994; 344, 77-81.
Pain perception from 24 weeks
Pain perception possible from
14 - 16 weeks
Long term implications: Hyperalgesia
Taddio et al. The Lancet 1997; 349, 599 - 603.
Nerve sprouting
Reynolds et al. J Comp Neur 1995; 358, 487 - 498.
– Does the fetus feel pain ?
– Indications and strategies to treat fetal
pain.
Indications to treat fetal pain.• Direct surgical trauma of the fetus.
• Late termination of pregnancy (> 20 weeks ???): analgesia +
fetocide.
• Endoscopic, intrauterine surgery on placenta, cord and
membranes.
– To avoid fetal movements:
• To improve surgical exposure.
• To avoid fetal pain.
• Painful, non-lethal conditions ???
• Vaginal delivery – instrumental vaginal delivery ????
Outline.
• Types of surgery: what to expect ?
• Anesthesia for fetal surgery: techniques and
what is expected from us ?
• Fetal pain perception !
• EXIT procedure.
CONCLUSIONS
• Fetal surgery is a clinical reality and no longer an
experimental procedure.
• Many challenges to the anaesthetist.