anesthesia for fetal surgery: what to expect –what’s · 2014. 6. 15. · marc van de velde, md,...

Marc Van de Velde, MD, PhD

Professor of Anaesthesia, Catholic University Leuven (KUL)

Chair Department of Anaesthesiology, University Hospitals Leuven (UZL)

Leuven, Belgium

Marc.vandevelde@uzleuven.be

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.