NM-268
PRESTO vs. EXIT for the Management of Prenatally Diagnosed Difficult Airway: Techniques and Outcomes
Lin E, Nelson O, Tran K, Isserman R, Javia L, Khalek N, Rintoul N, Oliver E, Hedrick H
Children's Hospital of Philadelphia, Philadelphia, PA, USA
Background: Anticipated neonatal difficult airway can be an indication for birth via Ex-Utero Intrapartum Treatment (EXIT) procedure. However, the EXIT procedure is not without additional maternal risk. An alternative management is a Procedure Requiring Second Team in the OR (PRESTO) where the fetuses are delivered by scheduled cesarean section and a multidisciplinary resuscitation team including otolaryngology, neonatology, anesthesiology, nursing, and respiratory therapy awaits to manage a potentially life threatening airway condition. We present airway management techniques and outcomes of 38 patients at a single tertiary care center from 2009-2017 who presented with anticipated neonatal difficult airway.
Methods: A retrospective chart review of fetuses with prenatal diagnosis of anticipated neonatal difficult airway evaluated at our center from 2009-2017 was performed. Operative notes, resuscitation records, anesthesia records, progress notes, prenatal diagnosis, and maternal blood transfusion rates were reviewed.
Results: 38 patients met inclusion criteria. 16 were managed by PRESTO and 22 by EXIT. Subjects managed by PRESTO had craniofacial syndromes associated with micrognathia or retrognathia (n=9), or neck masses anticipated to be smaller or less invasive than those managed by EXIT (n=7). Subjects managed by EXIT had large cervical lymphangiomas (n=7), teratomas (n=10), cystic masses (n=2), epulis (n=2) or goiter (n=1). Gestational age at delivery was 37.4 weeks for PRESTO vs. 36.4 weeks for EXIT (p=0.08). Four of the PRESTO cases did not require airway intervention. Of the 12 PRESTO cases where the neonate was intubated, 6 were intubated with a fiberoptic scope through a laryngeal mask airway, 3 with a rigid bronchoscope, and 3 by direct laryngoscopy. In 11 of 12 PRESTO cases where the neonate was sedated for intubation, IV ketamine was administered, and in 10 of the 12 cases, IV dexmedetomidine was administered. In this cohort, one mother experienced placental abruption during EXIT procedure, requiring transfusion of 2 units of packed red blood cells, whereas there were no intraoperative maternal complications in the PRESTO cohort.
Conclusions: The potential benefit to the fetus of placental bypass during EXIT procedure must be weighed against the increased maternal blood transfusion risk. PRESTO allows for decreased maternal morbidity as well as the use of medications that do not suppress neonatal respiratory drive to maintain spontaneous ventilation until the airway is secured.
Top
