Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942006000300008
Brazilian Journal of Anesthesiology
Clinical Information

Anestesia para tratamento intraparto extra-útero em feto com diagnóstico pré-natal de higroma na região cervical: relato de caso

Anesthesia for ex utero intrapartum treatment of fetus with prenatal diagnosis of cervical hygroma: case report

Angélica de Fátima de Assunção Braga; José Aristeu F. Frias; Franklin S. da Silva Braga; Monique Sampaio Rousselet; Ricardo Barini; Lourenço Sbragia; Juliana Guarize; Larissa C.C. Gil

http://dx.doi.org/10.1590/S0034-70942006000300008 Braz J Anesthesiol, vol.56, n3, p.278-286, 2006
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Resumo

JUSTIFICATIVA E OBJETIVOS: O tratamento intraparto extra-útero (EXIT) constitui procedimento realizado durante a cesariana, com preservação da circulação feto-placentária, que permite manuseio seguro da via aérea do feto, com risco de obstrução das vias aéreas. O objetivo deste relato foi apresentar um caso de anestesia para EXIT, em feto com higroma cístico na região cervical. RELATO DO CASO: Paciente com 22 anos, 37 semanas de idade gestacional, sem antecedentes anestésicos, estado físico ASA I, submetida ao EXIT para manuseio de via aérea e intubação traqueal em feto com risco para obstrução de vias aéreas. O procedimento foi realizado sob anestesia geral associada a peridural contínua; no pré-operatório foram utilizados metoclopramida (10 mg) e ranitidina (50 mg), por via venosa. No espaço peridural administrou-se bupivacaína a 0,25% com adrenalina (30 mg) associada a fentanil (100 µg), seguida de passagem de cateter cefálico, para analgesia pós-operatória. O útero foi deslocado para a esquerda. A indução anestésica foi feita em seqüência rápida, com fentanil, propofol e rocurônio e a manutenção com isoflurano 2,5% a 3%, em O2 e N2O (50%). Após histerotomia, procedeu-se à liberação parcial do feto, assegurando-se a circulação útero-placentária, seguindo-se as manobras de laringoscopia e intubação traqueal fetal. A seguir, foi realizada liberação total do feto, com pinçamento de cordão umbilical, administração de ocitocina (20 UI) em infusão venosa contínua seguida de metil-ergonovina (0,2 mg) por via venosa. Durante o procedimento, a pressão arterial sistólica materna foi mantida acima de 100 mmHg, com efedrina em bolus (5 mg) e cristalóide (3.000 mL). A concentração do isoflurano foi diminuída gradativamente durante o fechamento uterino. Ao final da intervenção cirúrgica o bloqueio neuromuscular foi revertido e injetou-se morfina (2 mg) pelo cateter peridural para analgesia pós-operatória. CONCLUSÕES: As principais recomendações para a realização do EXIT são segurança materno-fetal, relaxamento uterino para manutenção do seu volume, da circulação útero-placentária e imobilidade fetal para facilitar o manuseio das vias aéreas.

Palavras-chave

ANESTESIA, Obstétrica, CIRURGIA, Obstétrica, COMPLICAÇÕES, COMPLICAÇÕES, TÉCNICAS ANESTÉSICAS, Geral, Regional

Abstract

BACKGROUND AND OBJECTIVES: Ex utero intrapartum treatment (EXIT) is a procedure performed during Cesarean section with preservation of fetal-placental circulation, which allows the safe handling of fetal airways with risk of airways obstruction. This report aimed at describing a case of anesthesia for EXIT in a fetus with cervical cystic hygroma. CASE REPORT: Female patient, 22 years old, 37 weeks gestation without anesthetic background, physical status ASA I, submitted to EXIT for airway handling and tracheal intubation of fetus at risk for airway obstruction. Procedure was performed under general anesthesia associated to continuous epidural anesthesia. Patient was premedicated with intravenous metoclopramide (10 mg) and ranitidine (50 mg). Epidural 0.25% bupivacaine with epinephrine (30 mg) associated to fentanyl (100 mg) was administered, followed by cephalic catheter for postoperative analgesia. Uterus was displaced to the left. Anesthesia was induced in rapid sequence with fentanyl, propofol and rocuronium and was maintained with isoflurane in 2.5 at 3% in O2 and N2O (50%). After hysterotomy, fetus was partially released assuring uterus-placental circulation, followed by fetal laryngoscopy and tracheal intubation. Then fetus was totally released with umbilical cord clamping, administration of oxytocin (20 UI) in continuous infusion, followed by intravenous methyl-ergonovine (0.2 mg). Maternal systolic pressure was maintained above 100 mmHg during the procedure with bolus ephedrine (5 mg) and crystalloids (3000 mL). Isoflurane concentration was gradually decreased during uterine closure. At surgery completion neuromuscular block was reversed and morphine (2 mg) was injected through the epidural catheter for postoperative analgesia. CONCLUSIONS: Major recommendations for EXIT are maternal-fetal safety, uterine relaxation to maintain uterine volume and uterus-placental circulation, and fetal immobility to help airway handling.

Keywords

ANESTHESIA, Obstetric, ANESTHETIC TECHNIQUES, General, Regional, COMPLICATIONS, COMPLICATIONS, SURGERY, Obstetric, SURGERY, Obstetric

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