EXIT: Estado del arte y cómo lo hacemos

Resumen El protocolo EXIT (tratamiento ex-útero intraparto) es una técnica que permite establecer una vía aérea segura y estable, en un feto con obstrucción de esta o riesgo al momento del parto. Se basa en mantener la circulación uteroplacentaria con anestesia neonatal, logrando una hipotonía uterina controlada. Todo otorrinolaringólogo que se desempeñe en un hospital que cuente con un servicio de obstetricia de alta complejidad puede ser requerido en este tipo de casos y debe tener un protocolo establecido de cómo proceder. En nuestro medio se trata de un procedimiento poco frecuente que obliga a la revisión de la técnica. No existe un protocolo único en la literatura internacional, pero sí principios fundamentales. Se presenta caso clínico de un embarazo, en que se identifica una masa cervical fetal, realizándose el protocolo EXIT. Se realiza una revisión de la literatura, se describen los principios de esta técnica, así como también nuestro enfrentamiento y lecciones aprendidas.

Abstract The EXIT protocol (ex-utero intrapartum treatment) is a technique that allows establishing a safe and stable airway in a fetus with airway obstruction, or at risk of it, at the time of delivery. It is based on maintaining uteroplacental circulation with neonatal anesthesia, achieving controlled uterine hypotonia. Any otolaryngologist working in a hospital that has a highly complex gynecology and obstetric service may be required in this type of case and must have an established protocol of how to proceed. In our setting, it is an infrequent procedure, so it requires a revision of the surgical technique. There is no established protocol in the literature, but there are fundamental principles. We describe a clinical case of a pregnancy where a fetal cervical mass was identified, and an EXIT protocol was performed. A review of the literature is presented, the principles of this technique are described, as well as our procedure and lessons learned.

A well-orchestrated EXIT strategy: A case of a successful ex utero intrapartum treatment procedure for Cystic Hygroma / Philippine Journal of Obstetrics and Gynecology

@#A fetal neck mass such as cystic hygroma imposes a challenge in the continuing prenatal care and birth strategy for a 26-year-old gravida 2 para 1 (1001) with a scarred uterus from previous low transverse cesarean section (CS). An intricate delivery for the fetus with a potential airway obstruction necessitates an ex utero intrapartum treatment (EXIT) delivery. The patient was initially scheduled to undergo the procedure at 38 weeks of gestation, but preterm labor ensued. Close antenatal monitoring was done which carried the pregnancy to term. The multidisciplinary approach and planning requires consensus among varied specialties as this maternal–fetal surgery differs immensely from a regular CS. This aims to document and discuss the preoperative, operative and postoperative management done for this patient. The EXIT procedure was performed at 38 weeks' age of gestation with good maternal outcomes. The fetus was delivered safely.

Técnica EXIT como manejo de la vía aérea en masas gigantes congénitas de cuello / Ex-Utero Intrapartum Treatment for airway management in congenital giant neck masses

Resumen: Introducción: Las masas congénitas de cabeza y cuello se asocian a asfixia perinatal e injuria cerebral con elevada mortalidad. La técnica EXIT (Ex Útero Intrapartum Treatment) consiste en asegurar la vía aérea del neonato, sin interrumpir la oxigenación y perfusión materno-fetal a través del soporte placentario. Esta técnica no ha sido estandarizada en países de medianos ingresos. Objetivo: Describir el caso clínico de 2 neonatos manejados mediante la técnica EXIT. Caso Clínico: Se reportan dos casos, uno con malformación linfática diagnosticada a la semana 20 gestación y el segundo con tiromegalia y polihidramnios diagnosticados a la semana 35 de gestación. En ambos casos, duran te la cesárea se realizó la técnica EXIT con un equipo conformado por neonatólogo, ginecólogo, anestesiólogo, cirujano pediatra, otorrinolaringólogo, enfermero y terapeuta respiratorio. En los dos pacientes se logró asegurar la vía aérea mediante intubación orotraqueal al primer intento. En el caso 1 se confirmó la malformación linfática y recibió escleroterapia, y en el caso 2 se diagnosticó hipotiroidismo congénito asociado a bocio, que fue manejado con levotiroxina. Los pacientes se mantuvieron 7 y 9 días con ventilación mecánica invasiva respectivamente y egresaron sin complicaciones respiratorias. Conclusiones: La técnica EXIT en estos casos fue un procedimiento seguro, llevado a cabo sin inconvenientes. Se necesita un equipo multidisciplinario y la disponibilidad de una unidad de cuidados intensivos neonatales, con el objetivo de reducir potenciales complica ciones y garantizar el manejo postnatal. Para lograr su ejecución, es indispensable el diagnóstico prenatal oportuno.

Abstract: Introduction: Congenital head and neck masses are associated with perinatal asphyxia and brain injury, increasing the risk of death. The EXIT (Ex Utero Intrapartum Treatment) technique con sists of ensuring the newborn's airway while is still receiving placental support. This technique has not been standardized in developing countries. Objective: To describe the clinical outcomes of two infants who underwent the EXIT technique. Clinical Case: We present two cases, one with lymphatic malformation diagnosed at 20 weeks of gestational age (WGE) and the second one, a preterm newborn with thyromegaly and polyhydramnios, diagnosed at 35 WGE. In both cases, during the C-section, the EXIT technique was performed with a team of a neonatologist, a gyne cologist, an anesthesiologist, a pediatric surgeon, an otolaryngologist, a nurse, and a respiratory therapist. In both patients, the neonatologist achieved to secure the airway through orotracheal intubation at the first attempt. In the first case, lymphatic malformation was confirmed and re ceived sclerotherapy, and the second one was diagnosed with congenital hypothyroidism which was managed with levothyroxine. The patients needed invasive mechanical ventilation for 7 and 9 days, respectively, and were discharged without respiratory complications. Conclusions: In these patients, the EXIT technique was a safe procedure, carried out without inconvenience. A multi disciplinary approach and the availability of a neonatal intensive care unit are needed to reduce potential complications and ensure postnatal management. Timely prenatal diagnosis is essential to perform this technique.

Nursing care of the ex-utero intrapartum treatment in one case fetal neck mass oppressing airway / 中国实用护理杂志

Objective To explore nursing care of the ex-utero intrapartum treatment (EXIT) in fetal neck mass oppressing airway. Methods A case of EXIT in which a fetal neck mass was diagnosed on ultrasound was fully prepared supplies and carried out. Nursing care was well implemented and vital signs of the puerpera and fetus were observed in preoperative and intraoperative surgery. Results The EXIT procedure was successful performed and vital signs of the puerpera and fetus were steadied. The score of Apgar was seven to eight. Conclusions Adequate equipment, multi-department collaboration, preoperative exercise and close cooperation are the important guarantee for the success of ex-utero intrapartum treatment.

Using the EXIT(ex-utero intrapartum treatment)procedure in the preoperative and intraoperative caring of congenital diaphragmatic hernia of neonatus--report of 3 cases / 现代临床护理

Objective To report 3 cases of using the EXIT(ex-utero intrapartum treatment)procedure in the peri-surgical caring of congenital diaphragmatic hernia of neonatus.Methods Preparing and consulting of multiple clinical departments before operation,inhibit uterine contraction to avoid placental abruption.Keep puerperae and their babies warm.Result No complications happened to neither maternity nor neonatus.Conclusion Co-operations of multiple clinical departmens were essential to the successful using the EXIT(ex-utero intrapartum treatment)procedure in the congenital diaphragmatic hernia of neonatus.

A Case of Intrauterine Lingual Cyst with Successful Delivery Assisting Ex Utero Intrapartum Treatment Procedure / 대한주산의학회잡지

Congenital lingual cyst is rare and there has been no prior case report about prenatally detected lingual cyst in Korea. When a huge oral cyst is observed at prenatal period and can cause life-threatening airway obstruction at birth, ex utero intrapartum treatment (EXIT) procedure is needed to secure the airway. Herein we present a baby with a prenatally detected huge oral cyst. He was delivered safely assisting EXIT procedure and underwent an operation for resection of the cyst from his tongue. The oral cyst was diagnosed as a lingual cyst with rare histologic type consisting mixed gastrointestinal and respiratory epithelium.

Exit: tratamiento exútero intraparto: reporte de caso y revisión de la literatura / Exit: ex-utero intrapartum treatment: a case report and literature review

Introducción y objetivo: la técnica Tratamiento exútero intraparto (EXIT) permite el aseguramiento de la vía aérea fetal mientras se mantiene el soporte uteroplacentario íntegro. El objetivo de reportar este caso es describir el procedimiento y hacer una revisión de la literatura mundial respecto a consideraciones anestésicas y complicaciones asociadas. Materiales y métodos: presentamos el caso de una neonato femenina de 39 semanas de gestación que nace mediante la técnica Tratamiento exútero intraparto (EXIT) debido a una potencial obstrucción de la vía aérea detectada en una ecografía de tercer trimestre. Se realizó una búsqueda sistemática usando las palabras clave: Tratamiento exútero intraparto (EXIT), masas cervicales congénitas y CHAOS en las bases de datos Medline via Pub Med, Ovid, y la base latinoamericana SciELO. Resultados: se encontraron un total de 183 artículos, de los cuales 76 estaban relacionados directamente con el tema, de estos se seleccionaron 8 reportes de caso, 2 series de casos y 14 revisiones del tema. Conclusiones: la estrategia EXIT prueba ser una herramienta útil en el adecuado manejo de los neo-natos con obstrucciones congénitas de la vía aérea.

Introduction and objective: The EXIT procedure (ex-utero intrapartum treatment) is aimed at securing the fetal high airway whilst maintaining integral uteroplacentary circulation. The purpose of reporting this case was to describe the procedure and review the worldwide literature regarding anesthetic considerations and associated complications. Materials and methods: The case of a 39-week gestation female neonate is presented; she was born at the Clínica del Country (a private highlevel healthcare general hospital located in Bogota, Colombia) by the ex-utero intrapartum treatment (EXIT) technique due to a potential obstruction of the airway detected during third-trimester echography. A systematic search was made of Medline databases via PubMed, Ovid, and the SciELO Latin-American database using the following key words: EXIT, ex-utero intrapartum treatment, congenital cervical mass, CHAOS. Results: 183 articles were found, of which 76 were directly related to the topic; 8 case reports, 2 case series and 14 reviews of the topic were selected. Conclusion: The EXIT strategy has proved to be a useful tool in the suitable management of neonates suffering congenital obstruction of the airway.

Tratamiento extrauterino intraparto: manejo del recién nacido con síndrome de obstrucción congénita de la vía aérea superior: informe de un caso / Ex utero intrapartum treatment: management of neonatal congenital high airway obstruction syndrome: case report

En años recientes, el tratamiento extrauterino intraparto, que consiste en la intubación fetal extrauterina previa al nacimiento, ha adquirido relevancia en la reducción de la morbimortalidad de neonatos afectados por el síndrome de obstrucción congénita de la vía aérea superior. Caso clínico. Presentamos una madre con un feto de 22 semanas de gestación y diagnóstico de estenosis de la vía aérea, que anticipaba déficit ventilatorio fetal extraparto y derivó en la aplicación del tratamiento extrauterino intraparto para garantizar el intercambio gaseoso fetal en el momento del nacimiento. Conclusiones. La práctica oportuna del procedimiento extrauterino intraparto logró en este caso, mediante el control de los factores maternos y fetales que pudieran afectar la circulación feto-placentaria, el nacimiento de un niño cuya evolución inmediata y a largo plazo fue exitosa con desarrollo deuna vida normal.

In recent years, the ex utero intrapartum treatment (EXIT), that involves extrauterine fetal intubation prior to delivery, has become relevant for the reduction in morbidity and mortality of neonates affected by congenital high airway obstructionsyndrome (CHAOS). Clinical case. We report the case of the mother of an unborn child at pregnancy week 22, who was diagnosed a congenitalpulmonary malformation that precluded intrapartum fetal circulatory deficit and resulted in the conduction of an EXITtechnique, with the aim of ensuring fetal blood gas exchange at the time of delivery. Conclusions. A timely practice of the EXIT technique resulted, by monitoring both maternal and fetal factors that might affect fetoplacental circulation, in the birth of a child whoseimmediate and long-term outcomes were successful allowing the child live a normal life.

Anesthetic management of the ex utero intrapartum treatment (EXIT) procedure: A case report / 대한마취과학회지

The ex utero intrapartum treatment (EXIT) procedure is a very rare technique performed in cases of fetal congenital malformations. The EXIT procedure increases the rate of survival at delivery by maintaining the uteroplacental circulation until the airway of the fetus is secured. To maintain the uteroplacental circulation, a higher dose of inhalational anesthetics and/or intravenous nitroglycerin can be used as compared to conventional Cesarean section. The aim of this report is to share our anesthetic experience during the EXIT procedure with members of the Korean society of anesthesiology for the first time, and to highlight the maternal implications of the use of inhalational anesthetics and nitroglycerin during Cesarean section for the EXIT procedure.

A Case of the EXIT (Ex Utero Intrapartum Treatment) Procedure in Congenital Fetal Cervical Immature Teratoma / 대한이비인후과학회지

The exutero intrapartum treatment (EXIT) is an uncommon procedure indicated for fetal lesions with the potential to cause lifethreatening airway obstruction immediately after child delivery. Maintenance of the maternal-fetal circulation under the general anesthesia can allow time for the fetal airway to be secured before delivery. Cervical teratomas are rare congenital tumors derived from all three germ cell layers. The vast majority are histologically benign, but the significant size can potentiate life-threatening upper airway obstruction. We have recently experienced a case of the large fetal cervical teratoma diagnosed prenatally on ultrasonography and treated surgically using the EXIT procedure.

Ex utero intrapartum treatment (EXIT) for fetal intubation with giant neck mass: A case report / 대한마취과학회지

Large fetal neck masses can cause life threatening airway obstructions after delivery. The ex utero intrapartum treatment (EXIT) can be used to obtain a fetal airway while feto-maternal circulation is preserved. The relationship of neck mass to airway structures can be defined prenatally with ultrasound and magnetic resonance imaging (MRI). We present a successful EXIT case in which prenatally a large fetal neck mass was diagnosed on ultrasound and MRI at 35 weeks of gestation in 30 year-old paturient.

Study Progress of Ex Utero Intrapartum Treatment / 实用儿科临床杂志

Airway problems in foetus that may cause airway obstruction can be safely managed by using an ex utero intrapartum technique(EXIT).The EXIT procedure maintains a period of uteroplacental circulation for fetal oxygenation during delivery to provide time to explore and secure the airway of the fetus or to perform fetal operations before the umbilical cord is clamped.The common indication for the EXIT procedure is the presence of foetal airway obstruction,which is usually caused by neck mass,congenital diaphragmatic hernia,congenital high way obstruction syndrome,thoracic abnormality,congenital heart and lung dysfunction,conjoined twins,and so on.It avoids the acute airway obstruction in a neonate that has disastrous consequences.