Asymptomatic COVID-19 infection in a child with nasal foreign body.

While children, particularly infants, are susceptible to severe and critical COVID-19 disease, over 55% of pediatric cases are present in asymptomatic or mildly symptomatic children. Aerosolized SARS-CoV-2 viral particles remain viable for up to 3 hours, raising concern about risk to healthcare workers during aerosol generating procedures (APGs) in the airway and nasopharynx. Herein we describe the first case of a nasal foreign body in an asymptomatic child with SARS-CoV-2 infection. We discuss management of this child and highlight the importance of considering asymptomatic infection and preoperative testing when planning procedures of the airway in the COVID-19 era.

Assessing reverse 911®: a case study of the 2007 San Diego wildfires.

In October 2007, 250,000 residents of San Diego County were forced to evacuate as wildfires burned 62 miles(2) in 24 hours. In 2005, the Sheriff's Department invested in Reverse 911® to contact residents upon emergencies. The system was used during this wildfire, and by the following midday, had made 394,915 calls. Shortly thereafter, 1,210 residents were surveyed to investigate the effectiveness of this technology. Findings reveal that 42 percent of respondents received their first warning from a Reverse 911® call while an additional 7 percent received the same call, but not as their first warning, as compared to all other methods used.

Ex utero intrapartum treatment with placement on extracorporeal membrane oxygenation for fetal thoracic masses.

PURPOSE: We describe our experience with fetuses diagnosed with life-threatening chest masses who were delivered by ex utero intrapartum treatment with placement on extracorporeal membrane oxygenation (EXIT-to-ECMO). METHODS: The first fetus presented with a cystic mediastinal mass and enlarging echogenic lungs. Bronchoscopic evaluation during ex utero intrapartum treatment (EXIT) revealed complete airway obstruction secondary to a carinal bronchogenic cyst. The second fetus presented with a massive left congenital cystic adenomatoid malformation. The EXIT procedure was performed because of significant mediastinal shift, severe compression of the normal lung parenchyma, and signs of fetal distress. RESULTS: In both cases, extracorporeal membrane oxygenation (ECMO) was initiated while on placental support. The fetuses were then delivered, and a definitive resection of their thoracic lesions was successfully performed. There were no major perioperative complications. Both children made expedient recoveries without significant cardiopulmonary sequelae. CONCLUSION: To our knowledge, this is the first report describing the successful use of EXIT-to-ECMO as a bridge to definitive resection of large chest masses diagnosed in utero. EXIT-to-ECMO is a novel and effective management strategy for stabilizing patients with profound respiratory compromise secondary to congenital thoracic lesions.

Ex utero intrapartum treatment with extracorporeal membrane oxygenation for severe congenital diaphragmatic hernia.

PURPOSE: The purpose of this study was to determine whether ex utero intrapartum treatment with extracorporeal membrane oxygenation (EXIT to ECMO) is a reasonable approach for managing patients antenatally diagnosed with severe congenital diaphragmatic hernia (CDH). METHODS: A 6-year retrospective review was performed on fetuses with severe CDH (liver herniation and a lung/head ratio <1.4, percentage of predicted lung volume <15, and/or congenital heart disease). Fourteen of the patients underwent EXIT with a trial of ventilation. Fetuses with poor preductal oxygen saturations despite mechanical ventilation received ECMO before their delivery. Maternal-fetal outcomes were analyzed. RESULTS: There were no maternal-reported complications. Three babies passed the ventilation trial and survived, but 2 of them required ECMO within 48 hours. The remaining 11 fetuses received ECMO before their delivery. Overall survival after EXIT-to-ECMO was 64%. At 1-year follow-up, all survivors had weaned off supplemental oxygen, but 57% required diuretics and/or bronchodilators. CONCLUSION: This is the largest reported experience using EXIT to ECMO in the management of severe CDH. The EXIT-to-ECMO procedure is associated with favorable survival rates and acceptable pulmonary morbidity in fetuses expected to have a poor prognosis under conventional management.

Fetal surgery in otolaryngology: a new era in the diagnosis and management of fetal airway obstruction because of advances in prenatal imaging.

OBJECTIVE: To evaluate the efficacy, safety, and outcome of prenatal imaging and fetal surgery in the diagnosis and management of fetal airway obstruction caused by cervical teratoma or lymphatic malformation. SETTING: Tertiary care medical center. Patients A retrospective study of all consecutive fetal patients with cervical teratoma or lymphatic malformation between January 2001 and December 2003. RESULTS: The indication was potential airway obstruction due to a fetal neck mass in 8 patients. Prenatal images were obtained by ultrasonography and magnetic resonance imaging, and were consistent with teratoma in 4 patients. The mean cervical mass was 8.3 x 7.3 x 6.7 cm, with airway obstruction suspected in all 4 patients. All 4 patients were successfully delivered by ex utero intrapartum treatment, during which 3 newborns required tracheotomy and 1 was successfully intubated. Prenatal images were consistent with lymphatic malformation in the remaining 4 patients. The mean cervical mass was 4.6 x 4.4 x 3.4 cm. There was no indication of airway obstruction based on prenatal images. All 4 patients had an uncomplicated vaginal delivery. CONCLUSIONS: Technological advances in prenatal ultrasonography and magnetic resonance imaging have improved the ability to diagnose congenital abnormalities in utero. This allows for proper assessment of the airway to prevent any unexpected problems at delivery. We believe that many airway emergencies can be avoided by prenatal imaging and initiation of airway management in the prenatal period.

Combined general and epidural anesthesia for a child with alagille syndrome: a case report.

Alagille syndrome (syndromic paucity of interlobular bile ducts) is the most common form of familial intrahepatic cholestasis. We describe the perioperative management of a pediatric patient with Alagille syndrome undergoing ileal exclusion and the specific issues associated with epidural anesthesia with this syndrome.

Fetal endoscopic surgery: indications and anaesthetic management.

Fetal intervention for certain life-threatening conditions has progressed from being primarily experimental in nature to the standard of care in certain circumstances. While surgical techniques have advanced over the past few years, the anaesthetic goals for these interventions have remained the same; namely, minimizing maternal and fetal risk as well as maximizing the chances of a successful fetal intervention and optimize the conditions necessary to carry the fetus to term gestation. Fetal endoscopic techniques allow access to the fetus without the need for a hysterotomy incision, thus improving the chances of controlled post-operative tocolysis and term gestation after fetal intervention. This procedure, however, is not without associated risks to both fetus and mother. This chapter will address the fetal diseases that may benefit from fetoscopic intervention, the rationale behind why maternal and fetal anaesthesia is required, the various anaesthetics used for these cases and specific considerations of both maternal and fetal physiology that aid in the determination of the best anaesthetic technique for individual cases. Methods of intra-operative fetal monitoring and fetal resuscitation will also be discussed.

Epidural versus general anesthesia for twin-twin transfusion syndrome requiring fetal surgery.

OBJECTIVES: This paper describes our experiences with epidural and general anesthesia for selective fetoscopic laser photocoagulation (SFLP) of placental vascular anastomoses in patients with severe twin-twin transfusion syndrome (TTTS). METHODS: Retrospective review of 29 anesthetic and surgical operative records of 28 women undergoing SFLP at The Children's Hospital of Philadelphia from July 1996 to June 2001. RESULTS: Patients with anterior placentas were more likely to receive a general anesthetic. Patients receiving an epidural anesthetic received significantly more intravenous (i.v.) crystalloid but less i.v. fentanyl than those receiving a general or combined technique. CONCLUSIONS: The advantages of general anesthesia include increased ability of the patient to tolerate extreme positions and the surgical manipulation of the uterus (required in the technically more difficult cases), greater uterine relaxation, decreased use of i.v. fluids, but increased fentanyl requirements. Epidural anesthesia avoids the risks of failed tracheal intubation in pregnant women but may not reduce fetal responses to surgical stimuli unless the mother receives supplemental intravenous drugs. However, this may increase the risk of respiratory depression. The choice of anesthetic technique for SFLP in patients with severe TTTS must be made after careful consideration of maternal and fetal factors.

Ultrasonographic guidance for location of the trachea during the EXIT procedure for cervical teratoma.

Cervical teratomas are rare tumors of infancy that are associated with a high mortality rate caused by compression and distortion of the infant's airway. Recent attempts at managing the fetal airway before delivery have focused on the EXIT (ex-utero intrapartum treatment) procedure, in which time to secure an airway is provided while preserving uteroplacental gas exchange. The authors report the use of intraoperative ultrasound guidance during an EXIT procedure for an infant with massive cervical teratoma to aid in identification of the trachea.

The EXIT procedure: experience and outcome in 31 cases.

BACKGROUND: The EXIT (ex utero intrapartum treatment) procedure, although initially designed for reversal of tracheal occlusion in fetuses with congenital diaphragmatic hernias (CDH), has been adapted to treat a variety of fetal conditions. METHODS: A retrospective chart review of all consecutive EXIT procedures since 1996 was conducted. RESULTS: Thirty-one women underwent the EXIT procedure, with an average maternal age of 29 years (range, 20 to 38), and average gestational age of 34 weeks (range, 29 to 40). The indication was airway obstruction from fetal neck mass in 13, and reversal of tracheal occlusion from in utero clipping in 13. Singular indications included an EXIT-to-ECMO (extracorporeal membrane oxygenation) procedure for a fetus with CDH and a cardiac defect (n = 1), congenital high airway obstruction syndrome (CHAOS, n = 1), resection of a very large congenital cystic adenomatoid malformation of the lung (CCAM) on uteroplacental bypass (n = 1), unilateral pulmonary agenesis (n = 1), and thoracoomphalopagus conjoined twins. The mean duration on uteroplacental bypass (from uterine incision to umbilical cord clamping) was 30.3 plus minus 14.7 minutes (range, 8 to 66). No fetus experienced hemodynamic instability during uteroplacental bypass as recorded by fetal heart rate (FHR), pulse oximeter, and fetal echocardiography, except for one instance of reversible bradycardia from umbilical cord compression. The mean FHR and fetal saturation were 153.0 plus minus 38.5 beats per minute and 71.2% plus minus 19.9%, respectively. Five fetuses required a tracheostomy. Only 1 death occurred during an EXIT procedure because of inability to secure the airway secondary to extensive involvement by a lymphangioma. The average cord pH and pCO(2) were, respectively, 7.20 plus minus 0.11 and 63.2 plus minus 14.6. Two maternal complications occurred: bleeding from a hysterotomy site and dehiscence of an old hysterotomy scar noticed at a subsequent cesarean section. The average maternal blood loss was 848.3 plus minus 574.1 mL. CONCLUSION: The EXIT procedure was used successfully to ensure uteroplacental gas exchange and fetal hemodynamic stability during a variety of surgical procedures performed to secure the fetal airway or ensure successful transition to postnatal environment.