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SUM'20 - Advanced Principles > Week 2 Anesthesia for Fetal Surgery (everything) > Flashcards

Week 2 Anesthesia for Fetal Surgery (everything) Flashcards

1
Q

Fetal surgical therapy orignated in 1963 by

A

Dr Liley - successful performance of intraperitoneal blood transfusion to a fetus w/ erythroblastosis fetalis

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2
Q

ertythroblastosis fetalis is

A

a hemolytic anemia in the fetus caused by transplacental transmission of maternal antibodies to fetal RBC’s

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3
Q

Vesicostomy is

A

an opening created by the surgeon b/w the abd wall and the bladder

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4
Q

Box 7.1 Guidelines for Performing Fetal Procedures:

All of these must be met to perform a fetal procedure
all included just for reference

A

(Box 7.1 )Guidelines for Performing Fetal Procedures

  1. Accurate diagnosis and staging is possible.
  2. Other anomalies that would contraindicate fetal intervention are excluded.
  3. Progression, severity, and prognosis of the condition are understood.
  4. No effective postnatal therapy is currently available, and if not treated before birth, the anomaly would result in fetal death, irreversible organ damage, or other severe postnatal morbidity.
  5. Intrauterine surgery has been proven feasible in animal models, with demonstrated reversal of the deleterious effects of the condition.
  6. The maternal risk is acceptably low.
  7. Interventions are performed in specialized multidisciplinary fetal treatment centers within strict protocols and approval of the local ethics committee, with informed consent obtained from the mother or parents.
  8. There is access to high-level specialized medical care, including bioethical and psychosocial care and counseling.
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5
Q

*** Most correctable malformations are best managed

A

AFTER delivery**

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6
Q

Indicators and Clinical Rationale for fetal surgery include:

A
  1. Obstructive Uropathy
  2. Congenital Diaphragmatic Hernia
  3. Congenital Pulmonary Airway Malformations
  4. Fetal Anemia and Intrauterine Transfusion
  5. Sacrococcygeal Teratoma
  6. Myelomeningocele
  7. Twin-to-Twin Transfusion Syndrome
  8. Twin Reversed Arterial Perfusion Sequence
  9. Congenital Heart Defects
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7
Q

Intrauterine Transfusion may be indicated when

A

a fetus has anemia (low RBC count)

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8
Q

*Fetal anemia caused by:

A

Rh incompatibility (mother and fetus have different blood types; the antibodies in the mother’s blood may destroy blood cells in the fetus)

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9
Q

Intrauterine transfusions are performed using

A

20-22g needle w/ local anesthesia at site of needle insertion

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10
Q

Where is the needle inserted for an IUT?

A

percutaneously through the maternal abd and uterus under US guidance

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11
Q

For IUT, where does the transfusion occur?

A

Umbilical vein

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12
Q

Following an IUT, fetal Hgb levels

A

slowly decrease

and multiple IUTs are often required at 1-3 week intervals

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13
Q

Obstructive Uropathy is a condition in which

A

the flow of urine is blocked.

-causes the urine to back up and cause injury to one or both kidneys

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14
Q

Lower urinary tract obstruction (LUTO) occurs in approx how many births?

A

1:5,000

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15
Q

** congenital bilateral hydronephrosis results from

A

fetal urethra obstruction

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16
Q

hydronephrosis is

A

excess fluid in the kidney

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17
Q

Other causes of Fetal OU include:

A

obstruction of the uteropelvic junction or vesicoureteric junction

**and a number of other disorders in females

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18
Q

**What are the tx for fetal OU?

A
  • fetal cystoscopy

- placement of a vesicoamniotic shunt (VAS shunt)

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19
Q

What does a vesicoamniotic shunt (VAS) do?

A

allow drainage of urine from the fetal bladder

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20
Q

** This occurs when thediaphragm, the muscle that separates the chest from the abdomen, fails to close during prenatal development. This opening allows contents of the abdomen (stomach, intestines and/or liver) to migrate into the chest, impacting the growth and development of the lungs

A

Congenital diaphragmatic hernia (CDH)

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21
Q

**A diaphragmatic hernia is a

A

life-threatening illness and requires care in a neonatal intensive care unit (NICU).

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22
Q

** because their lungs are underdeveloped, babies with a diaphragmatic hernia are often unable

A

to breathe effectively on their own

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23
Q

What prenatal exam can detect CDH and alert PCP that further evaluation by a high volume fetal center is warranted?

A

prenatal ultrasound

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24
Q

** is a birth defect in which the backbone and spinal canal do not close before birth.

A

Myelomeningocele

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25
Q

** Myelomeningocele is a type of ____ . What is the cause?

A

The condition is a type ofspina bifida the cause is unknown.

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26
Q

Purpose of in utero surgery for Myelomeningocele

A

is to improve function later in life

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27
Q

*EXAM

the leading cause of mortality from birth defects

A

Congenital heart abnormalities and occur in approximately 1% of live births

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28
Q

Congenital heart abnormalities and occur in approximately %?

A

approximately 1% of live births

29
Q

**Exam

the most common minimally invasive intervention performed for a congenital heart defect.

A

Fetal valvuloplasty for aortic stenosis with evolving hypoplastic left heart syndrome is

30
Q

Additional closed fetal cardiac interventions include septoplasty for

A

hypoplastic left heart syndrome with an intact or highly restrictive atrial septum,

31
Q

pulmonary valvuloplasty is for

A
  1. evolving hypoplastic right heart syndrome with pulmonary atresia or stenosis without a ventricular septal defect and
  2. fetal pericardiocentesis
32
Q

Complications of congenital cardiac interventions include

A
  • fetal bradycardia,
  • pericardial effusion,
  • ventricular thrombosis,
  • preterm delivery, and
  • fetal demise.
33
Q

What are some good things about the intrauterine environment as it relates to surgery?

A

supports rapid wound healing, provides adequate nutritional and respiratory needs, and limits robust immune responses to interventions.

34
Q

Is serious maternal morbidity from intrauterine fetal surgery is relatively common or uncommon?

A

UNcommon,

but the welfare of the mom must always be emphasized.

35
Q

If the mom was to absorb significant amounts of crystalloids during uterine irrigation what may occur?

A

pulmonary edema could occur

36
Q

True or False

Fetal surgeries do affect future fertility?(bold in ppt)

A

False,

Fetal surgeries do not affect future fertility.

37
Q

Is the fetal risk of intrauterine surgery relatively high still? (bold in ppt)

A

Yes, it remains relatively high!

38
Q

What types of issues can occur to a fetus if intrauterine surgery occured?

A

central nervous system injuries, membrane separation, Premature Rupture of Membranes (PROM), placental abruption, preterm labor and delivery, blood loss, chorioamnionitis, post-operative amniotic fluid leaks with oligohydramnios, fetal demise

39
Q

How many patients are involved in fetal surgery (bold in ppt)

A

Fetal surgery involves 2 patients and the anesthesia provider must balance the needs of both.

40
Q

Who’s safety is paramount during fetal surgery? (bold in ppt)

A

Maternal safety is paramount.
(I assume she is more important than fetus according to this bullet point, could easy be a chose between mom or baby question) BUT know that the fetus is not an innocent bystander (stated in another bullet point)

41
Q

What needs to be completely relaxed during open fetal surgical procedure?

A

Complete uterine relaxation is necessary.

42
Q

Fundamental considerations for the anesthetic management of fetal surgery are similar to those for ???

A

non obstetric surgery during pregnancy.

43
Q

What kind of roles does the Anesthesia Provider play during fetal surgery?

A

Anesthesia Providers should participate in preoperative maternal assessment

Anesthesia Providers must understand the physiologic impact of pregnancy on anesthetic management

Anesthesia Providers should serve as a member of the multidisciplinary team.

44
Q

What should you review imaging studies for when considering fetal surgery? (what are you looking for?)

A

placental location, anatomic information.

45
Q

Is the fetus an innocent bystander if a surgery is performed during pregnancy?

A

No (according to ppt)

46
Q

What forms of anesthesia and analgesia can be provided to the Momma?

A

local infiltration, IV sedation, neuraxial anesthesia, general anesthesia or a combination of these techniques.

47
Q

How is Fetal analgesia and anesthesia achieved?

A

Fetal analgesia and anesthesia can be achieved via placental transfer of anesthetic agents given to the mother.

48
Q

What two administration methods of medications to the mom will transfer medication to the fetus?

A

IV (peripheral fetal vein or umbilical vein) or IM administration of agents or by a combination of these techniques.

49
Q

can you assess pain in a human fetus?

A

The subjective phenomenon of pain has not been , and perhaps cannot be, assessed in human fetuses.

50
Q

Know how pain is complex, that it is not just having a direct stimulus that causes pain. (the next slide is just information to know in general, no hard memorization.

A

Pain is multidimensional, subjective, psychological construct that can exist in the absence of physical stimuli (phantom limb pain) and it includes emotional and affective components that require higher-level cortical processing.
Although pain is commonly associated with noxious physical stimuli, it is more than a nociception (response to noxious or potentially harmful stimuli) or a simple reflex activity associated with withdrawal response.

51
Q

Do volatile anesthetic agents cross the placenta into the fetus?

A

With maternal administration of general anesthesia volatile anesthetic agents readily cross the placenta to the fetus.

52
Q

What two factors determine the fetal level of halogenated anesthesia?
(it states halogenated in the slide but I might assume these two factors are true for all volatile gasses?)

A

depends of both the inspired maternal concentration as well as the duration of administration.

53
Q

What has to be maintained so that the fetus does not have fetal hypoxia, hypercarbia, or acidosis even after 2 hours exposure to deep maternal inhalation anesthesia?

A

maternal arterial blood pressure must be maintained! (bold in ppt)

54
Q

Evidence for neuronal apoptosis in the developing brains of rats was shown after exposure to a wide range of anesthetic agents, what does this mean for human fetuses and neonates?

A

It is not known if anesthetic agents similarly affect human fetuses or neonates.

(these studies can not be performed so….)

55
Q

Even though issues with a babies brain can not be definitively proven with the use of anesthesia medications, what has the FDA stated in regards to this? (general information, not bold or anything in ppt)

A

Nonetheless in December of 2016 the FDA issued a communication warning “repeated or lengthy exposure to general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s’ brains.

56
Q

Tell me some way to monitor the fetus? (looking for three answers)

A

Fetal Heat Rate Monitoring

Ultrasonography ( including echocardiography and Doppler assessment of umbilical cord blood flow)

Blood gas and acid base analysis

57
Q

What is the most common (and sometimes simple) way to monitor a fetus during labor and delivery? (easy answer)

A

Fetal heart rate monitoring! Electronic or with a stethoscope.

extra info:
Fetal heart rate can be monitored intermittently with a simple Delee or Pinard stethoscope. Can also use Doppler ultrasonography or fetal electrocardiography (ECG) electrode can be used to monitor the FHR intermittently or continuously.

58
Q

what is the process physiologically for a decrease in fetal hear rate?

A

Parasympathetic outflow by means of the vagus nerve decreases the FHR.

59
Q

What physiologically increases FHR and CO?

A

Sympathetic activity increases FHR and cardiac output.

60
Q

What two receptors regulate fetal blood pressure and FHR?

A

Baroreceptors respond to increased blood pressure and chemoreceptors respond to decreased PaO2 to modulate the FHR through the autonomic nervous system.

61
Q

How does Cerebral cortical activity and hypothalamic activity affect the FHR?

A

through their effects on integrative centers in the medulla oblongata.

62
Q

Tell me all four ways FHR is regulated.

all four are listed separately in other slides, this is just bringing them all together in one condensed slide

A

Parasympathetic outflow by means of the vagus nerve decreases the FHR

Sympathetic activity increases FHR and cardiac output

Baroreceptors respond to increased blood pressure and chemoreceptors respond to decreased PaO2 to modulate the FHR through the autonomic nervous system.

Cerebral cortical activity and hypothalamic activity affect the FHR through their effects on integrative centers in the medulla oblongata

63
Q

Who has a lower FHR, term fetuses or preterm fetuses?

A

Term fetuses have lower baseline FHR.

64
Q

What is the initial fetal response to acute hypoxemia?

A

bradycardia

65
Q

What is baseline FHR defined as?

A

110-160 bpm

66
Q

bradycardia is the initial fetal response to acute hypoxemia, but after prolonged hypoxemia the fetus may have what and why?

A

tachycardia as a result of catecholamine secretion and sympathetic nervous system activity.

67
Q

What four features are assessed of a FHR?

A

Baseline, variability , accelerations, decelerations.

68
Q

You can measure the FHR internally and externally, do both allow for continuous assessment?

A

yes

69
Q

The FHR is superimposed over WHAT?

A

uterine contraction pattern.

SUM'20 - Advanced Principles (16 decks)

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