Fetal Surgery-Myelomeningocele Repair

Fetal Surgery-Myelomeningocele Repair

  • General anesthesia and occasionally boluses of nitroglycerine generally required for uterine relaxation (alternative is neuraxial block with nitroglycerine infusion; rarely used)
  • Premed with bicitra
  • Rectal indomethacin is given preoperatively by nursing on 15 L to provide preop tocolysis
  • Lumbar epidural placed prior to procedure; test dosed but not otherwise activated
  • Minimize premeds/opioids to decrease the incidence of hypotension under general anesthetic
  • Once in the OR, monitors placed, table tilted for left uterine displacement
  • Rapid sequence induction with propofol and succinylcholine; 6.5 cuffed ETT typically used.
  • Additional large bore IV access obtained and connected to hotline; consider arterial line placement especially if nitroglycerine is to be used.
  • Type and cross-matched blood in the operating room for the mother; O- irradiated blood in the operating room for fetus
  • Emergency drugs for fetus should be prepared in weight-based single dose aliquots for intraoperative use (atropine 20 mcg/kg, epinephrine 1 mcg/kg). These should be transferred to the scrub nurse prior to incision.
  • 2-3 MAC of halogenated vapor (we usually use sevoflurane) to provide maternal/fetal anesthesia and tocolysis
  • Non-depolarizing muscle relaxants occassionally used; monitor train-of-four closely (effects potentiated by magnesium)
  • IV nitroglycerine (50-200 mcg) can be used to supplement uterine relaxation
  • Intraoperatively MAP should be maintained within 10% of baseline of >65mmHg for adequate placental perfusion. Use phenylepherine infusion, as needed, +/-ephedrine boluses.
  • Limit maternal crystalloid delivery to the mother to typically <2L (to avoid pulmonary edema
  • Sterile temperature probe is passed over the drape to monitor intrauterine temperature; make sure 2 probes/cables are ready
  • At the start of surgical closure:
  • magnesium 4g given over 20 min, followed by infusion of 1-2g/hr;
  • volatile agent discontinued after the magnesium load;
  • epidural activated, usually with 2% lidocaine--notify pain service about epidural and complete epidural orders;
  • Awake extubation
  • Patients recover on 15L; transport with a proPAC/pulse Ox.
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This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.