title: Supplementing desflurane with intravenous anesthesia reduces fetal cardiac dysfunction during open fetal surgery.
abstract: OBJECTIVE
  To lower the incidence and severity of fetal cardiovascular depression during maternal fetal surgery under general anesthesia.
  
  
  OBJECTIVE
  We hypothesized that supplemental intravenous anesthesia (SIVA) with propofol and remifentanil would lower the need for high-dose inhalational anesthesia and provide adequate maternal depth of anesthesia and uterine relaxation. SIVA technique would minimize prolonged fetal exposure to deep inhalational anesthetics and significant intraoperative fetal cardiovascular depression.
  
  
  BACKGROUND
  Fetal hypoxia and significant fetal hemodynamic changes occur during open fetal surgery because of the challenges such as surgical manipulation, hysterotomy, uterine contractions, and effects of anesthetic drugs. Tocolysis, a vital component of fetal surgery, is usually achieved using volatile anesthetic agents. High concentrations of volatile agents required to provide an appropriate degree of uterine relaxation may cause maternal hypotension and placental hypoperfusion, as well as direct fetal cardiovascular depression.
  
  
  METHODS
  We reviewed medical records of 39 patients who presented for ex utero intrapartum treatment and mid-gestation open fetal surgery between April 2004 and March 2009. Out of 39 patients, three were excluded because of the lack of echocardiographic data; 18 patients received high-concentration desflurane anesthesia and 18 patients had SIVA with desflurane for uterine relaxation. We analyzed the following data: demographics, fetal medical condition, anesthetic drugs, concentration and duration of desflurane, maternal arterial blood pressure, intraoperative fetal echocardiogram, presence of fetal bradycardia, and need for intraoperative fetal resuscitation.
  
  
  RESULTS
  Adequate uterine relaxation was achieved with about 1.5 MAC of desflurane in the SIVA group compared to about 2.5 MAC in the desflurane only anesthesia group (P = 0.0001). More fetuses in the high-dose desflurane group compared to the SIVA group developed moderate-severe left ventricular systolic dysfunction over time intraoperatively (P = 0.02). 61% of fetuses in the high-dose desflurane group received fetal resuscitative interventions compared to 26% of fetuses in the SIVA group (P = 0.0489).
  
  
  CONCLUSIONS
  SIVA as described provides adequate maternal anesthesia and uterine relaxation, and it allows for decreased use of desflurane during open fetal surgery. Decreased use of desflurane may better preserve fetal cardiac function.
authors.affiliation: Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA. anne.boat@cchmc.org
authors.forename: Anne
authors.initials: A
authors.lastname: Boat
authors.forename: Mohamed
authors.initials: M
authors.lastname: Mahmoud
authors.forename: Erik C
authors.initials: EC
authors.lastname: Michelfelder
authors.forename: Erica
authors.initials: E
authors.lastname: Lin
authors.forename: Pornswan
authors.initials: P
authors.lastname: Ngamprasertwong
authors.forename: Beverly
authors.initials: B
authors.lastname: Schnell
authors.forename: Charles D
authors.initials: CD
authors.lastname: Kurth
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Crombleholme
authors.forename: Senthilkumar
authors.initials: S
authors.lastname: Sadhasivam
mesh_terms: D000328:Adult; D000768:Anesthesia, General; D000771:Anesthesia, Intravenous; D018685:Anesthetics, Inhalation; D018686:Anesthetics, Intravenous; D000077335:Desflurane; D004452:Echocardiography; D005260:Female; D005315:Fetal Diseases / Q000601:surgery; D005333:Fetus / Q000601:surgery*; D005865:Gestational Age; D006331:Heart Diseases / Q000517:prevention & control*; D006349:Heart Valve Diseases / Q000503:physiopathology / Q000601:surgery; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control; D007530:Isoflurane / Q000031:analogs & derivatives*; D016343:Monitoring, Intraoperative; D010880:Piperidines; D011247:Pregnancy; D015742:Propofol; D000077208:Remifentanil; D016896:Treatment Outcome; D014599:Uterus / Q000502:physiology
chemical_list: D018685:Anesthetics, Inhalation; D018686:Anesthetics, Intravenous; D010880:Piperidines; D000077335:Desflurane; D007530:Isoflurane; D000077208:Remifentanil; D015742:Propofol