Maternal and fetal safety of fluid-restrictive general anesthesia for endoscopic fetal surgery in monochorionic twin gestations

• Published in: Journal of clinical anesthesia 2014-05, Vol.26 (3), p.184-190
• Main Authors: Duron, Vincent D., MD, Watson-Smith, Debra, RN, Benzuly, Scott E., MD, Muratore, Christopher S., MD, O’Brien, Barbara M., MD, Carr, Stephen R., MD, Luks, Francois I., MD, PhD
• Format: Article
• Language: English
• Subjects: Academic Medical Centers; Adult; Anesthesia; Anesthesia & Perioperative Care; Anesthesia, General - adverse effects; Anesthesia, General - methods; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Birth defects; Blood pressure; Drug dosages; Female; Fetal surgery; Fetofetal Transfusion - surgery; Fetoscopy; Fetoscopy - adverse effects; Fetoscopy - methods; Fetus - surgery; Fetuses; Fluid Therapy - methods; Fluids; Hernias; Humans; Infant, Newborn; Laser Therapy - adverse effects; Laser Therapy - methods; Lasers; Medical sciences; Pain Medicine; Patients; Placenta; Placenta - blood supply; Postoperative period; Pregnancy; Pregnancy Complications - etiology; Pregnancy Outcome; Respiratory Tract Diseases - epidemiology; Respiratory Tract Diseases - etiology; Retrospective Studies; Statistical methods; Surgery; Twin-to-twin transfusion syndrome; Young Adult
• ISSN: 0952-8180; 1873-4529
• DOI: 10.1016/j.jclinane.2013.10.010

Abstract Study Objective To review our experience with general anesthesia in endoscopic fetal surgery for twin-to-twin transfusion syndrome (TTTS), and to compare fetomaternal outcome before and after protocol implementation. Design Retrospective impact study. Setting University-affiliated medical center. Measurements Data from 85 consecutive patients who underwent endoscopic laser ablation of placenta vessels for severe TTTS were studied. Outcomes were compared in patients before (2000–2007) and after (2008–2012) a change to strict intraoperative intravenous (IV) fluid and liberal vasopressor management. Perioperative parameters (IV fluid administration, vasopressor use, maternal hemoglobin [Hb] concentration); maternal complication rate (respiratory, hemorrhagic); pregnancy outcome; and fetal and neonatal survival were recorded. Main Results Patients in the early group (2000–2007; n = 55) received 1634 ± 949 mL of crystalloid fluid intraoperatively, compared with 485 ± 238 mL ( P < 0.001; Student’s t test) given to the late group (2008–2012; n = 30). Maternal pulmonary edema and any respiratory distress were seen in 5.5% and 12.7% of patients in the early group, respectively, and in none of the late group patients ( P < 0.05; Chi-square analysis). Conclusions A significant risk of maternal respiratory complications exists after general anesthesia for endoscopic fetal surgery. Judicious fluid management significantly decreases this risk.