EXIT Procedure

Here’s a case study of a delicate ex-utero procedure that highlights the importance of meticulous planning and teamwork

EXIT Procedure

Babies with anticipated breathing problems are delivered through EXIT procedure. This method is opted during Cesarean Section. The conditions such as the presence of tumours which occur in the neck of babies as in cervical teratomas, cystic hygromas or hygromas or congenital high airway obstruction syndrome may be the cause for breathing problems. These will be picked up by ultrasound.

Dr.Karthik Nagesh, Chairman& HOD Neonatologist, NICU has noted that the Neo- Natal perinatal unit at Manipal Hospital, Bangalore has received several references of babies having a compromised airway before birth.

Antenatal scans show that tumours in the neck or inside, causes obstruction or extrinsic compression. This makes the windpipe to compromise in babies. There are cases where babies are born with a defect in the diaphragm. This condition is called as congenital diaphragmatic hernia.

Dr Karthik Nagesh mentions that the above common existing conditions in babies are referred for EXIT procedure.

A proper planning of EXIT procedure has to be done to assure that the baby is delivered with minimal cerebral damage or other complications due to hypoxia. A normal Cesarean section is performed and the head and upper limb is delivered. The placental circulation is maintained to prevent hypoxic damage & this is the main goal of EXIT procedure.

This procedure gives the doctor ample time to put in a breathing tube into the narrow, obstructed or difficult airway. There is no haste or stress as the baby will be still receiving its circulation & oxygen from the placental circulation. The baby will be handed over to the Neonatologist after the airway is well secured.

Dr Jayashree Simha, consultant Anaesthesiologist Manipal, affirms that in all the six cases referred, the team of doctors were able to successfully secure the airway& get the child out without any hypoxic damage.

EXIT procedure will consist of a team of doctors which includes a gynaecologist, neonatologist, anaesthesiologist, ultrasonologist along with the backup of ENT and Paediatric surgeons.

In this exit procedure, the role played by anaesthesiologist is vital as they are required to deal with mother and unborn foetus.

Dr Suma Sriramanan, HOD and Consultant Anaesthesiologist concurs that it is a team work involving not only the doctors but also their technicians and other paramedical staff inside the operation theatre. This procedure also includes modifications in the technique of administering anaesthesia.

The foetus is also anaesthetised after the mother is given anaesthesia, a pulse oximeter is connected to monitor the baby as the head of the baby  is delivered with one upper limb.

Dr Suma informs that general anaesthesia is given so that things will be well under control. Invasive monitoring along with routine monitoring will be done while the mother is put to sleep. Then the foetus is anaesthetised. This is done so that it does not struggle while its airway is being secured.

Dr.Jayashree stresses on the fact that the EXIT procedure has the salient feature of meticulous planning at multidisciplinary levels. She elucidates that a routine laryngoscopy & securing of the airway will be followed as a protocol by doctors. A supraglottic airway device will be opted if they have to face problems. And if this too fails, the procedure may involve the surgeons, who are on standby.

A successful case of a baby with a large tumour in the neck, referred to Manipal Hospital is shared by Dr Gayathri Karthik Nagesh, Consultant in Obstetrics. The airway was successfully established in the baby after an EXIT procedure. The baby was transported to Neonatal intensive care unit in the hospital. The baby was further connected to a ventilator to give supportive respiratory care.

Dr Karthik Nagesh explains that the best care that could be provided for the baby was being contemplated upon Investigations including MRI were done to determine if it was a tumour that was vascular in origin.

A conservative approach was adopted in the management of the condition by the doctor. A drug called propranolol was used to shrink the tumour. The doctor said that the baby was taken off the ventilator & oxygen support after 2 weeks.

Dr Karthik Nagesh says that he expected the tumour, which was considerably shrunk to shrink further. The baby would not have any problem.

The baby is presently devoid of any respiratory support& difficulty. It will be discharged.

Dr Karthik Nagesh affirms that the team of doctors are   very happy to inform us that the baby is breathing normally on her own. 

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