Best practice & research. Clinical anaesthesiology
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Research in fetal surgery is currently ethically controversial, especially because it poses risks to both the fetus and the pregnant woman. We provide an ethical framework for fetal surgery research based on the concept of the fetus as a patient. This framework results in criteria for preliminary investigation of new fetal surgery techniques, for the initiation and termination of clinical trials, the informed consent process, inclusion or exclusion of women based on abortion preferences and the obligations of physicians to refer patients to fetal research protocols. We demonstrate the applicability of this framework to fetal surgery research for spina bifida, a common fetal anomaly.
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Best Pract Res Clin Anaesthesiol · Jun 2004
ReviewEx utero intrapartum surgery (EXIT): indications and anaesthetic management.
The ex utero intrapartum treatment (EXIT) procedure is a technique for safely managing airway obstruction at birth, in which placental support is maintained until the airway is evaluated and secured. In addition to the usual considerations of anaesthesia in obstetrics there are special considerations relating to the EXIT procedure: maintaining fetoplacental circulation by profound uterine relaxation and achieving fetal anaesthesia for airway manipulations. This chapter focuses on the key issues involved in managing this procedure: the indications, preoperative concerns, organization of a multidisciplinary team, problems of maternal and fetal anaesthesia, maintenance of the uterine relaxation and control of fetal airway.
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Best Pract Res Clin Anaesthesiol · Jun 2004
ReviewFetal endoscopic surgery: indications and anaesthetic management.
Fetal intervention for certain life-threatening conditions has progressed from being primarily experimental in nature to the standard of care in certain circumstances. While surgical techniques have advanced over the past few years, the anaesthetic goals for these interventions have remained the same; namely, minimizing maternal and fetal risk as well as maximizing the chances of a successful fetal intervention and optimize the conditions necessary to carry the fetus to term gestation. ⋯ This chapter will address the fetal diseases that may benefit from fetoscopic intervention, the rationale behind why maternal and fetal anaesthesia is required, the various anaesthetics used for these cases and specific considerations of both maternal and fetal physiology that aid in the determination of the best anaesthetic technique for individual cases. Methods of intra-operative fetal monitoring and fetal resuscitation will also be discussed.
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It is not known if the fetus can actually feel pain, but noxious stimulation during fetal life does cause detectable stress responses. These responses cause both short and long-term changes in the central nervous system, which can affect subsequent pain behaviour. ⋯ However, the optimal amount of suppression required and the best method of achieving this (opioid or regional anaesthesia techniques) remain unknown. Prevention and treatment of pain is a basic human right, regardless of age, and if the technique of fetal surgery is to progress then a greater understanding of nociception and the stress response is required.
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Anaesthetic care during thoracic surgical procedures in neonates combines components of the knowledge bases of neonatal anaesthesia with those of thoracic anaesthesia. This chapter reviews the principles of anaesthesia during thoracic surgery in neonates including the pre-operative evaluation, anaesthetic induction techniques, maintenance anaesthesia and options for post-operative analgesia. ⋯ Techniques to provide OLV in the neonate and the principles of anaesthetic care during OLV are reviewed. Finally, specific scenarios of neonatal thoracic surgery are reviewed including anaesthetic care during: (1) laryngoscopy and rigid bronchoscopy, (2) thoracoscopy, (3) repair of tracheo-oesophageal fistula, (4) resection of congenital cystic adenomatoid malformation, and (5) treatment of congenital lobar emphysema.