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Chapter 12 - Sacrococcygeal Teratoma
- from Section 3
- Edited by Olutoyin A. Olutoye
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- Book:
- Anesthesia for Maternal-Fetal Surgery
- Published online:
- 19 November 2021
- Print publication:
- 11 November 2021, pp 168-190
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Summary
Sacrococcygeal teratoma (SCT) is a common tumor of the neonatal period. Prenatal diagnosis of SCT carries a high mortality rate because of the potential for high output heart failure and hydrops. Tumors can also rupture, leading to severe anemia and death. The mother’s health is also at risk if maternal mirror syndrome develops. Prenatal evaluation includes high resolution ultrasound, fetal echocardiography, and magnetic resonance imaging. Pregnancy management includes frequent assessment of the tumor size, growth, and the effects on the fetal cardiovascular system. Treatment options depend on the tumor characteristics and cardiac function, as well as maternal health and support. Fetal therapy aims to debulk or devascularize the tumor, thereby alleviating high output failure and minimizing the risk of spontaneous rupture and hemorrhage. Decisions regarding a symptomatic fetus with SCT may include prenatal intervention or early delivery. Anesthetic management of fetal treatment for SCT is tailored to the mode of therapy chosen; this may include a minimally invasive approach, in-utero surgery, or an EXIT procedure. The nuances of management of this condition center on understanding of the pathophysiology of a hydropic fetus as a result of the SCT and being prepared for resultant cardiovascular instability and massive hemorrhage.
3434 The Study of Fetal Tracheal Occlusion to Treat Congenital Diaphragmatic Hernia in the EXTEND Model
- Barbara Elizabeth Coons, James Moon, Ryne Didier, Anush Sridharan, Felix DeBie, Holly Hedrick, Marcus Davey, Alan Flake
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- Journal:
- Journal of Clinical and Translational Science / Volume 3 / Issue s1 / March 2019
- Published online by Cambridge University Press:
- 26 March 2019, pp. 156-157
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- Article
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OBJECTIVES/SPECIFIC AIMS: The goal of this project is to study fetal pulmonary vasculature in a CDH animal model, to understand how FETO affects developing vasculature, and to develop a modifiable fetal tracheal occlusive therapeutic device that avoids previously seen sequelae of FETO, like alveolar distension, decreased surfactant production, and decreased Type II Pneumocytes. The primary outcome is lung volume/kilogram. The secondary outcomes are contrast-enhanced ultrasound perfusion metrics (Time to Peak, Mean Transit Time, Wash-in Rate, Wash-in Perfusion Index), pulmonary vascular density, Lung Injury Histology Scores, and Lung Compliance upon ventilation. METHODS/STUDY POPULATION: Congenital diaphragmatic hernias will be modeled by surgical hernia creation via maternal laparotomy and hysterotomy at gestational age 72 - 74 days. The ewe will undergo a second laparotomy at 105 - 115 days gestational age. After a second hysterotomy is made, the fetus will be removed from the amniotic sac, though placental circulation will be maintained (EXIT Procedure). The animal is cannulated via the umbilical vein and arteries onto the pumpless ECMO circuit. The balloon and pressure sensor complex is placed into the trachea via direct laryngoscopy, and the fetus aseptically sealed into the Biobag. The wires of the tracheal occlusive device (balloon catheter and pressure sensor) will egress via the port of the Biobag. The fetus remains in the Biobag for fourteen days, with the tracheal occlusive device in place for ten days, followed by a four day recovery period. Daily contrast-enhanced ultrasounds and pulmonary artery dopplers are performed. Upon study completion, the fetus is intubated and placed on a conventional ventilator. A full necropsy is then performed, with perfusion fixation of the lungs via the pulmonary artery. RESULTS/ANTICIPATED RESULTS: Hypothesis 1: Modifiable Tracheal Occlusion will have statistically different effects on developing lung parenchyma, surfactant production, and abundance of Type II Pneumocytes Hypothesis 2: Modifiable Tracheal Occlusion will have lower levels of pulmonary hypertension than negative control animals, as measured by contrast-enhanced ultrasound (pulmonary artery velocity and washout time). DISCUSSION/SIGNIFICANCE OF IMPACT: This project will provide insight into the development of pulmonary hypertension in the CDH fetus. It will provide insight into the physiology of FETO, a novel therapy for congenital diaphragmatic hernias, and will demonstrate the utility of the EXTEND System for fetal treatments that are not possible in the maternal uterus.
5 - Special considerations for neonatal ECMO
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- By Maria V. Fraga, University of Pennsylvania, James Connelly, The Children's Hospital of Philadelphia, Holly L. Hedrick, The Children's Hospital of Philadelphia, Natalie Rintoul, The Children's Hospital of Philadelphia
- Edited by Haresh Kirpalani, Monica Epelman, John Richard Mernagh, McMaster University, Ontario
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- Book:
- Imaging of the Newborn
- Published online:
- 05 March 2012
- Print publication:
- 24 November 2011, pp 98-105
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Summary
Extracorporeal membrane oxygenation (ECMO) describes extended extracorporeal cardiopulmonary support for acute, severe, reversible cardiac and respiratory failure unresponsive to conventional medical management. ECMO provides cardiopulmonary rest, while allowing the underlying pulmonary or cardiac dysfunction to resolve without the risk of further injury from hyperoxia and baro-trauma. This involves bypassing the pulmonary circulation to effect oxygenation external to the body. It requires extrathoracic vascular cannulation for extended periods of time, usually ranging from 3 to 20 days, as well as adequate anticoagulation to prevent thrombus formation throughout the circuit.
ECMO is indicated as a supportive intervention for infants of > 2.0 kg and > 34 weeks gestational age, who are at high risk of dying despite optimal treatment [1]. It has been used in newborns for multiple intractable conditions, including respiratory distress syndrome/hyaline membrane disease, sepsis/pneumonia, congenital diaphragmatic hernia, meconium aspiration syndrome, persistent pulmonary hypertension, and congenital heart disease.
This chapter focuses on the imaging of patients on ECMO, including the technical devices required (circuit and cannulae) and ECMO complications.
Correct placement of ECMO cannulae: a radiological assessment
Neonatal ECMO requires the placement of cannulae in the major blood vessels of the neck. Support may be either venovenous (VV) or venoarterial (VA).
Venovenous ECMO
In VV ECMO, the blood is removed from and returned to the venous circulation via the right internal jugular vein into the right atrium (RA). This mode of support relies on native left ventricular function for delivery of oxygenated blood to the systemic circulation.