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Andrew B. Kairalla MD, Editor
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EXIT Strategy
Albanese CT, The EXIT Strategy. Neoreviews (September 2005); 6:e431.
The Ex Utero Intrapartum Treatment (EXIT) strategy was developed as a means of establishing an airway after iatrogenic occlusion of the fetal trachea to promote lung growth for fetuses that have severe congenital diaphragmatic hernia (CDH). Although there have been anecdotal reports of intrapartum laryngoscopy or bronchoscopy for fetuses that have neck masses, in none were attempts made to prevent uterine contraction and placental separation. In contrast, the EXIT strategy can be viewed as a "half" delivery in which a hysterotomy is performed, only the head and shoulders are "delivered," and uterine relaxation is maintained by high concentrations of an inhalational anesthetic and intravenous tocolytics, ensuring the maintenance of uteroplacental blood flow and gas exchange. Using this strategy, operations as long as 3 hours on uteroplacental "bypass" have been performed without significant maternal bleeding and uterine contraction. Such an approach provides time to perform procedures such as direct laryngoscopy, bronchoscopy, tracheotomy, arterial and venous access, administration of surfactant, resection of neck or lung masses, select general surgical procedures, and cannulation for extracorporeal membrane oxygenation support, thereby converting a potential emergency cardiorespiratory crisis into a controlled situation.
Comment. This seems like a great way to manage selected
cases where intubation or resuscitation may be problematic. A good example
of this would be a baby with a large cystic hygroma of the neck. As long as
the baby is receiving “uteroplacental life support”, there is no urgency
about establishing an airway. I can’t help but wonder if one day we will
approach the resuscitation and stabilization of all tiny preemies in this
fashion. ABK.
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