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BRIEF COMMUNICATION
Year : 2013  |  Volume : 57  |  Issue : 2  |  Page : 195-197  

Anaesthesia management in foetus-ex-fetu


1 Department of Anaesthesia and Critical Care, Grant Govt. Medical College, Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
2 Department of Paediatric Surgery, Grant Govt. Medical College, Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India

Date of Web Publication15-May-2013

Correspondence Address:
M B Prashantha
Department of Anaesthesia and Critical Care, Grant Govt. Medical College, Sir J. J. Group of Hospitals, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.111860

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How to cite this article:
Gosavi KS, Prashantha M B, Kondwilkar BD, Dhende NP. Anaesthesia management in foetus-ex-fetu. Indian J Anaesth 2013;57:195-7

How to cite this URL:
Gosavi KS, Prashantha M B, Kondwilkar BD, Dhende NP. Anaesthesia management in foetus-ex-fetu. Indian J Anaesth [serial online] 2013 [cited 2019 Dec 5];57:195-7. Available from: http://www.ijaweb.org/text.asp?2013/57/2/195/111860


   Introduction Top


Conjoined twins is a rare entity with incidence of 1 in 50,000 to 1 in 200,000. [1] Foetus in fetu [2] is another congenital abnormality in which a nonviable, parasitic foetus grows within the body of its twin. We came across a similar but an extremely rare condition in which a malformed foetus was attached to a live foetus externally. We called it 'Fetus ex fetu'. Foetus ex fetu in craniopagus position can be a great challenge to anaesthetist due to difficult airway.


   Case Report Top


On 1 st day of his life, this 3.4 kg male neonate was admitted to Neonatal Intensive Care Unit (NICU) with a foetus like mass attached to his face. The mass looked multilobulated with roughly 18 cm length, 7-8 cm diameter and was attached to his nasal region with 2/5 th of it extending above bridge of nose on forehead [Figure 1]. Remaining part of it had engulfed the nose, upper lip, and gums almost completely and was hanging down to middle of chest. The mass was slightly mobile and could be lifted off the face so that the mouth could be uncovered partly. The baby was being nursed in the lateral position. Feeding was almost impossible.
Figure 1: A nonviable foetus attached to a normal foetus like a craniopagus

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This child had no other congenital anomalies and breathing orally. Eyes were widely placed but normal. The mass had limb buds in respective positions, palpable cranium, pelvic bones and femur bilaterally but no signs of cardiac activity. X-ray showed no bony attachment between them. Ultrasonography and 2-D echo were within normal limits. Intravenous maintenance fluid was started through a 24 G i.v. line.

In operation theatre, the baby was placed supine with an assistant constantly lifting the mass off the face and flushing O 2 with Jackson Ree's (JR) circuit near patient's mouth continuously. SpO 2 probe, electrocardiogram (ECG) was connected. Paediatric intubation equipments and laryngeal mask airway (LMA) of size 1.0 were kept ready. Neonatal tracheostomy set with tube no. (2.5 and 3) was also kept ready with surgeon scrubbed to tackle the emergency. Premedication-Inj. Atropine 0.06 mg, Inj. Ondansetron 0.3 mg, Inj. Fentanyl 6 mcg and Inj. Midazolam 0.1 mg. Inj. Ketamine 3.0 mg was injected slowly watching the spontaneous breathing movements. A check laryngoscopy was done using Miller blade by pulling the mass away as far as possible. Cormack-Lehane grade 3 view was obtained. Then LMA of 1.0 no. was successfully inserted. The patient was ventilated with O 2 and Sevoflurane on JR-circuit monitoring SpO 2 and EtCO 2 . Anaesthetic plane was deepened with Inj. Propofol and Inj. Atracurium. LMA was removed after ventilating for 3 min, so that a definite airway is secured to facilitate surgery. The traction on the mass was continued and laryngoscope was inserted. Although laryngoscopy was difficult, Cormack-Lehane grade II could be obtained by external laryngeal pressure given by an assistant. Trachea Intubated with Portex ETT 3.0 mm and confirmed by EtCO 2. Anaesthesia was maintained using N 2 O and O 2 and Inj. Atracurium. A Paracetamol suppository of 80 mg was inserted. Surgical area draped carefully to avoid kinking of the tube. Surgery was uneventful. Trachea was extubated after reversal of neuromuscular blockade. Postoperative period was uneventful. The child was started on breast feeds on second postoperative day and was discharged from hospital on 7 th day. Regular follow up for 6 months was normal.


   Discussion Top


Highest incidence of conjoint twins is encountered in humans. Conjoined twinning happens when the twinning event occurs at about the primitive streak stage of development, at about 13-14 days after fertilization and is associated with the monoamniotic monochorionic type of placentation. [3] Preoperative diagnosis in this case was based on clinical findings viz rudimentary eyes, upper and lower limbs and head. Radiological findings such as the presence of cranium, femurs and vertebrae like structures were confirmatory.

Surgery was urgent because breathing and feeding was difficult and the malformed foetus was dead. [1] This was also a privilege compared to other conjoint twins where sharing of multiple organs and transfer of anaesthetic through blood are core issues. Still, airway management was a crucial issue, more difficult than the surgery itself.

We were facing two problems. First: Whether we would get adequate mouth opening and space to introduce the laryngoscope? And second was how to maintain ventilation between induction and intubation.

Mask ventilation was impossible which ruled out possibility of inhalational induction. Oral fibreoptic intubation was an option but proper sized fibrescope was not available. So, intravenous induction was the choice.

We used Ketamine [4] for sedation to maintain spontaneous breathing as it is known to stimulate the respiration. Pulling the mass away could uncover the mouth partly. This important observation provided the idea of LMA [5],[6] insertion before paralyzing the patient for intubation. The classic LMA is recommended as a safe airway device in many such indications. [7] As ventilation was possible, so muscle relaxants were used. LMA had to be removed as fixing it in position was difficult and chances of its displacement and kinking during surgical manipulations were high. Also, inserting a throat pack to protect trachea was easier with ETT.

Check laryngoscopy [8] helped us to use muscle relaxants to facilitate tracheal intubation prevent a possible laryngospasm. If we had failed in intubation, LMA could be resumed till mass excision. Emergency tracheostomy preparations ready as a part of contingency plan.

In conclusion, difficult paediatric airway like foetus ex fetu can be tackled with careful airway assessment, planning with anticipation and proper use of equipments and procedures like check laryngoscopy.

 
   References Top

1.Spitz L. Surgery for conjoined twins. Ann R Coll Surg Engl 2003;85:230-5.  Back to cited text no. 1
    
2.Borges E, Lim-Dunham JE, Vade A. Fetus in fetu appearing as a prenatal neck mass. J Ultrasound Med 2005;24:1313-6.  Back to cited text no. 2
    
3.Kaufman MH. The embryology of conjoined twins. Childs Nerv Syst 2004;20:508-25.  Back to cited text no. 3
    
4.Reves JG, Glass P, Lubarsky DA, McEvoy MD, Ruiz RM. Intravenous Anesthetics. In: Miller RD, editor. 7 th ed. Philadelphia: Elsevier Churchill Livingstone; 2009. p. 1611-21.  Back to cited text no. 4
    
5.Walker RW. The laryngeal mask airway in the difficult paediatric airway: An assessment of positioning and use in fibreopticintubation. Pediatr Anesth 2000;10:53-8.  Back to cited text no. 5
    
6.Ghai B, Malkar IK, Bhardwaj N, Wig J. Laryngeal mask airway insertion in children: Comparison between rotational, lateral and standard technique. Paediatr Anaesth 2008;18:308-12.  Back to cited text no. 6
    
7.Höhne C, Haack M, Machotta A, Kaisers U. Airway management in pediatric anesthesia. Anaesthesist 2006;55:809-19.  Back to cited text no. 7
    
8.Mishra SK, Kavitha J, Kumaravel S, Lalatendu KK. Anesthestic management of a newborn for pedunculatedteratoma of oral cavity. Anesth Essays Res 2010;4:124-5.  Back to cited text no. 8
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