continuous remifentanil - rocuronium intravenous anaesthesia (civa) and target controlled propofol (tci) anaesthesia is the technique of choice for exit procedure caesarean section.

Gatt S, Collins D, Turner R, Downs C, Thind A.

University of New South Wales, Kensington, n.s.w., Australia

Sydney children's hospital and Royal hospital for women, Randwick, n.s.w., Australia

The EXIT procedure involves delivery of the head and torso of a fetus to allow surgery on the head and neck while the fetus is still attached to, and oxygenated by, the intact placenta. In this situation, the uterus must be kept quiescent and uncontracting, maternal (and, secondarily, fetal) oxygenation must be optimised, hypotension must be minimised the mother and fetus must be kept anaesthetised for a Caesarean section which may last for over 1 hour. Uterine bleeding must be minimised and controlled. The infant must be discouraged from any spontaneous breathing.

Potent, short acting, easily titratable agents which can be stopped or adjusted at anytime are best for this operation.

Both propofol and inhalational agents will reduce basal uterine tone and inhibit uterine contraction. In vitro studies on uterine muscle strips from our laboratory will be presented to show the effect of stable state plasma levels of propofol on uterine muscle contractility. The combination is also effective in securing maternal anaesthesia.

Remifentanil infusion will produce good intraoperative analgesia at the doses administered, will stop the neonate from breathing. The neonate can be paralysed using a dose of intravenous non-depolorizing muscle relaxant (NDMR) once a venous line has been established in the baby.

Bleeding from the uterus is secured using a linear cutting and stapling device applied prior to delivery of the fetus instead of the usual uterine incision.

Oxygen-enriched air can then be used to ventilate the mother who is paralysed using a bolus of rocuronium or other NDMR followed by an NDMR infusion. Bispectral index monitoring for maternal depth of anaesthesia and continuous oximetry to maintain oxygen saturation at 100% is recommended.

Hypotension needs immediate correction. The technique described should produce very stable haemodynamic and excellent operating conditions.