by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA
The goal of the Ex Utero Intrapartum Treatment (EXIT) procedure is to gain access to a compromised neonatal airway before complete delivery takes place. The EXIT procedure involves both patients, Mom and Neonate, and uses a team of professionals managing each patient, with the teams being totally synchronized through prior planning. This provides a controlled situation, rather than a probable delivery emergency.
In a typical EXIT procedure, a cesarean delivery is started through a low cervical incision. The neonate’s head and arms are brought out through the uterine incision and appropriate treatments are provided to the neonate. In rapid succession, a laryngoscopy and/or bronchoscopy are done, followed by endotracheal intubation or tracheostomy. Once the airway is established, the cord can be clamped and mechanical ventilation can begin. The cord is then cut and the neonate is completely delivered.
Each neonate’s case is different and a specific diagnosis can affect the procedures that are planned. There are four different types of EXIT that can be used, based on the diagnosis. They are:
EXIT to Airway – This is the typical type and is used to achieve an airway in diagnoses such as congenital high airway obstruction or CHAOS (a blanket term describing a variety of upper airway anomalies that compromise an airway, such as atresia or absence of upper airway body parts).
EXIT to Resection – The head and arms are brought though the incision and surgery on a neck or chest tumor is done while the neonatal circulation and respiration are maintained through the placenta. This is performed because an airway cannot be established with the tumor in place.
EXIT to ECMO – In this procedure, an airway is established and ECMO cannulation takes place while the neonatal circulation and respiration are maintained. This is done for congenital diaphragmatic hernia or severe congenital heart defects such as aortic stenosis or hypoplastic left heart syndrome.
EXIT to Pacing – Following airway establishment, external pacing leads are placed for ventricular pacing, performed for complete atrioventricular block (CAVB).
A sample case might look like this: The patient is diagnosed with CHAOS during fetal ultrasound with a possible diagnosis of atresia of larynx. Plans are made for an EXIT to Airway procedure with a tracheostomy at 38 completed weeks. The planned cesarean delivery is performed through an incision in the lower uterine segment with a special opening device that controls bleeding. The neonate’s head and arms are withdrawn and the neonatologist performs a direct laryngoscopy to confirm the diagnosis. The trachea is identified via ultrasound guidance and an open tracheostomy is performed, with the tracheal rings being exposed. Once the airway is open, the umbilical cord is clamped. Mechanical ventilation is started and confirmed. The cord is cut and the neonate is taken to the neonatal intensive care unit, where the neonate is maintained on mechanical ventilation for the entire stay, greater than 96 hours.
Z38.01 Single liveborn infant, delivered by cesarean
P28.89 Other specified respiratory conditions of newborn
Q31.8 Other congenital malformations of larynx
0B110F4 Bypass Trachea to Cutaneous with Tracheostomy Device, Open Approach
0CJS7ZZ Inspection of Larynx, Via Natural or Artificial Opening
5A1955Z Respiratory Ventilation, Greater than 96 Consecutive Hours
O35.8xx0* Maternal care for other (suspected) fetal abnormality and damage, not applicable or unspecified fetus
Z37.0 Single live birth
Z3A.38 38 weeks gestation of pregnancy
10D00Z1 Extraction of Products of Conception, Low, Open Approach
*Note: Consideration is currently being given to greatly increasing the number of ICD-10-CM codes in the O35 category to provide far more detailed coding of suspected congenital anomalies that may require special care for the mother. This change may take place with the FY2020 code set. If implemented, the detailed O35 code would be matched to the suspected anomaly for which the EXIT procedure is performed.
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