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Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child

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health around the globe.

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Hi, I'm Em Gordy from Cincinnati Children's Hospital Medical Center.

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And last year in October 2022, Cincinnati Children's hosted the Quad Conference, which

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was a combination of four conferences.

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The International Organization for Isophageal Atresia, the Area Digestive Society Conference,

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the Cincinnati Children's ARAE course, and the Cincinnati Children's Pediatric Dysphagia

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Series.

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And today, we are going to review preoperative considerations for isophageal atresia repair

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and how anesthesiology can help facilitate surgical exposure, implications of one lung

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ventilation, and patient selection with Dr. Nathan Thuy.

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He's an anesthesiologist and Cincinnati Children's.

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So let's start.

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Birth history is really important in how big the child is.

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Also, their physiologic status, what's going on from a ventilation standpoint, is particularly

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important as well as a cardiac standpoint.

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Nature of their underlying pathology, VACTRL, and its association with cardiac abnormalities,

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is particularly relevant to their technique.

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We can help make better decisions ahead of time and probably spend less time in the operating

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room with a child under anesthesia if we have a good look at what that child's airway looks

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like before we start.

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They have four goals in the operating room.

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First, they need to make sure that kids don't remember, which is kind of easy considering

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the ages of these kids.

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Akinesis or keeping the kids still can be very challenging in these small children, especially

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when intraoperative neuro monitoring is involved.

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The most common technique for keeping these kids still is the use of short-acting opioid

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infusions, as those can often result with relatively little in terms of hemodynamic

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instability.

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Volatile anesthetics can also be used, and they're especially useful when preservation

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of spontaneous ventilation is desired.

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Analgesia is an important component and there's a bunch of different approaches to this, as

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well as autonomic and hemodynamic considerations with regard to insufflation of the chest, as

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well as the pain responses that the children can't see.

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Intraoperative neuro monitoring involves monitoring an airway, whether that's with needles, special

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endotracheal tubes, and adhesive surface electrodes.

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As far as the anesthetic goes, it precludes our use of neuromuscular blocking drugs like

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urocuronium, vecuronium, and others.

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As far as facilitating surgical exposure goes, a lot of the time, insufflation is a perfectly

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good technique.

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That just involves using the capnothorics that's instituted when you place the trocars

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in the chest to basically overcome your peak inspiratory pressures, and that allows the

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lung to collapse.

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It's really useful for small kids who have really good lung compliance.

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It's not so good in kids who have real severe bronchopulmonary dysplasia or other compliance

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abnormalities.

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It's because they often require higher peak inspiratory pressures or mean airway pressures

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in general, which can result in the need to use really quite high insufflation pressures.

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Then lung isolation is required from a mechanical standpoint.

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The physiologists use a bunch of different devices to actually prevent the ventilation

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of the operative lung.

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And its utility is restricted by the patient size and airway anatomy specifically, and

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requires, quite frankly, a fair bit of expertise in specialized equipment.

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So let's talk a little bit about airway anatomy and lung isolation.

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There's three dimensions that are really important.

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There's the tracheal diameter, in particular the AP diameter because the trachea is elliptical

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in most cases.

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The tracheal diameter tells you basically what kind of devices you have at your disposal

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and what you can accommodate.

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The bronchial diameters are relevant to the kinds of devices you could use to perform

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the lung isolation.

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And the length of the right main stem bronchus between the carina and the right upper lobe

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takeoff is really important.

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There are three different devices that are most commonly used.

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Regular old endotracheal tube is probably the most common in neonates because it's

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relatively straightforward to main stem.

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You main stem it in the left for most esophageal atresia repairs which has a nice good landing

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zone for that balloon.

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And it is technically a little bit easier than the placement of some of the other devices.

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Bronchial blockers or Fogarty catheters can be used for lung isolation as well.

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This is where that right upper lobe takeoff and that landing zone on the right is really

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important.

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For this, you have to have enough space between the carina and the right upper lobe takeoff

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for that balloon to sit.

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When kids with a pig bronchus or similar situation, this really becomes very difficult.

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If you're like me, you're probably wondering what a pig bronchus is.

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A tracheal bronchus or in some variations also known as a pig bronchus is an anatomical variant

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where an accessory bronchus originates directly from the suprachorinaltrechia.

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You almost have to do selective lobar blockade in those children.

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But this can be very helpful in kids with abnormal parenchyma.

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So if you're having to use higher ventilatory pressures and you don't want to use higher

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insufflation pressures within the chest, placing one of these can be very useful.

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In larger kids who come back with other recurrent fistulas, if they're usually eight years

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older above, they can use a double lumen tube.

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Which is quite frankly the easiest thing to lung isolate with because you have a balloon

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that goes into the bronchus that allows you to ventilate the two lungs independently.

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Before we finish, let's talk about some implications for patient selection.

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And this physiologist won't turn out early and have conversations with the surgeons about

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the specifics of the patient.

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It is a part of the process of deciding the best modality for each individual patient

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as early on in the process as possible.

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There are people who just really won't tolerate some of these things very well.

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Unrepaired single ventricle kids are really sensitive to changes in their ventilation

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because they can have swings in the direction of their circulation based on their pulmonary

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vascular resistance.

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These kids may be some of the ones that you can consider either doing open or using techniques

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like ECMO to help make sure that they do well.

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And then the insufflation itself causes changes in preload.

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And so kids who are really preload sensitive, in particular young people who have passive

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pulmonary circulations of one kind or another are really quite sensitive to that insufflation.

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In summary, preoperative assessment is critical.

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So please consider birth history, physiology, and underlying pathology.

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Interoperative neuro monitoring helps ensure patient safety during surgery.

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Techniques for maintaining patient stillness include short-acting opioids and volatile

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anesthetics.

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Long isolation varies based on patient size and airway anatomy.

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Bronchial blockers and double lumen tubes offer options for long isolation.

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And early conversations between anesthesiologists and surgeons are essential to patient-specific

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planning.

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Considerations for circulatory and pulmonary sensitivity guide patient selection.

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Thank you for watching this video.

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in pediatric surgery.

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Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child

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health around the globe.