Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child
health around the globe.
Hi, I'm Em Gordy from Cincinnati Children's Hospital Medical Center.
And last year in October 2022, Cincinnati Children's hosted the Quad Conference, which
was a combination of four conferences.
The International Organization for Isophageal Atresia, the Area Digestive Society Conference,
the Cincinnati Children's ARAE course, and the Cincinnati Children's Pediatric Dysphagia
Series.
And today, we are going to review preoperative considerations for isophageal atresia repair
and how anesthesiology can help facilitate surgical exposure, implications of one lung
ventilation, and patient selection with Dr. Nathan Thuy.
He's an anesthesiologist and Cincinnati Children's.
So let's start.
Birth history is really important in how big the child is.
Also, their physiologic status, what's going on from a ventilation standpoint, is particularly
important as well as a cardiac standpoint.
Nature of their underlying pathology, VACTRL, and its association with cardiac abnormalities,
is particularly relevant to their technique.
We can help make better decisions ahead of time and probably spend less time in the operating
room with a child under anesthesia if we have a good look at what that child's airway looks
like before we start.
They have four goals in the operating room.
First, they need to make sure that kids don't remember, which is kind of easy considering
the ages of these kids.
Akinesis or keeping the kids still can be very challenging in these small children, especially
when intraoperative neuro monitoring is involved.
The most common technique for keeping these kids still is the use of short-acting opioid
infusions, as those can often result with relatively little in terms of hemodynamic
instability.
Volatile anesthetics can also be used, and they're especially useful when preservation
of spontaneous ventilation is desired.
Analgesia is an important component and there's a bunch of different approaches to this, as
well as autonomic and hemodynamic considerations with regard to insufflation of the chest, as
well as the pain responses that the children can't see.
Intraoperative neuro monitoring involves monitoring an airway, whether that's with needles, special
endotracheal tubes, and adhesive surface electrodes.
As far as the anesthetic goes, it precludes our use of neuromuscular blocking drugs like
urocuronium, vecuronium, and others.
As far as facilitating surgical exposure goes, a lot of the time, insufflation is a perfectly
good technique.
That just involves using the capnothorics that's instituted when you place the trocars
in the chest to basically overcome your peak inspiratory pressures, and that allows the
lung to collapse.
It's really useful for small kids who have really good lung compliance.
It's not so good in kids who have real severe bronchopulmonary dysplasia or other compliance
abnormalities.
It's because they often require higher peak inspiratory pressures or mean airway pressures
in general, which can result in the need to use really quite high insufflation pressures.
Then lung isolation is required from a mechanical standpoint.
The physiologists use a bunch of different devices to actually prevent the ventilation
of the operative lung.
And its utility is restricted by the patient size and airway anatomy specifically, and
requires, quite frankly, a fair bit of expertise in specialized equipment.
So let's talk a little bit about airway anatomy and lung isolation.
There's three dimensions that are really important.
There's the tracheal diameter, in particular the AP diameter because the trachea is elliptical
in most cases.
The tracheal diameter tells you basically what kind of devices you have at your disposal
and what you can accommodate.
The bronchial diameters are relevant to the kinds of devices you could use to perform
the lung isolation.
And the length of the right main stem bronchus between the carina and the right upper lobe
takeoff is really important.
There are three different devices that are most commonly used.
Regular old endotracheal tube is probably the most common in neonates because it's
relatively straightforward to main stem.
You main stem it in the left for most esophageal atresia repairs which has a nice good landing
zone for that balloon.
And it is technically a little bit easier than the placement of some of the other devices.
Bronchial blockers or Fogarty catheters can be used for lung isolation as well.
This is where that right upper lobe takeoff and that landing zone on the right is really
important.
For this, you have to have enough space between the carina and the right upper lobe takeoff
for that balloon to sit.
When kids with a pig bronchus or similar situation, this really becomes very difficult.
If you're like me, you're probably wondering what a pig bronchus is.
A tracheal bronchus or in some variations also known as a pig bronchus is an anatomical variant
where an accessory bronchus originates directly from the suprachorinaltrechia.
You almost have to do selective lobar blockade in those children.
But this can be very helpful in kids with abnormal parenchyma.
So if you're having to use higher ventilatory pressures and you don't want to use higher
insufflation pressures within the chest, placing one of these can be very useful.
In larger kids who come back with other recurrent fistulas, if they're usually eight years
older above, they can use a double lumen tube.
Which is quite frankly the easiest thing to lung isolate with because you have a balloon
that goes into the bronchus that allows you to ventilate the two lungs independently.
Before we finish, let's talk about some implications for patient selection.
And this physiologist won't turn out early and have conversations with the surgeons about
the specifics of the patient.
It is a part of the process of deciding the best modality for each individual patient
as early on in the process as possible.
There are people who just really won't tolerate some of these things very well.
Unrepaired single ventricle kids are really sensitive to changes in their ventilation
because they can have swings in the direction of their circulation based on their pulmonary
vascular resistance.
These kids may be some of the ones that you can consider either doing open or using techniques
like ECMO to help make sure that they do well.
And then the insufflation itself causes changes in preload.
And so kids who are really preload sensitive, in particular young people who have passive
pulmonary circulations of one kind or another are really quite sensitive to that insufflation.
In summary, preoperative assessment is critical.
So please consider birth history, physiology, and underlying pathology.
Interoperative neuro monitoring helps ensure patient safety during surgery.
Techniques for maintaining patient stillness include short-acting opioids and volatile
anesthetics.
Long isolation varies based on patient size and airway anatomy.
Bronchial blockers and double lumen tubes offer options for long isolation.
And early conversations between anesthesiologists and surgeons are essential to patient-specific
planning.
Considerations for circulatory and pulmonary sensitivity guide patient selection.
Thank you for watching this video.
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in pediatric surgery.
Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child
health around the globe.