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Update Course 2021: UPDATE COURSE 2020: REVIEW OF LAST YEAR'S IMPORTANT T OPICS

Video Published 2022-05-19 Updated 2026-08-01

Topic Overview

This is the opening session of the 2021 Update Course, reviewing key topics from the 2020 course to assess practice changes. The session covers biliary atresia management including intraoperative ICG use and MMP7 testing, blunt abdominal trauma resuscitation protocols, rectal prolapse sclerotherapy options, sutureless closure for abdominal wall defects, Enhanced Recovery After Surgery (ERAS) implementation, thoracoscopic hemostasis techniques, and social determinants of health initiatives. Poll results show significant practice variation across institutions, with notable adoption of sutureless closure (89% use it always or selectively) but limited uptake of MMP7 testing and ICG visualization for biliary atresia.

Key Takeaways

Sutureless closure for abdominal wall defects widely adopted: 89% use always or selectively vs only 11% never use (12:23)
Initiate balanced resuscitation in pediatric trauma when approaching 40 cc/kg blood transfusion (8:30)
ERAS pathways reduce cost, antibiotic use, and length of stay; most utilized by hospitalists and pediatric residents (19:09)
For thoracoscopic pulmonary vessel bleeding, energy sources effective as initial hemostasis in low-pressure system (21:18)
Hypertonic saline most common sclerotherapy for rectal prolapse (46%); phenol access limited by institutional barriers (10:35)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Rod Girardos — guest

Chapters

0:00Course Introduction and Format — Host introduces the Update Course format, emphasizing rapid-fire review of important topics from the previous year, interactive discussion, and acknowledgment of sponsoring institutions. Explains the session will be recorded and made available throughout the year.
3:47Biliary Atresia Management Review — Review of biliary atresia topics from 2020 including MMP7 biomarker, intraoperative ICG use, antiretrovirals and steroids postoperatively. Poll shows 51% do not use ICG, 26% do use it, and most do not use MMP7 testing.
7:45Blunt Abdominal Trauma Resuscitation and Rectal Prolapse — Discussion of resuscitation strategy for hypotensive pediatric trauma patient after initial crystalloid bolus, with emphasis on early blood therapy and massive transfusion protocol. Brief review of sclerotherapy options for rectal prolapse.
10:35Gastroschisis Closure and ERAS Introduction — Review of sutureless abdominal closure for large defects showing 89% adoption (50% always, 39% selectively). Introduction to ERAS protocols and their components.
15:12ERAS Implementation Discussion — Extended faculty discussion on challenges and strategies for implementing ERAS protocols, emphasizing need for multidisciplinary buy-in, starting with small pathway changes, and institutional culture shift.
21:18Thoracoscopic Hemostasis and Social Determinants — Brief discussion of hemostasis techniques for pulmonary vessel bleeding during thoracoscopic lobectomy, followed by review of social determinants of health initiatives showing most institutions are addressing or working on these issues.

Key claims

0:00The Update Course has approximately 2000 people signed up — Speaker 1
3:47MMP7 could be used to distinguish biliary atresia from other cholestatic diseases — Rod Girardos
3:47Intraoperative ICG can be used to determine biliary flow or identify a transaction — Rod Girardos
4:4526% of respondents use ICG to visualize the biliary tree, 23% use it in select patients, and 51% do not use it — Speaker 1
5:48MMP7 testing is often a send-out test at non-freestanding children's hospitals — Rod Girardos
5:48Children with biliary atresia presenting at five weeks have limited time to achieve best outcomes — Rod Girardos
8:30For pediatric trauma patients, early blood therapy and massive transfusion protocol are where ATLS and literature are leading — Rod Girardos
8:30There is currently no great definition of what constitutes massive transfusion protocol in pediatric patients — Rod Girardos
8:30Balanced resuscitation should be initiated when approaching 40 cc per kg blood transfusion — Rod Girardos
10:35Hypertonic saline is the most common sclerotherapy choice at 46%, with phenol, ethyl alcohol, and dextrose in water at 10-16% each — Rod Girardos
10:50Getting phenol into the operating room for sclerotherapy is not always easy due to institutional and pharmacy restrictions — Speaker 1
10:50There are case reports showing mucosal sloughing with phenol use — Speaker 1
10:50Deflux, used by urology for vesicoureteral reflux, has been reported in case reports for rectal prolapse — Speaker 1
11:483% sotradecol is used as an alternative sclerotherapy agent — Rod Girardos
11:56D50 from the code cart is easier to acquire than 3% saline in some operating rooms — Rod Girardos
12:2350% of respondents always use sutureless closure for large abdominal wall defects, 39% use it in select patients, and only 11% do not use it — Speaker 1
16:14ERAS is a bundle of interventions to help patients get through the hospital faster with less pain and less narcotics — Rod Girardos
16:14ERAS includes a carbohydrate drink two hours before surgery, changing from traditional NPO protocols — Rod Girardos
16:42ERAS implementation requires anesthesiologist buy-in because it represents a big change from traditional practice — Rod Girardos
17:55ERAS protocols are difficult to implement because they require the whole hospital to adopt a different culture and philosophy — Rod Girardos
19:09Surgical pathways created for ERAS are used more by hospitalists and pediatric residents than any other pathways — Rod Girardos
19:09Surgical pathways have led to decreased cost, antibiotic utilization, and decreased length of stay — Rod Girardos
19:42Starting with one component like decreasing opioid use intraoperatively and perioperatively can be an entry point for larger ERAS implementation — Rod Girardos
21:18For pulmonary vessel bleeding during thoracoscopic lobectomy, energy sources work well as initial hemostasis because it is a low-pressure system — Rod Girardos
21:38Multiple hemostasis options including energy, clips, and sutures should be available for thoracoscopic vessel bleeding — Rod Girardos
21:50Most institutions are either addressing social determinants of health or working on it, with few saying no — Speaker 1

Open questions

What is the optimal definition and trigger criteria for massive transfusion protocol in pediatric patients?
How can institutions without ready access to MMP7 testing incorporate it into clinical decision-making for biliary atresia?
What is the most effective strategy for implementing ERAS protocols in institutions without strong anesthesia buy-in?
Is deflux a viable alternative sclerotherapy agent for rectal prolapse compared to traditional options?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Enhanced Recovery After Surgery (ERAS) in Pediatric Practice: Building Protocols That Work

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why ERAS Exists

Traditional perioperative care evolved through caution — nothing by mouth after midnight, liberal opioid use, prolonged bed rest. Each element made sense in isolation, but the cumulative effect was longer hospital stays, more pain, and delayed return to normal function. Enhanced Recovery After Surgery protocols emerged to challenge these assumptions systematically 16:14. The discipline exists because bundled interventions, applied consistently across the perioperative period, produce better outcomes than the sum of their parts 16:14.

The Core Problem

ERAS addresses a structural inefficiency: hospitals operate on institutional inertia rather than evidence. A carbohydrate drink two hours before surgery contradicts decades of NPO-after-midnight teaching, even though the evidence supports preoperative carbohydrate loading 16:14. Regional anesthesia reduces opioid requirements, yet many institutions default to systemic narcotics. ERAS is not a single intervention but a framework for aligning practice with evidence across multiple disciplines 16:14.

The goal is concrete: patients move through the hospital faster, with less pain and fewer narcotics 16:14. This matters clinically — earlier mobilization reduces complications — and practically, as surgical volumes increase and families prefer home recovery 16:14.

How the Approach Works

ERAS functions as a bundle, analogous to central line infection prevention protocols 16:14. No single component drives the benefit; the system works through cumulative effect. Key elements include preoperative carbohydrate drinks two hours before surgery, intraoperative opioid reduction, regional anesthesia where feasible, early mobilization, and standardized postoperative pathways 16:14.

Implementation requires anesthesia buy-in because the protocol represents a fundamental shift from traditional practice 16:42. The two-hour carbohydrate drink alone challenges ingrained teaching about aspiration risk. Regional blocks require technical skill and time. Reducing systemic opioids demands confidence in multimodal analgesia.

Surgical pathways — standardized order sets and care plans for specific procedures — serve as the operational backbone 19:09. These pathways have demonstrated decreased cost, reduced antibiotic utilization, and shorter length of stay 19:09. Notably, hospitalists and pediatric residents use surgical pathways more than any other standardized protocols, suggesting that clarity and communication drive adoption beyond the surgical team 19:09.

Where Practice Remains Contested

The central tension is not whether ERAS works — the evidence is clear — but how to implement it. ERAS requires institutional culture shift and multidisciplinary alignment 17:55. A surgeon cannot unilaterally implement ERAS; anesthesia must modify their approach, nursing must adjust mobilization protocols, pharmacy must stock different analgesics, and hospitalists must follow unfamiliar pathways.

Starting small offers a practical entry point. Reducing opioid use intraoperatively and perioperatively can serve as a single-component pathway that builds toward comprehensive ERAS implementation 19:42. This incremental approach allows teams to demonstrate benefit, gain confidence, and expand the protocol without overwhelming institutional capacity.

The difficulty is real. One discussant noted that while adopting sutureless gastroschisis closure requires only surgeon behavior change, ERAS demands "the whole hospital to be in a different culture, in a different philosophy" 17:55. This is not a technical problem but an organizational one.

When to Involve This Approach

ERAS applies to any patient undergoing major surgery where length of stay, pain control, and recovery trajectory matter. The protocol scales: some institutions use ERAS for several procedures, others for only a few 16:14. The choice depends less on procedure type than on institutional readiness to support the bundle.

For surgeons considering ERAS, the referral question is internal rather than external: does your institution have the infrastructure — anesthesia support, nursing protocols, pharmacy formulary, hospitalist engagement — to sustain the bundle? If not, the pathway forward involves building that infrastructure incrementally, starting with one component and expanding as buy-in grows 19:42.

The practical reality is that ERAS implementation is easier when driven by anesthesia or a multidisciplinary team rather than surgery alone 16:42. Institutions where anesthesia has adopted the philosophy see broader uptake across surgical services. Where surgery leads, progress depends on demonstrating benefit through pathways and data, then recruiting other disciplines to expand the protocol 19:09 19:09.

ERAS is not a consultation service but a care model. The question is not when to refer but when your institution is ready to change how it delivers perioperative care.

Takeaways from this story

ERAS is a bundle of interventions — preoperative carbohydrate drinks, regional anesthesia, reduced opioids — that together reduce length of stay and pain
Implementation requires anesthesia buy-in because protocols like two-hour preoperative drinks contradict traditional NPO teaching
Surgical pathways reduce cost, antibiotic use, and length of stay, and are used more by hospitalists than other standardized protocols
Starting with single components like reducing intraoperative opioids allows incremental adoption before full ERAS implementation
ERAS requires institutional culture shift across surgery, anesthesia, nursing, and pharmacy — not just surgeon behavior change

Building Institutional Change: From Diagnostic Tools to Cultural Transformation

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Diagnostic Innovation Meets Practical Constraints

MMP7 can distinguish biliary atresia from other cholestatic diseases 3:47, but the test's clinical utility depends entirely on turnaround time. At many non-freestanding children's hospitals, MMP7 is a send-out test 5:48. When a child presents at five weeks with suspected biliary atresia, waiting days for results means losing the narrow window for optimal outcomes 5:48. The lesson is not whether MMP7 works — it does — but whether your institution can deliver results fast enough to change management. If you cannot, proceed with clinical judgment and intraoperative assessment rather than delaying for a test that will arrive too late.

Intraoperative ICG to visualize biliary flow or identify transection 3:47 represents a different adoption curve: 26% of respondents now use it routinely, 23% in select patients, and 51% do not use it 4:45. A year earlier, almost no one was using it. This is what early adoption looks like — enough uptake to suggest the technique has merit, not enough to call it standard. The question for your practice is not whether ICG is validated, but whether you have access to the equipment and whether your volume justifies the learning curve.

Resuscitation Thresholds in Pediatric Trauma

Current ATLS guidelines and literature support early blood therapy and massive transfusion protocol for pediatric trauma patients 8:30, moving away from multiple crystalloid boluses. The challenge is that no consensus definition exists for what constitutes massive transfusion in children 8:30. The working threshold offered here: initiate balanced resuscitation when approaching 40 cc per kg blood transfusion 8:30. This is not a hard cutoff — it is a signal to shift strategy. The point at which you are giving that much blood is the point at which crystalloid alone will not restore perfusion, and continuing down that path delays the intervention the child actually needs.

Sclerotherapy: What Works vs. What You Can Get

For rectal prolapse sclerotherapy, hypertonic saline is the most common choice at 46%, with phenol, ethyl alcohol, and dextrose in water each used by 10-16% of respondents 10:35. The variation reflects not just preference but availability. Getting phenol into the operating room is difficult at many institutions due to pharmacy restrictions 10:50, and case reports document mucosal sloughing with its use 10:50. Alternatives include Deflux, used off-label based on case reports 10:50, 3% sotradecol 11:48, and D50 from the code cart, which one discussant noted is easier to acquire than 3% saline in some operating rooms 11:56. The teaching point: your sclerotherapy agent is determined as much by what your pharmacy will release as by what the literature recommends. Know your institution's formulary before you are standing in the OR.

ERAS as a System Problem, Not a Surgical One

ERAS is a bundle of interventions designed to reduce pain, opioid use, and length of stay 16:14, including elements like a carbohydrate drink two hours before surgery instead of traditional NPO protocols 16:14. Implementation requires anesthesiologist buy-in because it represents a fundamental departure from established practice 16:42. The difficulty is not clinical — the evidence supports ERAS — but cultural. Successful implementation requires the entire hospital to adopt a different philosophy 17:55. One entry point: surgical pathways, which standardize care and have been adopted more readily by hospitalists and pediatric residents than by surgeons themselves, leading to decreased cost, antibiotic use, and length of stay 19:09. Starting with a single component, such as reducing intraoperative and perioperative opioid use, can build momentum toward a comprehensive protocol 19:42.

Hemostasis Strategy in Low-Pressure Systems

For pulmonary vessel bleeding during thoracoscopic lobectomy, energy sources work well as initial hemostasis because the pulmonary circulation is a low-pressure system 21:18. If energy fails, clips are the next option, followed by suturing if necessary. The principle is to have multiple techniques available and to escalate in a logical sequence 21:38. This is not a question of which device is best — it is a question of matching your intervention to the physiology and having a backup plan when the first approach does not achieve control.

The through-line across these topics is that clinical knowledge alone does not change practice. You also need institutional infrastructure, pharmacy cooperation, anesthesia buy-in, and a realistic assessment of what your system can deliver. The gap between evidence and implementation is where most improvement efforts fail.

Takeaways from this story

MMP7 for biliary atresia is only useful if turnaround time allows action within the narrow window for optimal outcomes.
Initiate balanced resuscitation in pediatric trauma when approaching 40 cc/kg blood transfusion, not after multiple crystalloid boluses.
Sclerotherapy agent choice depends on institutional formulary access as much as clinical preference; know what your pharmacy will release.
ERAS implementation requires hospital-wide cultural change; start with single components like opioid reduction to build momentum.
For thoracoscopic pulmonary vessel bleeding, start with energy in the low-pressure system, then escalate to clips or sutures as needed.

Translating Evidence Into Practice: Adoption Patterns From Year-Old Teaching

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

Diagnostic tools must match clinical timelines

MMP7 can distinguish biliary atresia from other cholestatic diseases 3:47, but the test is often a send-out at non-freestanding children's hospitals 5:48. When a child presents at five weeks, the window for optimal outcomes is already narrow 5:48. Waiting days for a biomarker result when you could proceed directly to operative cholangiography means the test, however accurate, becomes clinically irrelevant. The question is not whether MMP7 works — it is whether your laboratory infrastructure allows you to use it before the decision point passes. If the answer is no, do not let an unavailable test delay definitive management.

Pediatric massive transfusion thresholds remain institution-dependent

ATLS and current literature support early blood therapy and massive transfusion protocols for hypotensive pediatric trauma patients 8:30, but there is no consensus definition of what constitutes massive transfusion in this population 8:30. The 40 cc/kg threshold for initiating balanced resuscitation 8:30 represents a practical trigger, but the real work is building the protocol before the patient arrives. If your institution has not defined ratios, transfusion triggers, and activation criteria for pediatric MTP, you will improvise during the resuscitation — and improvisation in a bleeding child costs time you do not have.

Sclerotherapy agent choice is constrained by institutional access

Hypertonic saline is the most common sclerotherapy choice at 46%, with phenol, ethyl alcohol, and dextrose in water each used by 10-16% 10:35. Phenol is not always easy to bring into the operating room due to institutional and pharmacy restrictions 10:50, and case reports document mucosal sloughing with its use 10:50. D50 from the code cart is easier to acquire than 3% saline in some operating rooms 11:56, and 3% sotradecol is used as an alternative 11:48. The lesson: your preferred agent matters less than knowing which agents you can actually obtain when you need them. Survey your pharmacy and anesthesia cart before the case, not during it.

ERAS implementation requires cultural change, not just protocol writing

ERAS is a bundle of interventions to help patients move through the hospital faster with less pain and fewer narcotics 16:14, including a carbohydrate drink two hours before surgery rather than traditional NPO protocols 16:14. But implementation requires anesthesiologist buy-in because it represents a fundamental shift from traditional practice 16:42, and the difficulty lies in changing institutional culture and philosophy across the entire hospital 17:55. Surgical pathways created for ERAS are used more by hospitalists and pediatric residents than any other pathways 19:09 and have led to decreased cost, antibiotic utilization, and length of stay 19:09. Starting with one component — decreasing opioid use intraoperatively and perioperatively — can be an entry point for larger ERAS implementation 19:42. Do not attempt to launch a complete ERAS program in one meeting. Build one pathway, demonstrate the outcome improvement, and use that credibility to expand.

Thoracoscopic hemostasis strategy should match the pressure system

For pulmonary vessel bleeding during thoracoscopic lobectomy, energy sources work well as initial hemostasis because it is a low-pressure system 21:18. Multiple hemostasis options including energy, clips, and sutures should be available 21:38. The pulmonary circulation tolerates energy-based sealing better than the systemic circulation does, but that advantage disappears if you do not have clips and suture immediately available when the energy device fails. The sequence matters: energy first, clip if that fails, suture if the clip fails. But all three must be in the room before you divide the vessel.

Practice change happens when barriers are lower than evidence

50% of respondents always use sutureless closure for large abdominal wall defects, 39% use it in select patients, and only 11% do not use it 12:23. This represents a dramatic shift from prior years, when adoption was minimal. The technique did not become more effective — it became more familiar, and the perceived risk of trying it decreased. Most institutions are either addressing social determinants of health or working on it, with few refusing 21:50. The pattern repeats: when a practice change requires only surgeon behavior modification, adoption accelerates. When it requires institutional infrastructure change — like ERAS or send-out laboratory tests — adoption stalls regardless of evidence quality.

Takeaways from this story

MMP7 for biliary atresia is clinically useful only if turnaround time allows action before the 5-week presentation window closes
Pediatric MTP lacks consensus definition; 40 cc/kg is a practical trigger for balanced resuscitation but requires pre-built protocols
Sclerotherapy agent choice depends on institutional pharmacy access more than efficacy; know what you can obtain before the case
ERAS implementation fails without anesthesia buy-in; start with single-component pathways like opioid reduction to build credibility
Thoracoscopic pulmonary vessel bleeding: energy first in low-pressure system, but have clips and suture immediately available

Keywords

biliary atresia cholestatic diseases blunt abdominal trauma closed head injury pelvic femur fracture rectal prolapse gastroschisis omphalocele vesicoureteral reflux intraoperative ICG biliary flow visualization massive transfusion protocol sclerotherapy sutureless abdominal closure thoracoscopic lobectomy

Transcript

We are, we all live in our own little country and we do our own little thing. And it's only when we talk to each other from all over that we do true learning. And it's still incredible that after all these years, we have so many people, we have 2000 people signed up almost. And it's very exciting. And to answer questions, yes, this is all recorded. And Ellen and Cisco and Rod Gerardo, the fellows at Cincinnati Children's and Akron, they're going to be chopping this up and pushing this out all year round. So you'll be able to see this on social media and the State Current app. To remind everyone what this is about, this is about rapid fire. We're not doing in-depth stuff here. This is rapid fire, important topics that we feel and that a lot, that's why we bring new faculty in every year, that the faculty feel are kind of the real important points that we need to be highlighting all over the world that came up over the last year or so. So we're going to ask a question, see what you do, and then kind of give a new slant on what we think is maybe a new way of doing things in pediatric surgery. But we're wrong half the time. So argue with us. Tell us we don't know what we're talking about. This is interactive. We're not always right. So say, with all due respect, I totally disagree with you. Fine. We love it. Bring it on. We're going to have fully interactive. You're going to, this is, if you want to say something, chat it. Put it, we'll give you poll results. I promise you, I'm making this promise every year, something will glitch. Okay? I've been saying this for nine years. Even a few years ago, the whole power went out in the city and we had to drive to my living room. Something will glitch. Bear with us. We'll communicate with you through email, through chat, whatever we can. Let us know if you're having any difficulties with anything. And we'll try our best to get this fixed. But do not worry. It's all being recorded. In fact, let's make it a point this time to make sure, Garrett, just wanted to highlight, is this being recorded? Want to make sure it's all being recorded. And let's make sure I'll even record this room, just in case. Yes, this is being recorded. Okay, cool. So now, this only, as you know, this is free. This is free because, and we've been trying to keep this free as long as we can. We try to believe that knowledge should be free as long as we can do it, as best we can do it. It's not really free. It's free to us to watch because of the very generous contributions from the sponsoring institutions. And that is Akron Children's Hospital, Children's Mercy of Kansas City, Cincinnati Children's. We've got UCLA. We've got O'Shea Children's Buffalo Children's Hospital. We have APSA sponsoring this and the Journal of Pediatric Surgery. All of these. Did I forget anyone? I think I got everyone there. This would not happen without those hospitals. Every year, they keep contributing to make this happen. So thank you very much. What else can I say? I think we're going to get going. And you're going to meet tons of faculty. You're going to hear us disagreeing a lot. And hopefully, we'll learn a lot today. So Rod Girardos is the first talk. He is in mid-flight because his flight got canceled. So I'm going to try to give Rod's talk. Fortunately, I don't, it's all, you know, mostly Rod's talk. Rod shows. So I don't have to say much. But this is what it's going to be. What we're doing is at the start of every update course, we review what the main points were from last year. So Rod's going to go through. We're going to show you a clip. And then we're going to see if you were here last year, did this change your management? So Garrett, Sam, go ahead and roll the first presentation. Rod Girardos. Hi, I'm Rod Girardos. Research resident at Cincinnati Children's Hospital Medical Center. And last year's update course was awesome. In case you missed it, here's some highlights. We started off strong with a session about biliary atresia. New research suggests that MMP7 could be used to distinguish biliary atresia from other cholestatic diseases. We talked about considering antiretrovirals and steroids in the postoperative period. And then we discussed a revised algorithm for biliary atresia. But one of the most interesting topics is the use of intraoperative ICG to determine biliary flow or identify a transaction. So I got to ask, how many of you out there in the audience utilize intraoperative ICG to visualize the biliary tree? Most people are saying no. Yeah, most people are saying no. So it's changing quite a bit. It's moving a lot. But it looks like 26% say yes, 23% say no, select patients, and 51% say no. That's probably a big jump from last year where it was probably almost nobody. So I think that's great. So, Garrett, go ahead and play the talk. And if you could broadcast the live sound with us, that would be great in this room. If not. And next, we have a second question, and it's already up. People are answering that, too. Whether or not you use MMP7 to differentiate biliary atresia from other pathology. Looks like, again, most people are saying no. So this one was the big one for me. I'm curious what everyone else in the faculty said here. This is what I learned last year, the MMP7. It's not really available, Todd. But after the course last year, I wasn't a speaker, but I actually watched. It was something that we implemented here at the University of Rochester. Unfortunately, as you know, some of these children present at five weeks, and we have a limited time to get the best possible outcomes for them. And for, I believe, many of not freestanding children's hospitals, MMP7 is a send out. And so what happens is, you know, we're using it almost as a study, but I don't wait for it, especially if the child is already quite advanced. And, you know, we want to get biliary, the diagnosis and biliary flow as soon as possible. That's, so is that true without others are finding that it's, it's a send out, it's not going to be sort of there readily available enough for it to make a clinical difference? Okay. Okay. Let's keep going then to the, we'll keep playing the PowerPoint. Then we had APSA jump in with the PDC or Professional Development Committee. They brought up a whole lot of new topics that were popular in the NAT or not a textbook. We talked about everything from CDH to sleep apnea. They covered so many topics. But one of my favorites, I gotta ask you, if you had a blunt abdominal trauma patient who was hypotensive and tachycardic in the trauma bay, injuries listed here, and they already received a 20 cc per kg bolus of crystalloid, what's your next step? So, so we have the next poll question up for everyone. All right. So the poll question here is, so this is a question that really changed my management. The first time I heard about this was really when David Notrica presented this. So you have a 10-year-old hit by a truck. Upon arrival is unconscious. Heart rate's 140. Systolic blood pressure is 80. Closed head injury. Suspected abdominal injury. Pelvic femur fracture. The choices are going to be a second bolus of crystalloid. Transfuse blood, type-specific blood. Initiate massive transfusion protocol. Administer TXA or implement permissive hypotension with a systolic blood pressure of greater than 70. What does everyone here think? Todd, I think we're going to discuss this a little bit later on again. I'm glad this keeps coming up because I think it's an important topic to discuss. And I think you have two potential answers in there discussing, you know, initiation of blood. We want early blood therapy of these patients as well as potential for massive transfusion protocol. And I think currently we don't have a great definition of what an MTP is in pediatric patients. There's still a lot of debate about what constitutes that. I think 40, you know, per kilo blood once we start going there. We need to start doing a balanced resuscitation. So I think those that are starting early blood as well as that massive transfusion protocol and a balanced resuscitation are the ones that are where ATLS and where the literature is leading us to go. All right. So, Rob, you're going to talk to us about that, which is awesome. But let me tell you this. What is the tiny percentages are not that many people want to give a second bolus of fluid, which is good. And the administer TXA was the smallest option and permissive hypotension was also really, really low. So it was about either massive transfusion protocol. And I can't wait to hear now because I'm curious exactly how I know when to do that. So we'll get to that. All right. I'm going to go to the next video here. Then we had a session about colorectal surgery. And we talked about treating predisposing factors medically first. We talked about rectal prolapse, but a controversial topic that we also discussed. I got to ask you, which one of the following is your sclerotherapy of choice? Okay. So here are the choices. We've got ethyl alcohol, phenol, hypertonic saline, dextrose in water, or cow's milk. What would people use? What is their sclerotherapy of choice? Okay. And it looks like hypertonic saline is waiting. Ellen, what are you showing? What are we seeing here? Yeah. Hypertonic saline, 46% are saying that. And then the other options, phenol, ethyl alcohol, or dextrose in water are about 10% to 16%. Okay. I'd just add, you know, fortunately we have a colorectal group, so they see these patients, not me. But I think hypertonic saline is what I have traditionally used. And in some institutions, including ours, getting phenol into the operating room to be able to use that for sclerotherapy is not always an easy thing. So, you know, I don't think that that's always possible just based on restrictions from the institution and the pharmacy. Great point. I think there's also case reports that show mucosal sloughing with phenol. Now, interestingly, there's a couple of case reports that use deflux, which is a compound that is used by our urology colleagues to help with vesicle ureteral reflux. Does anyone in this panel use that at all? Okay. I haven't used that, Marge, but I do use 3% sotradecal is what our pharmacy carries. Okay. And how about D50? Because it's also hypertonic. That's what we use, Marge. The D50 out of, you know, out of the code cart. Right. That's, for us, that's actually easier to acquire than the 3% saline in the operating room. Those two. Okay. So, what we're going to, why don't we keep going and we'll get as many as we can. We only have about eight minutes left, so we'll see as many as we can get to here. Then we had a session about gastroschisis and omphalocele. We talked about complex gastroschisis and how that's like a totally separate thing altogether. We talked about the management for gastroschisis. We talked about different methods of closure, including silo. But I got to ask you, how many of you out there utilize suture-less abdominal closure for large abdominal wall defects? This is the common question. So, suture-less abdominal wall closure. We've hit this topic a bunch. So, choices are, do you utilize suture-less closure for large abdominal wall defects? Yes or no, or only in select patients? I'm going to go ahead and do my answer, which is yes, I do it. And it looks like... You're in the majority. Tell me, Ellen, what are you finding? Yeah, most people are saying yes. Okay. And then the next one is only in select patients. And then you run back to Cincinnati and leave us to take care of it. Yeah, that's all I have to do is get it closed and hand it off. But, you know, would you guys... I think this, maybe not, but over the last nine years, I know we did this early on, almost eight or nine years ago. And the numbers were not this high. I mean, I love how we see changes in practice happening over time. So, it's good that we're reviewing this. 50% of people do it. But I would say that I probably would change my answer to only... How about this? Only 11% don't do it. So, 90% do it always or in select patients. This is clearly a big change in management. And probably this deserves more time for another session. But that's a good review from last year. All right, here we go. Next slide. Another hot topic we talked about was ERAS, or Enhanced Recovery After Surgery. We talked about how to build a team. How multidisciplinary that team could be. We talked about perioperative pain control and how it really takes a village. And then we reviewed some different guidelines. So, I gotta ask. How many of you out there utilize ERAS for your pediatric surgical patients? So, this is the question. Do we use ERAS at your institution? Yes, for several procedures. Yes, but only for a few procedures. No, but in the process of developing it. Or absolutely not. We do not use ERAS. While we're waiting for the polls, let's hear you guys. What do you think? Dan? Yeah, Todd. This is definitely something that is in evolution, I would say, here. Started with our colorectal group pushing this. Now we're actually studying oncology patients and using it for oncology patients. So, I would say our answer is yes in selected cases. But we're trying to do it in a way where we can actually get some data from it and expand the populations. Our urology group uses it very aggressively for their patients. So, it is one of these things where practice has very much changed in our institution. And I think getting patients out of the hospital sooner is a huge advantage as we get pushed for volumes. And it's a lot nicer for the patients to be at home. So, this is one of those great changes in care. Okay. So, that was a perfect, and I bet you that represents most. By the way, everyone, you will see the person who knows the least about most of these things is me. So, do not be shy asking something if you don't know. There was a question asked, what is ERAS? Mark Wilkin, have you ever heard of that term, ERAS? Never heard of it before. Tell us what it is. Enhanced recovery after surgery. For those that don't know, it's actually, it's a bundle. Just like we have central line bundles to prevent infection, this is a bundle to help the patient get through the hospital faster with less pain, less narcotics, up and moving around. And it includes things like a carbohydrate drink two hours before surgery. I mean, that was- Let me stop you. Let me stop you. That's a huge, that's one example of a big change. Because it used to be NPO, NPO, and now you drink two hours before. Drink two hours. That's why it requires the team. You got to have your anesthesiologist on board with that because that's a big change. Yep. Yeah. You know, I'll tell you that, you know, Kurt Heiss started doing this in Atlanta sort of subversively. And then all of a sudden, he showed us our data, much like NUST did. And then we started doing it in many more procedures and implementing it. When I came up here to Akron, I mean, I was just blown away by it. I'd say almost all of our patients that undergo major surgery are having some form of ERS. But that's because it's actually not driven by, it is driven by the surgeons, but it's really driven by anesthesia. And they just totally bought into this. So they are just making sure that we do regional blocks where we can do regional blocks and doing all these. Again, like I said, it's a bundle. It's a whole bunch of different little things that you do that add up to getting the patient out of the hospital faster. Yeah. Great point. Yeah. Go ahead. Can I say that, like, they're really difficult to implement, I must say, because the benefit, it's true, it's out there. But comparing to the previous slide that you showed, I think it's much easier to say, let's do suture-less gastro-schesis. Something that you only do when it's really easy to bring in. But this involves, like, I don't know, the whole hospital to be in a different culture, in a different philosophy. So I found this very difficult to implement. I have an idea. It's a good point, Jose. Here's what I want to do. I want to do an event later in the year, not a course where there's lectures. It's fully interactive where if anyone is interested in starting this at their institution, we get those on here who have done it where we can say, okay, almost like a little full-day thing about how to get your teams to come, your anesthesia, everyone. And we go through the steps and answer questions so we can see that more and more people are starting to do this over time. I think this has been, you know, it's scary to tell your patient to drink when you're not 100% sure that anesthesia is not going to cancel your case. And, Mark, your point was it was no ERAS and then all of a sudden tons of ERAS because two specific people came, anesthesia and head of surgery, head of anesthesia, and that's what it takes. So this was an amazing – yeah, Steve. Can I add, you can start small with surgeons by having pathways, and that standardizes care. And what we've done is created some pathways, and interestingly enough, it's the surgical pathways that our hospitalists and our pediatric residents use more than any other pathways because they like that standardization and communication, and that has led to decreased cost, antibiotic utilization, as well as decrease length of states. Yeah, I would agree with that too, Steve. I think, and to Jose's comment, it is difficult, but if you chip away at these things, right, decreasing opioid intraoperatively and perioperatively is a pathway that you can start as part of a larger ERAS protocol and as part of a larger ERAS system at your hospital. So take one thing and start to work on it and get by-in from your anesthesia, your nursing staff, and everybody around you because that's really what it's going to take. And I think you chip away at these things before you know it, you find that you have a larger ERAS protocol ahead that really is making a difference. This is a great discussion. Clearly, this is something that's a hot topic again. And by the way, you'll notice with the update course, we hit on a lot of the topics every few years, and it's okay. And it's okay that it's discussed more than one time a year at different meetings because we want to hammer these ideas home. Hopefully, you'll learn soon about the PDC and how that's their whole purpose. So we'll get to that. All right, next one. Lastly, we had a lively debate about what to do when complications arise. We talked about all sorts of stuff from how tight to make a curl closure, different techniques for mesh use, challenges with diagnosing lung lesions. But another piece that was kind of interesting, let's say you're doing a loracid case and you see some bleeding from a pulmonary vessel. How do you secure that hemostasis? So you're doing a thoracoscopic lobectomy. You notice a bleeding pulmonary vessel. How do you get hemostasis? Clips, ties, energy, stapler, or a combination of multiple? Mark Wolkin, I'm going to go to you, and then I'm going to go to Mac. I'll start with an energy source. You know, one of the sealing devices I think usually work pretty well. Remember, it's a low-pressure system. And then if you need to, then if that's not working, you can go to a clip, and you can even suture if you have to. All right, Mac? I hate to agree with Mark, but I think I agree completely with this technique. The answer is multiple. You need to have multiple options. But I think the energy sources that we have these days are a good start. All right, so here's what I think. We're over time. I'm going to fly through and see what we got here. I think, I don't know how many more he has, but let's just play the video. One more. Here we go. Then we had a really interesting conversation about social disparities in health care. We talked about racial biases, economic distress, the toxicity of poverty, and hopefully brought awareness to a lot of surgeons who were at the update course last year. So I have to ask, is your institution taking steps to address social determinants of health? All right, so this is a huge topic last year. Did this make a difference? Did other hospitals do this on their own? How much is your institution? And I'm curious how this works. Obviously, this is a very international audience. So the social determinants of health strategy should be the same, but the results may be different. So let's see here. Alan, what are we finding? Yeah, most people are saying either yes or they're working on it. Not many people are saying no, which is good. Okay. That's great. That's really, really a huge step because this was something that just was not discussed enough before, and I'm glad we keep addressing it as many meetings as possible. This was in a great session last year. By the way, you can get all of these sessions on the Stay Current app or the website. Go there and watch any of these sessions in completion at any point in time.

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