The first topic is we are going to do a review of the top things from last year's event, in case you missed it. So with that, we have the Pediatric Surgery Fellows at Akron Children's and Cincinnati Children's, Dr. Alex Gibbons, Dr. Ray Hanke, and Dr. Alejandra Kassar. And they are going to go through quickly what you missed last year. So, Alex? Yes. So the practice gaps identified by the Pediatric Surgery Practice Professional Development Committee last year were very popular. They're also very popular on social media, and you've seen our videos. Number 10 for last year was restrictive transfusion protocols, using a target hemoglobin of 7 for transfusions, instead of 8 or 9 or 10, like some institutional protocols did. And it showed that there was no difference in mortality. They also recommended to be aware of the risk of DVT, use in blood transfusions. Just so you know, just two days ago, I had a baby that I was operating on. And because you taught me this, the hemoglobin, they were going to transfuse up to a hematocrit of thoracin. No, I learned from the PDC. We don't have to do that anymore. Transfuse clinically. Transfuse clinically. So we want to ask a question. Has your practice changed since last year when we presented this? So the poll should be loading, and you can start participating. Who here? See, you guys don't count because you're skewed. You guys are ahead of everybody else because you're the PDC. But is anyone here still transfused to a hematocrit of 30 or a hemoglobin of 10? So I was the only one. So embarrassing. Every year. Every year. Yeah, every year. Only the exception would be sickle cell disease. So sickle cell disease, there's some poor evidence to suggest that their hematocrit needs to be around 30. Or you need to measure their sickle cell fraction and make sure that the HPSS is below, what is it, 50%? To make sure that they can go through easily. That's good. That's a great point. 60% of you were doing it already. That's awesome. 20% have converted, and 20 didn't know. So pay attention to the gaps this year so you'll know for next year. Here we go. Yeah, that's why we're reviewing it this year. So number nine was enteral nutrition and pancreatitis. So what the PDC emphasized is that early feeding decreases morbidity, infectious complications, and overall mortality. They found that nasogastric is equal to nasogejunal feeding. It's equally tolerated, which I found fascinating because it's always been NJ feeds for my training. And then operate early for gallstone pancreatitis. So question for you all. Are you enteral feeding children with pancreatitis early on? I remember last year's update course, one of the highlight reels was Dr. Rusty Jennings saying that this single teaching point made the whole update course worth it because he didn't realize this, and it totally changed his practice. Yep. He had like a Todd Ponsky mind-blown moment. Yeah, this is one of those things I was doing wrong again. I would wait until their symptoms were improving. I wasn't following lipase and amylase, but I was waiting for their symptoms to improve. And now you don't have to do that. You just feed right away if they can tolerate it. So the eighth one, to paraphrase the rapid childish Gambino, is like an accent mark. It was all about the ovaries. So this was referring to ovarian torsion specifically, and the points that the PDC wanted to emphasize were, one, that ultrasound is not a great tool to be using for diagnosis at this stage. So really don't be basing your clinical judgment off of that. And then, two, when you go in to detource, even if the ovary looks black and dead, you leave it in place because they can still have recovery afterwards, and it helps preserve fertility. Number seven, we have VTE prophylaxis in high-risk trauma patients. And the learning gap was that for low bleeding risk, we should be doing SCDs and low molecular weight heparin. And for high bleeding risk, we should be doing SCDs until the patients are ambulatory, and then do a screening ultrasound on ICU day seven. The question was, are you using low molecular weight heparin and SCDs in low-risk trauma patients? So, first of all, what age? Is this any age? Or is this a certain age we should start using low molecular weight heparin? I don't know. Does anyone know? We'll have to look that up. Because I don't know, do you have to do this in a five-year-old, or is this only a teenager? Who is it that you need to give low molecular weight heparin? Do you guys know? I don't know. No? What do you do? What do you do in your practice? So our institution policy is 12 and over. 12 and over. Yes, sir. And you do both SCDs and low molecular weight heparin if they don't have a head bleed? Correct. Well, if they're high risk, they get both. If they're low risk, they get just SCDs. And high risk would be solid organ injury, or is that not high risk? Femur fractures, cervical spine fracture, intubated. Anyone do anything different? No? There was data presented at APSA this year by the group, I think the TOMAC group and their subsidiaries. They presented some data on that, trying to adopt VTE prophylaxis protocols. So they're doing more and more prophylaxis. And it's mostly the teenagers, as Liz mentioned, who have ambulation issues, and they are supposed to be at high risk. No one knows what that risk is, though. Okay. The other group that's at high risk are kids with IBD. Really? They're probably the most at-risk group for deep venous thromboses. Okay. All right. What's next? So, number six, the PDC called attention to the topic of physician wellness. They reviewed that burnout, it directly impacts patient care and outcomes and emphasized the importance of establishing support systems that are established during education as well as practice. And this is something that needs to be proactive so that surgeons don't necessarily have to go out. When you're burnt out, you're not likely to seek out help. It's not necessarily in our mentality. It's not our norm. So that was another point that they emphasized. So let me, while we put your poll up, I'm going to ask. So have you talked to your hospital system about a proactive physician wellness program or participating in one yourself? So my answer to that is C. Well, it's not that I'm not convinced. I just haven't. Let me ask the leadership here, people that are in leadership positions, which I think are all of you. Have you done anything at your hospitals officially or formally for this? Mark Wolkin says yes. Come up here. While we're waiting. Yeah. No, that's okay. No, we have a very formal program. Most people know my partner, Kurt Heiss, who has set up the whole second victim program, but we're also, our wellness committee looks really extensively at burnout. We polled the medical staff about burnout, and then we try to do things to help with that. Dan? I would say we also have a similar program, but I think it's also important to recognize that it's not just physicians who have this burnout issue in healthcare. And so we have representatives from patient services and from HR for the staff for issues of burnout. And, you know, we have an approach where we do acute interventions for things like we had a couple of kids pass away in the emergency department a while back, very close to each other. And so there were interventions made to help the staff down there deal with those sorts of issues. But it is a real issue. That's a great point. Yeah, that's actually a great point. And I'm curious for the international community. We'd love to hear if this is everywhere. Is this just a big United States thing right now, or is this happening all over the world? So please leave your comments and tell us if it's happening in your neck of the woods. All right, what's next? So next one is also a more U.S.-specific one. It was looking at firearm injury prevention and referring to gun violence as a public health issue and an epidemic, really. And APS just in the most recent JPS issue for July had position statements that they had. And one was for non-accidental trauma and the other one was for firearm injuries. A fantastic physician paper, so definitely recommend everybody take a look at that. But this practice gap was also addressing that and just emphasizing that physicians should be talking to their patients about whether there's a firearm in the home. And if there is, whether it's safely stored. And then the other aspect of it was kind of emphasizing advocacy and pushing for better policies that really help address the problem of gun violence. All right, I need some help here. So I don't get where we fall into the politics arena. I have never talked to a patient about firearms, ever. And so I'm the one that needs to get into that mode. But I don't know how this works. How does APSA, how do pediatric surgeons, are we allowed to take a political stance on something? So this erupted into a big political controversy in Florida recently. The American Academy of Pediatrics wanted to include this as a question that physicians should feel comfortable asking all parents. And as a matter of fact, they wanted to say that physicians should ask it and put it on their list of things they should ask. And it became a huge controversy. And the legislation, they basically, in Tallahassee, they shut that down. And they did not want that to go through as that. So I think as soon as you bring up a question like this and try to formalize it, you enter into the political arena with both feet. And so I think if you're going to do this, you have to be prepared to do that. What are we supposed to do, Salim? It says, do you ask them, okay, do you have firearms in the house? Yes. Is it that we're supposed to tell them, do you have safety mechanisms? Okay. So do you have firearms in the house? If the answer is yes, how do you store them? Are you keeping them under a lock and key? And are they loaded or are they kept unloaded? Is the ammunition kept separate from the guns or is it right next to them? And who has access to them? So that is what primary care physicians especially are supposed to do. And I've kind of done it a few times when there's been a trauma situation. It's kind of after the horse has already left the barn in a lot of ways. But yeah. By the way, I had two friends, one this past week. I know someone who injured themselves by cleaning their gun. And apparently this happens a lot. It's cleaning the gun. There's a stray bullet. You either shoot yourself or someone else in the house. So that's something else to keep in mind. Interesting variation there in the answers. Next. Practice gap number four. This one was really interesting last year because everyone said they knew about it. And probably like 90% of people were still not doing it. So this is a transition from before where isotonic fluids would be switched to hypotonic fluids for maintenance and resuscitation to the current strategy that should be to continue isotonic fluids throughout. And this decreases the risk of hyponatremia. And it had similar morbid mortality otherwise. Let's see what the poll says. So comments on this. So I was blown away by this. I have always go, okay, first day, resuscitate them. The next day, put them on maintenance fluid at a hypotonic solution. I said, oh, my God. Okay, now I need to keep everybody on isotonic. And I can't do it. A lot of it's because of our epic. Protocols. What? Order sets. Order sets. Order sets that I'd have to go change the whole epic order set. So even though I tried, we still end up giving, switching over. It's been too hard of a mountain to push. What about everyone here? Do you switch? At our institution, we switched the order sets. You did switch them? Yes. You guys do everything right. They got it going. It was at the push of the pediatricians. So all the order sets throughout the institution were changed. Amazing. At our institution, we had lots of education with the residents, particularly surgery residents, neurosurgery residents that take care of kids. The pediatricians were doing this, but we had to do that to make the change. Steve, not babies, right? What about pylorics? Do you keep? I've switched for pylorics. For them too. Yes. Because last year, that was unclear. When we talked about what about babies, it was a bit unclear at what age this starts. But you do it in everybody. Okay. Salim? No, I agree. It's the biggest thing. It was almost like a culture change. Because when we were teaching medical students, we were teaching them that we're basing their fluid requirements on their sodium requirement on a daily basis. And so that's what we were traditionally teaching them in lectures and everything. So it was overcoming that. And once the pediatricians kind of were convinced, then that helped us as well because the floors then wanted to do it. So we've switched over. Okay. So once again, what is this? Question nine. I'm still the only one who's getting everyone wrong. Okay. Let's keep going. It seems like 46% of people were already doing this. 38 have converted and 15 didn't know. I'm just curious. At your hospitals, they won't hear or see you on camera, but did you guys all switch to this? This is Dr. Fred Rescorla, who we haven't introduced yet, from Indiana. Yeah. So we switched for many of our patients. We had a big discussion with our peds nephrology division, and they actually didn't want us to switch on everybody. We were starting a protocol of following lights on some of these kids, but they didn't think it was quite as big of a deal. And they thought this was kind of a quick jump on the pediatric group. Interesting. So a little bit of a more tailored, measured approach. Okay. All right. Okay. So practice GAB number three, they identified violations of the Wilms tumor protocol. So a few things that we highlighted were remember to take the nodes every time, every operation, because if you don't, it automatically upstages your kids. Remember that there's local and systemic staging and that pulmonary metastasis doesn't preclude doing a primary nephrectomy. So I have two questions for the audience. So first, have you been sure to remove these nodes in your kids when you're operating for a Wilms tumor? Okay. So a comment about this. I think people know you're supposed to. Yeah. I'm guessing what happens is you're patting yourselves on the back that you took out the tumor. Like, okay, sweat. Let's close. And I think it's a lapse because you were focused on the tumor. So it might be a good trick to tell the staff in the operating room, make sure you remind me to get nodes. Put it on the whiteboard on the timeout. Make sure people have a hemostat to something and say, remind me to get the nodes. Maybe I think that might be part of it. Anyone comments? So, Liz, the question again here is this is for sampling of nodes, and it's for primarily staging purposes, right? Correct. And so if you have a patient who does have known pulmonary mets, how important is it then to make sure that you take nodes in that situation? If your stage is already four? Well, I think, I mean, that's an excellent question. What's the point? But on the other hand, to Todd's statement, if you get into the practice of doing it every time, then you're going to do it every time. Do you want to? There's also a. Go ahead. Go ahead, Dan. Just it's important to still take the nodes because you treat the local disease, and it has an impact on the treatment for the abdominal disease, whether they have lung mets or not. So it is important to take the nodes. Regardless. This was a great discussion. Did you want to make another point, Liz? I'm good. Thanks. That was actually high yield right there. So separating systemic and local disease and some system of doing it regularly so you just don't forget. So the number two practice gap was talking about non-operative management of uncomplicated appendicitis and just emphasizing that this is a possible treatment option now. So and not only is it possible, but it also has decreased days of hospitalization, decreased days of disability, and equal outcome measures otherwise. So I know standard of care is obviously still the appendectomy, but this was emphasizing that this is a viable treatment option. So our question for the audience is, are you considering non-operative management of acute appendicitis? So while this is polling, of course, Dr. Holcomb has something to say about this. Not surprised. So most people here in the United States know that there are a couple of prospective trials looking at the efficacy of non-operative management versus operative management for non-perforated appendicitis. To me, the important point in this discussion is not whether or not non-operative management is effective for six months or a year. It's what's going to happen 10 years down the road or 20 years down the road or 40 years down the road. It's hard to believe that the appendix doesn't scar somewhat due to the inflammation, which may predispose it to developing an obstruction and acute appendicitis later. And whether that's, again, 10 years or 30 years or whatever, that's going to be really important, I think, in trying to determine if non-operative management is really effective. So the point is that these patients, I hope, will be followed for a long time, this cohort of patients in these trials, so that we'll really know, you know, 20 or 30 years later if non-operative management truly is effective. Currently, it appears somewhere between 10 and 20 percent develop recurrent appendicitis, although somewhere between perhaps 20 and 40 percent develop or have an operation. At some point, because they have symptoms that are either similar to appendicitis or their parents are concerned they have appendicitis. So anyway, all that data is just as important, to me at least, whether or not the actual management is effective. It's does the patient get an operation for whatever reason, either soon after the non-operative management or 10 or 20 or 30 years down the road. I think that's a great point. We just don't know enough yet. Yeah. The APAC trial, which was an adult study, mostly based in Finland, looked at five-year outcomes. It randomized adults to either get an appendectomy, which in Finland, apparently, they still do open appendectomy. So it was open appendectomy to a non-operative management. And at five years, when they looked back, 41 percent of the non-operative group underwent an appendectomy. So and when this was published in JAMA earlier this year, and the editorial accompanying that said they consider this a success, that non-operative management of appendicitis is great. I don't know if any surgeon would look at that and go 41 percent failure rate is a success. So we would add that in the adult population, there is a PCORI-funded study that is multi-institutional based out of Seattle, but we participated in Los Angeles. And part of the ramp up to that, we had to survey parents to see what they would accept as a potential success for non-operative management. That's great. And parents actually came up with if there was a 50 percent chance of being successful, they would enroll in the study. So it just I think it really shows the differences between what the patients view and what we view as surgeons. And in addition, you know, where we are in Los Angeles, lots of patients are coming in, families just asking. We want non-operative management. And so we have to actually address this head on. Yeah, I think my comment to that would be that I think the parents are more focused on the here and now. That is what's happening at that moment in the emergency room. Whereas we as their caregivers need to be thinking about what's best for the total life of the patient, whether it's a child or an adult. And that's why I think the long-term follow-up is going to be vitally important for this group of patients. Right. We have them now in a controlled environment versus when they get it the next time. Who knows where they'll be and if it's going to be perforated. I use this as something in my back pocket now. So I don't do it, but I have it there. So if someone's not a good surgical candidate, for whatever reason, I don't want it. Then I know I have it as an option, but I don't do it. What's interesting, Steve, is that no one has ever asked me for it. So it shows you how it's either an education thing. People are hearing stuff. Somehow people have never asked me, but in your facility, people ask all the time. It's very interesting. And then the poll for this one. Most people are not convinced, 72%. And then we had about 20% who were already doing it and 6% who were converted. I want to just do this sometimes, so I apologize. We're going to jump back because there was a question that I either want Dan or Liz to answer. The question about the Wilms nodes. How many nodes? Which sites should you take it from? Contralateral nodes as well. Do either of you want to address that? Right. This is a big controversy. Quote, how many nodes? One node? 10 nodes? 20 nodes? No one knows. So there are some data to show that nine nodes, seven nodes are probably adequate. But plucking nodes from the mesentery or plucking nodes out of the pelvis is not helpful just to get, quote, nine nodes. And a lot of it depends upon how your pathologist counts nodes, right? If you send them a group of nodes, are they counting that as one node? Or are they dissecting out every node and looking at every node separately? So I think that those are data that we just don't have. Okay. All right. But you should take nodes from both sides. But Dan says you should take nodes from both sides. Is that okay that I asked a question from the audience? You're totally allowed. That's okay. Talk to me. All right. Okay. All right. Both sides of the cava and the aorta. Yeah. Yes. Both sides of the cava. You don't have to dive into the renal hilum on the other side. Yeah. Yeah. Yes. Yeah. Yeah. Yeah. So I just want to clarify that. Both sides of the cava and the aorta. Not necessarily dissecting. Not opening up gerotis fascia on the other side. Great. Great discussion. Next. So we're finally at practice gap number one. Number one. And this was identified as the most important one because it's the one that impacts most people. Because it's not just our patients, but it's their families and the communities that these medications are going to. And it's about the opioid crisis. And the recommendations we had were to reduce the total amount of opioids prescribed, use non-opioid analgesia, non-pharmacological approaches, and educate on the disposal of unused opioids. This was addressed very thoroughly at APSA annual meeting this year. Many institutions are coming up with protocols either in order sets or family and patient education. They have disposal protocols. And I'm interested in seeing what everyone is doing, including teaching residents, because a lot of people just want to give them opioids. So what I want to do is get the poll results. David Taal taught me something last year. What our new strategy is, is that we like repeating topics, even if we did it last year, if it's something that's important enough. We think the best way to get everyone learning something is to keep repeating it over and over again. So Mac Harmon is actually going to be talking about this as well later in more depth. So we're just going to do it again this year. So I was doing this already. It's interesting. Well, there we go. That's more like I thought. But I've absolutely this is one I completely after last year's update course completely flipped my management. I almost never prescribe narcotics now. OK. And then the kind of enhanced recovery after surgery protocols that have been around in the adult world for a while and are kind of now making their way into the pediatric world have also been great at reducing opioids, both in the inpatient setting and at the time of discharge. Awesome. Let's see. So the poll over here, I know I was doing it already. They call me the narc police in my residency program. But it looks like 70 percent were doing it already. Twenty three percent have converted and eight percent did not know about this. So I'm really glad we're covering it this year so we can reinforce all these strategies. Awesome. Great review. Thank you. The three of you. That was fantastic. We'll do this again next year. We'll review the top things from from this year. I'm going to move on now. I'm going to move on now to the next section, which is the practice development committee of APSA. We explained what this was last year. I'm going to explain again. So APSA, we are very proud to have as a partner of the annual update course. And what APSA is providing is a review of what are the biggest knowledge gaps. And we have Dr. Liz Byerly from Alabama, Dr. Stephen Lee from UCLA and Dr. Salim Islam from University of Florida, who are going to review this year's most important knowledge gaps. Did I summarize what PDC was adequately or do you want to make a couple more comments? Did I say it? Is that accurate? Okay. So I think, Liz, you're starting off. Are you starting off with antibiotic stewardship? Okay. Okay. So I have this set up as a case vignette and then question. Perfect. So we'll start out with the vignette. You have a full-term infant who was prenatally diagnosed with an omphalaceal and underwent an elective delivery without any problems. There was no maternal history of fever or chorioemdianitis. And on exam, the baby is stable. There's no respiratory distress. The omphalaceal is intact and covered. You plan to do an abdominal wall closure in a couple of days after the workup for associated anomalies is completed. And the question is, assuming there are no signs of infection, the most appropriate antibiotic management of this patient should consist of. So what the PDC would like to advocate and what the data would indicate is that preoperative antibiotic given one hour before incision and discontinued within 72 hours is the most appropriate answer. Okay. Given one hour before incision. So within one hour. Yes. So when do you usually give it? We usually give it when the baby arrives in the operating room. And the reason that we do that is because if we order it preoperatively, we have no, I mean, y'all have the same kind of schedules we do. You never know when this kid's going to get to the OR, right? You could have a gunshot window, the admin show up or, you know, it takes them two hours to turn your room over or whatever. So we give it when the baby arrives in the operating room. In the pre-op area or in the OR. Correct. Yes. Okay. Does anyone give it, like, around the time of timeout right before the operation, or does everyone give it right when the baby arrives? One of the points about this is that the baby doesn't need antibiotics just because they showed up in the NICU. I think that there's a feeling that, you know, the baby's in the NICU, they have an ophal seal, they need antibiotics. And I think the point of the PDC, correct me if I'm wrong, Liz, is that that baby doesn't need antibiotics until they go to the OR. And all they need is standard prophylactic antibiotics. Correct. That's the whole point of this vignette in this scenario is we are probably using too much, too many antibiotics in children that don't actually need them, especially neonates. And, you know, some of the evidence that we have on the next slide would say that based on the recommendations for the AAP and for neonatology is that as long as the baby is well and the mother has no signs of sepsis or choreo, you don't need to give antibiotics for children that don't have an open abdomen. So this obviously ruptured on phallosyl, gastroschisis, those are a different ballgame. Those children basically have an open abdomen and you probably should give them antibiotics. But, you know, children that have even duodenal atresia, they probably don't need antibiotics if they're going to the operating room within the next 24 to 48 hours. What do you do with patients that you don't bring to the operating room with them phallosyls that you just paint and wait? We just paint and wait. No antibiotics. As long as the mom didn't have choreo, as long as the baby doesn't have a fever, we just paint and wait. Great. The problem is that in our facility, at least, the neonatology folks will probably start antibiotics on them. And I don't know what the role of measuring inflammatory markers are in that situation either. So especially in a post-op baby, they measure inflammatory markers like CRP or now procalcitonin. And because they're elevated, they will go ahead and start empiric antibiotic therapy on them. What should we do on that? Well, I guess, you know, you take a baby to the operating room, their inflammatory markers are going to go up. And I don't know, you know, perhaps we should base this on data. And, you know, maybe we need a randomized trial to look at how actually these inflammatory markers are, you know, what effect they have on the use of antibiotics or on whether or not we need antibiotics. That's a great idea for a study. Well, just a comment about we've got the AAP telling us to cut back on our opioids. And it sounds like the surgeons are telling neonatologists they need to cut back on antibiotics. How does the AAP help us with that? That's a great question. I think antibiotic stewardship is something that's coming up. It's one of those hot topics, which is why the PDC felt that it was important enough to bring to the fore. I think that we've discussed it at previous occasions when we had a combined neonatology pediatric surgery conference at the AAP. Perhaps it should be brought up again. Is this unique to the neonatologists in particular? Because I know in my place there are loud pediatrician advocates for antibiotic stewardship and their whole programs and committees and all that. Is this something unique to the NICU? I would say at our institution, we have loud advocates on both sides from surgery and our pediatric colleagues. And they are actually helping lead the cause of actually accusing us of giving too much antibiotics as well for patients with tracheosophageal fistulas, gastroschisis, and so forth. And I think the best pathway for that is really multidisciplinary conferences and pathways that we've developed. So that's what we've developed at our institutions for abdominal wall defects and so forth and addresses those issues. So nobody, we keep each other in line for that. But I think they are our most powerful advocates is to get everybody on the same page. Yeah, I think that's a great point to engage your colleagues in the pediatricians and the NICU and the PICU and try to come up with protocols and pathways to really streamline things. And have adherence to those pathways. This one was a practice gap, again, that we felt from the PDC to bring up. We discussed it at the APSA meeting this year. So the vignette is that of a nine-month-old boy who presents to the emergency room with a history of being lethargic, has a temperature of 39.8 degrees centigrade, so is febrile, is tachycardic at 180, has a systolic blood pressure of 60, so is somewhat hypotensive, with warm extremities. During the course of that ED visit, he gets intubated and receives a total of 60 cc's of normal saline boluses, 60 cc's per kilo, over 320 cc per kilo boluses. His hemoglobin on evaluation was 12 grams per deciliter. So at this point, you note that he continues to have a systolic blood pressure in the 60s, despite those boluses. And you did administer broad-spectrum antibiotics during this first hour that this child was in the ED. So according to the sepsis guidelines from the Surviving Sepsis Campaign, the next best step is to start an epinephrine infusion. And what they say in their guidelines, which first came up in 2004, modified in 2008, just think of it as it comes with every Olympics. The last time it was modified was in 2016. The latest pediatric guidelines are 2012, and they talk about the importance of fluid bolus. So one, recognize that this is a child who may have sepsis. Two, initiate fluid management. Three, initiate broad-spectrum antibiotics. Four, if they are still hypotensive despite the fluid boluses, at that point, you must consider initiating vasopressors. The question then is, which vasopressor should you use? And in adults, it's actually norepinephrine is the vasopressor of choice. For children, for the longest time, dopamine used to be our fallback for when we wanted to use a vasopressor. There are two randomized trials that have been recently concluded, which showed that when you compare dopamine with epinephrine, which was the comparison, actually mortality was better in one of the studies for those who were randomized to epi. And in the other study, epi had a better improvement or more rapid and sustained improvement in the systolic blood pressure compared to dopamine. So epinephrine is probably of the choices. Epinephrine would be the treatment of choice. Others would say, what about vasopressin? There's some good adult data to suggest that the use of vasopressin or vasopressin-like drugs can be very efficacious in increasing their blood pressure. In pediatric trials, they've just been too few and not randomized. Therefore, the data is not there yet. So we have to stay tuned for that. The next final question is, what is the role of hydrocortisone? And so, in fact, in the surviving sepsis campaign, there is a role for hydrocortisone, and that is for patients who are vasopressor refractory, meaning you started vasopressors and their systolic blood pressure remains low. The next algorithmic step is to consider hydrocortisone for vasopressor recalcitrant blood pressure issues. Okay. We also have a question from the audience for Dr. Barley. There was a question about for duodenal atresia specifically, starting preoperative antibiotics. They would do that because of the risk for bacterial translocation. So they were wondering why you wouldn't give preoperative antibiotics for duodenal atresia. So the reason that we would not is because we would take the child to the operating room on a fairly, not, I don't want to say urgent, but on an expeditious basis. So babies with duodenal atresia at our institution go to the OR the next morning or as soon as their echo is done. And I guess that would depend upon how long they think it's going to be before they can get the child to the operating room. So again, this just goes up to showing what the pediatric sepsis guidelines are, which were from 2012. You give 20 cc per kilo boluses of isotonic fluid, in this case saline, or you can give colloid if you choose to do so, like albumin, up to 60 ml per kilo. Your goal is perfusion improvement. So with this, at 40 cc per kilo, if you're seeing perfusion improvement, you don't have to give the third bolus. Your goal is to see perfusion improvement. You stop if you're seeing over-perfusion. For example, patients develop RALs on auscultation or their liver gets large and enlarged. You must start antibiotics. There's data to show, in adults especially, that if you wait over three hours to start antibiotics in a patient who's septic, and these are all empiric antibiotics, that your survival goes down. So you must do that. If their hematocrit or hemoglobin is less than 10, then a transfusion may be indicated in this particular scenario because of their actively being septic. There's no role for activated protein C in this situation. So, again, sepsis guidelines recognize flow fluids, antibiotics, and vasopressors if needed, all within the first hour. The question from Dr. Harmon was, is there recommendations on which antibiotics? The recommendation is broad spectrum. So you want to cover pretty much everything. Something like an extended-spectrum penicillin, like pipericillin-tazobactam, or ampicillin-celbactam. Something which is, again, very broad spectrum. You want to cover everything. It's empiric, so you want to cover everything. And if you're concerned about fungal infection, throw that in as well. So broad spectrum antimicrobial therapy. And in terms of cultures, I know in the adult world we say try to get them before we start antibiotics, but don't delay starting the antibiotics if you're waiting for the call. That's a great question, and that's a great point. The revised guidelines in adults came out last year, 2016, and, in fact, emphasized that you draw blood. And you draw blood for a few things. One, to check a lactate level. Two, to send cultures just prior to starting the antibiotics. You don't wait, but you want to send those cultures as soon as possible. Because that led everybody in the previous sepsis campaigns, it led to patients being on antibiotics, broad spectrum antibiotics, for a very prolonged period of time. And so what came up as a subsequent recommendation was antibiotic stewardship, as Dr. Byerly mentioned in her previous discussion. That you follow those cultures and titrate those antibiotics down or stop them altogether if in three or four days patients have improved and it's no longer an infectious issue. Thank you. Salim, I think one more thing that you might want to talk about or you may want to mention is surviving sepsis as source control. So where does that fall in on the surviving sepsis campaign? So the adult surviving sepsis campaign, which was revised, talks about managing infection, managing resuscitation, using ventilation where required, and then finally system improvement. When you talk about the manage infection part, antibiotics is just one thing. Source control is key. So if you have an abscess, if you have somebody who has perforated appendicitis or something of that nature, source control is key. And as the third part of manage infection, they introduced antibiotic stewardship as part of the whole deal. In fact, the odds ratio in one study for not starting antibiotics within three hours in children was a 3.92 odds ratio of dying. Almost four times likely to die. And then same thing in manage resuscitation, fluids, you have a target, mean arterial pressure target, and the use of vasopressors. So these steps have been shown to clearly reduce mortality in patients with sepsis. And then, of course, now we have to deal with when they've survived sepsis, which now a lot more are, what are the consequences of that? And now there's more discussion on the consequences of sepsis. Perfect. Can I ask one more thing? So, Salim, can you discuss or give us a little bit of an idea of where ECMO falls in on this surviving sepsis issue? That's a great question. And so, as you keep going down that pathway, so in patients who have not responded to vasopressors, they're still hypotensive. You start hydrocortisone, you give them a bolus, and they still are hypotensive at that point. Warm or cold, you know, irrespective, they're still hypotensive at that point. Three things have been brought up as adjuncts. One is extracorporeal life support, or ECMO. One is the use of renal replacement therapy. And three, the use of plasmapheresis as an adjunct in this situation. Of the three, the one that's been studied the most and is still in use is extracorporeal life support. And it's not formally mentioned in the sepsis guidelines, but it certainly is there as an adjunct so that in institutions where you have the ability to use ECMO or extracorporeal life support, that in those patients who are still not responding, to initiate and consider ECMO in that situation. The survival for patients who went on ECMO with severe sepsis with recalcitrant hypotension is about 46% overall, when you look at it as all comers, which is better than zero. All right. So we're going to now move on to Dr. Lee, who's going to talk to us about trauma. Great. Thank you. Thank you. Dr. Lee, who's going to talk to us about the best of the patients that are in the hospital lab shows a hemoglobin of 11 milligrams per deciliter. And our examination is otherwise normal, except that he has a seatbelt sign across his chest and abdomen. And abdominal exam shows no evidence of peritonitis. He does get a CT scan. And the CT scan shows a grade 4 splenic injury with moderate free fluid and a contrast blush. In the emergency department, he was given a 20 ml per kilogram of normal saline bolus. And his repeat vital signs show a heart rate of 110, blood pressure of 120 over 60, and same respiratory rate of 16. So the question we have is, the best next step in management for this patient is emission and A, observation, B, bolus with an additional 20 ml per kilo of normal saline, C, transfuse 10 ml per kilo of packed red blood cells, D, selective angioembolization, or E, exploratory laparotomy. And while people are waiting just to repeat the case, any comments about this before? Now, this is an example of the same with the opioids. Those of you who are loyalists to this event and have been coming every year, you know that we did this with Dr. Notrica. This is one that's important enough to hit on again. So I'm glad that we're presenting this again. Hopefully, we learned some things from Dr. Notrica. And the correct answer here would be observation. So here are the updated APSA blunt liver spleen injury guidelines. This was presented at the APSA annual meeting. Lots of work went into this by the trauma committee of APSA. And as you know, David Notrica, as well as the rest of the atomic group, was instrumental in developing these guidelines. So as shown for admission, basically the bottom line for this, which is what I learned at this meeting, was we really want to treat on patients' hemodynamic status. And as they stated before, is the patient bleeding or have recently bled or is the patient stable? And there are different ways to determine that. And they used a shock index, which was modified for pediatrics, as one way. And that's basically the heart rate over the systolic blood pressure. And based on age, you can determine whether that patient is, you think, maybe still bleeding. And in those instances, then we would recommend an ICU admission. Otherwise, if patients have responded to the normal saline bolus and remain hemodynamically stable, then those patients just need to be observed. Okay. So that's probably the biggest key. It's not really based on grade book. I know that that's been or the grade of the injury. I think that's been shown multiple times in prospective studies. So that's one key point. As you can see under the admission parameters, if the patient's admitted to the ward, then they would need really just another hemoglobin check in six hours. They're able to have a regular diet. And there's really no activity restrictions for them. You don't want them jumping up and down on the bed, but they really don't need any additional activity restrictions. Interesting that angioembolization was one of the things people have shown or have chosen as one of the answers. And what's shown for the procedures portion is, again, only transfuse if patients are unstable or, again, that critical threshold of a hemoglobin less than seven. If there are signs of ongoing bleeding, then, again, you would want to transfuse. Angioembolization in stable patients does not need to be done, even with a contrast blush, particularly in patients with splenic injuries. Those have shown that they do not continue to bleed. But if there's evidence of ongoing bleeding, then that's when the angioembolization should be performed. And obviously, we know for any patients who have continued bleeding, then you need to proceed to the operating room. Questions? Yeah, we've got a lot. I mean, I do. So I want to make sure I review this because the big thing that I learned last year or two years ago was that I was always giving two boluses of fluid. I would give fluid. If it didn't work, I'd give another bolus of fluid. Now it's give blood early. Give blood after your first bolus. Correct. Is that right? Correct. So after your first 20 ml per kilo of normal saline bolus, then if a patient still requires any additional fluids, then give blood. Okay. And that's a great point. Some people define boluses different. Some are 10 cc per kilo, 20 cc per kilo. We're saying a 20 cc per kilo bolus of fluid if they're still hemodynamically unstable. So, you know, whatever that might be, whether that's 125 or whatever number we choose, if it's still seeming like they are symptomatic, you would give blood at that point. That's correct. Okay. And you would give 10 cc per kilo of blood. Correct. Okay. Other big things to sort of repeat here. If you look, again, I want to highlight things you talked about. Again, this should be available for people to download if you want these, I think. Right, Jay? Because this is a good thing, a good slide. So the activity. You'll notice that there's no activity restrictions. Big change from when we were using the gradebook before. Yes and no. I think the original guidelines actually did not address activity restrictions. Well, I guess for in-house bed rest. That was not originally addressed. Some people interpreted it to be, but it really wasn't. Yeah. So, but basically that's correct. So now I think the recommendations is if they're admitted to the floor or the ward, then they do not need any activity restrictions. They can go to the bathroom. They can walk around and all those other things. Anyone doing angioembolization ever at their institution? No? Okay. So that was a change at, because we practice at multiple institutions. And one of our institutions is with a predominantly adult trauma base. And that was one of the things that they would do in 15, 16-year-old kids was angioembolization for contrast. But now we're really putting the brakes on that. Okay. Also, you don't have to blush on CT. You don't have to do anything about that. Again, not unless they have evidence of bleeding. If they do have evidence of bleeding, that's when angioembolization would be indicated. Okay. And this is a little bit tangentially related, but there's a paper released a couple months ago that was looking at non-invasive monitoring of hemoglobin, where essentially where like a pulse ox-like device that is able to give a pretty decent estimation of hemoglobin, at least in terms of trends. Have you had any experience with that yourself? We have not had any experience with that, but that would be very interesting because some would advocate that you probably don't even need to monitor the hemoglobin, and your physical exam is probably a better indicator as far as capillary refill and other indications, heart rate, particularly for hemodynamic status. The question is, curious how many in the audience in a hemodynamically stable patient with a great force plenic laceration with active blush and hemoperitoneum, who goes to the floor on admission based on this protocol, would order a regular diet immediately? Want to address that? Well, I think based on the guidelines, that's what is recommended. Obviously, guidelines are meant for assisting, and every patient will be treated based on the clinician's experience and expertise. But I would personally, particularly in splenic injuries, if they've stopped bleeding, meaning they responded to the normal saline bolus, then I would advocate to advance to a regular diet. I think that whoever, I don't know who you are, PBHIII, but I'm curious where you're from, so let us know. I think I love the way you actually phrased that question, because you put it into real-life situation, and it made me think, because I'm thinking I follow these guidelines. But you're right. I'd feel a little uneasy, even though I probably, I might delay the diet just a little bit. But I think grade four, yes. Blush. Is there anyone here that would be afraid to admit to the floor with a blush? You guys would all admit to the floor with a blush. You would not? In my program, we wouldn't have, but I'm learning, too. Yeah, okay. So the way I interpreted the question was that the patient had a significant injury, has a blush, so that takes some time. During that time, your patient's being resuscitated, getting to the floor. And so, in my mind, that could be a four- to six-hour process. So by that time, you have a chance to evaluate if the patient's stable or not. And four- to six hours later, if the patient's stable, then starting a regular diet is not unreasonable. It's also not unreasonable to either keep him or her NPO for a few hours or start some clear liquids. The point is that a regular diet can be started if you feel the patient's comfortable. Okay. Great point. Dan? I guess from my perspective, the question is, what is the risk of starting a regular diet? And how many times do you, if it's because you're worried that the patient's then going to go have anesthesia and they should have an empty stomach, first of all, they probably don't have an empty stomach to start with. And second of all, in my career, I think I've taken out two spleens for trauma, and I probably shouldn't have taken out one of them. So the risk that you're actually going to go to the operating room is really very low. So if that's the rationale for not starting a diet, then I think you can probably be pretty confident in starting a diet. If the patient doesn't tolerate, you're not going to force them to eat. But putting them on a diet is probably not unreasonable. Okay. Yeah. To what Dan said, I think all of us know that what we order and what actually happens are completely not, they're not connected, right? You can order the kid a regular diet, but if they don't feel well, and if they have a bad hemoperitoneum and an ileus, they're probably not going to eat it. Yeah. So. That's a great point, actually. I hate disagreeing with my boss, but I'm fired. I say, what's the hurry? I totally hear you. And even if there was an issue, it's not that you would go to the operating room. You might give more blood or something. You would not have to rush them right then to the operating room. However, I don't see the hurry in just waiting a few more hours. But, yeah, but I agree. They're probably not going to be starving after. I mean, if they're that sick, they're not going to have a Big Mac and an order of fries. Right, right, right. Yeah. You hope so. Okay. Go ahead. I have a couple questions from the audience. So I know when they're talking about operative intervention, an indication is unstable vitals despite packed red blood cell transfusions. But their question is, how many are you giving? So based on the atomic protocol, 40 mLs per kilogram of packed red blood cells. So once you reach that threshold, you really should be going to the operating room. That's a great question. That's a great question. Great question. Great point. Just to say that again, 40 cc's per kilo. Now, is it when you hit 40 cc's per kilo or is it if you need more than 40 cc's per kilo? When you need more than 40 cc's. So it's greater than, not equal. Right. So if you need more than 40, it's time to go to the operating room. Or some places would do angioembolization. Correct. Okay. And then I know we talked about grade plus two for restriction of activity. Would this apply even for contact sports? So if somebody plays football, you let them go play football in a few weeks after injury? Correct. Okay. Yeah. So Steve, Witt had a question. Can you tell us, so give us a background on Atomic. What hospitals the Atomic stands for? I know it's not all of them because I know we don't have a letter on that. Right. But so what is Atomic in general? You might not know all that, but what is the gist? So Atomic was started in 2010, and it was a group of level one pediatric trauma centers coming together to really study the vital questions for trauma in a prospective fashion. Atomic, I believe, is Arkansas, Texas, Oklahoma, Memphis, and I is, or A is another A. Arizona. Arizona. Africa was part of it too. And so, and now it's expanded even to more, I believe, Akron. I think Kansas City is part of it. And so they really came up with initially a set of guidelines for management of blunt and spleen injuries, isolated injuries. And then they went ahead and prospectively studied it. They've come up with a number of publications based on that. And that really kind of redefined the guidelines that were adopted by APSA this past year. Yeah. And just to make a comment about that in general, we need to do more of these. Yes. Congratulations to that team for finally putting a bunch of hospitals together to collect real data. We need to do more of that. The Midwest Pediatric Surgical Consortium does something very similar. This needs to be the trend over the next 10 years that we need more consortiums popping up because I know that some of them can only have a certain number. But this is the way we're going to get answers to our questions. Any other questions? So go ahead. The transfusion, the 40 cc per kilo target. At what point also are you going to be doing the massive transfusion protocol? So like the one-to-one-to-one ratio? That's a great question. I think that goes back to the original question. If you think the patient is still bleeding, then there's not great evidence in the pediatric literature for the one-to-one-to-one. There's mixed results with that. But if the patient is certainly still bleeding and unstable, that's when you would want to think about activating the massive transfusion protocol. Great. Great question. So we are going to be bringing in a new guest faculty here, Dr. Mira Kodagal, who is at Cincinnati Children's. And she is going to be working with the PDC. She's going to give a topic that the PDC had, which was cervical spine clearance. And she's going to be giving that presentation. And then we'll have some interaction with everyone here at the PDC on their comments and beat up Mira and tell her she had it all wrong or whatever. Perfect. All right. So, Mira. All right. So we are going to talk about cervical spine clearance. We'll start with the case because I think that's a nice way to get everybody thinking about things. So the patient is a two-year-old male who was the restrained passenger in an MVC. It was a high-speed motor vehicle crash going about 60 miles an hour. There was significant intrusion into the passenger side of the vehicle, but the driver was also severely injured. And you see this patient when they present to the trauma bay. They are crying loudly and moving all four extremities. The heart rate is 120. Blood pressure is 98 over 65 with SATs of 97% on room air. There's some bruising on the abdomen and the forehead, but no other obvious injuries that you can tell on initial primary survey. Okay. They are in a C collar, which was placed by EMS in the field. So the question to start with is, what would you do next? And we have a poll. This patient has no distracting injuries? Has no distracting injuries that you're, you can't, I mean, it's two, so a little bit more challenging to know whether or not he has abdominal pain because he does have bruising of the abdomen. Okay. And some bruising of his forehead. So hard to know kind of from a pain standpoint. Okay. But has some evidence, obviously, of being in a significant mechanism, blunt trauma. But otherwise, yes, no distracting injuries. Okay. Neurologically, relatively normal. You would say GCS 15. Moving all extremities spontaneously. I didn't give you all the things for GCS, but let's say that the patient's GCS 15. Okay. So while we're waiting, so just so you know, there's a 60 second delay. They see you 60 seconds after you give your, so we'll wait a little bit. What would you all do? So if you think that the kid doesn't really have any distracting injuries and you can clinically clear them in the trauma bay, clinically clear them in the trauma bay. What's the answer? So I don't know that there's necessarily a right answer, which is part of the fun of this question. I asked you if I could pick a question that didn't have a right answer. So I think there's a couple options for things that are appropriate. I think I tried to make the patient seem like they were screaming and not consolable. At least in the bay, because I think it is sometimes hard to clear them in the bay, particularly when there's a lot of activity in there too, and they're, you know, agitated, hard to figure out whether your clinical exam is reliable or not reliable. So I think a lot of times people would leave it in place and re-examine later, and you should be able to clinically clear that patient. I think for some patients, particularly when they have a high mechanism injury and you're concerned about whether or not they have, you know, intracranial findings or abdominal findings, some people might get plain films before they remove the collar. But I think any of those are appropriate. Obviously, in a neurologically normal kid, you don't need to jump to an MR. So I have a question. So in a two-year-old, their most likely injury is going to be ligamentous. That's correct. And what use are plain films without any point tenderness or anything else? What are the purpose of your plain films and how would that change your man? If you think the kid has tenderness, you'd leave the collar on, probably get an MRI, consult neurosurgery. Yeah, the data suggests that, you know, about 50% of the injuries in that age group under eight, right, are bony and about 50% are ligamentous or, you know, spinal cord injury without radiologic abnormality. So I guess there's some chance that they could have a bony injury, especially if you think you can't get a clear exam. If you can get a clear exam, there's no reason that you need to get films. Do you have any other comments about what's been said so far? No, I think just to emphasize the point, if you can clinically clear the patient, that would be the best way to do it. This is a particularly difficult age group, but in older children particularly, the mechanism of injury should not play a role in that. But in this age group, there may be, in the younger patients, particularly those that were suspected non-intentional trauma, have a higher risk of cervical injury. So those are the ones that you may want to image more, but in a motor vehicle collision in older children like this, you can clear clinically. Steve, go ahead. Can I ask a question? We standardly include a C-spine film as part of our skeletal survey in children where you're concerned about non-excelital trauma. Do you do that? Do you think that's necessary? Do you think that's overkill? I think that would be great. Yeah. So I just want to hear that again. In a suspected NAT. When we get a skeletal survey. We changed that name, by the way. The name is now Child Abuse. It's not NAT anymore. Right? Explain that again real quick. Who said that? It's like the CDC. They have, I guess, in the past year or so, transitioned back over to calling it Child Abuse. Institutionally, it's still going to vary place to place, but nationally, CDC calls it Child Abuse now. Interesting. If you look at the APSA position statement that was just released, they'll call it Child Abuse, and you can see what APSA recommends for its management as well. Okay. And that can be found on the APSA website? And on our app and social media. And on the state current app. And last month's edition of JPS. Okay. So no, just that those kids you think have concern for child abuse or non-accidental trauma, whatever you want to call it, need a skeletal survey as part of their evaluation. In addition to, oftentimes we get belly labs if we're concerned about abdominal trauma as part of screening. But as part of that skeletal survey, you need at least a single view of the cervical spine. So I want, I need help. Tell me how you clear your babies. What do you do? You take off the collar. So a lot of times people do just active motion. So watching them, seeing if they seem to splint. I think you don't want to necessarily like force them one direction or another because you, if they're not comfortable doing that, you may cause them an injury. So a lot of times we will just take off the collar and observe them and see if they see like they're uncomfortable. We do, you know, palpate obviously along the midline, looking for tenderness and some response, but it's a little bit challenging. We do the same thing. Okay. Take off the collar and watch. Maybe feel their C-spines. Probably there's, there's more evidence to go towards a risk-based kind of algorithm, which I think you're going to probably talk about. So I'll say that. Okay. Thank you very much. Okay. So we're going to just talk very briefly, obviously. Oh, sorry. I was just going to say at our institution, the neurosurgeons are very bought into pediatric trauma and they, we actually have a protocol. Any child three and under gets cleared by the neurosurgeons. Interesting. Wow. Does anyone else have a policy like that? Okay. We do not. Okay. But I do think, and we'll come back to this, but one of the biggest points I think in thinking about cervical spine clearance is you need a protocol. You need some guideline that your institution follows. There was a recent study done by the, it's an orthopedic group that looks at pediatric spine injury and they found that 46% of places don't have a protocol for cervical spine clearance in children. So you need some sort of pathway and you can decide based on, and the evidence gives you lots of options for how to proceed, but you need some sort of pathway. So since we don't have a poll for that, let me just ask people to put in the chat, do you have a cervical spine clearance protocol at your hospital? Go ahead, Mira. Okay. So cervical spine injury is not super common, obviously in kids. It's about one to 2% of all pediatric traumas. In older children, like we were just sort of talking about, they tend to follow adult patterns. They had 70 to 80% of those injuries are bony injuries. Whereas in younger children, like Dr. Wilkin mentioned, they're more likely to have ligamentous injuries. So about 50% of kids less than or equal to eight will have isolated fractures, but 50% will have ligamentous injury, dislocations, or spinal cord injury without radiologic abnormality or scuora, which is obviously a fun word to say. But 60 to 80% of vertebral injuries in kids will be in their cervical spine compared to in adults where you're more likely to see thoracic and lumbar injuries. So 30 to 40% of vertebral injuries in adults will be in the C-spine. So much higher rate of cervical spine injury amongst the vertebral injuries, although they're not that common. And then, like I mentioned, greater concern for ligamentous injury in children. So I guess before we go there, let me just mention, obviously everyone knows sort of nexus criteria and the Canadian cervical spine criteria that were established in the late 1990s, early 2000s. And a lot of people still use those. And in older children, they're a totally reasonable way to think about how you clear older children. But like we've discussed, it's the younger kids that are the most challenging, and particularly those kids sort of less than three. So the AAST actually did a study to try to understand what are the things that are predictors of cervical spine injury and how can we think about clinical clearance in that younger population? So kids younger than three. They looked at over 12,000 kids who'd undergone blunt trauma and looked for rates of cervical spine injury. And I think they found 87. It's a pretty low percentage. 0.6% of kids had some sort of cervical spine injury. And when they looked at them, there were four independent predictors. GCS less than 14, a GCI of one. They were involved in a motor vehicle crash. So they actually included mechanism for those younger kids. And then whether or not they were greater or equal to two years. And they gave points for each of those. And if you add up the points that you get when you assess your patient, patients who had zero to one points had a negative predictive value for having a C-spine injury of over 99%. So those kids did not need imaging by their recommendations. Those within two to four points need some clinician discretion. And then obviously, the more points you have, five to eight, they recommend that you get some imaging. And I think it's worth noting there were five patients that had a cervical spine injury score less than two, but actually had injury. But those patients had concurrent significant traumatic injuries. So facial fractures, skull fracture, long bone fractures, and loss of consciousness. And then the other thing, neck pain and splinting, which makes sense, right? We would not clinically clear patients who seem like they're in pain or have splinting. And so those patients need some imaging and would automatically sort of fall out of the no imaging category. Really quickly on the imaging, we have a question from the audience asking which single view x-ray should you get for the C-spine? Should it be AP or lateral? So when we do it for a skeletal, we include a lateral. That's the view that's in the skeletal survey. Obviously, if you're using imaging because you think you need it to clear for a cervical spine, you need two views at least. So you need an AP and lateral. But as part of our routine skeletal survey where you have a low suspicion for cervical spine injury, but you think you're doing it to reel out child abuse or non-accidental trauma, we use a lateral as our single view. And just to be clear, if people want, a lot of people are writing no, that they don't have a C-spine protocol. Where can they get this? Yes. So, I mean, we can obviously share. Jay, what would you want to share? There's a slide. Right after the question slide, there's the protocols that include our protocols, which we're happy to share with people, for both patients with a reliable exam and patients with an unreliable exam. Jay, no hurry. We can do this. At some point, we will put that C-spine protocol, make it available. You should also be able to go to trauma.pem.com. I can never get it in the right order. Well, it's on our app. So that one's easier for me. Perfect. It's on the Stay Current app. You can also go. There's a trauma website for all of the Cincinnati Children's Trauma Protocols. And I will remember what it is and tell you. I think it's trauma.com. Yeah, exactly. PennCinternatty.com. This is going to be a plug. So because of this, the app, for those of you who don't know, there's an app. We'll give you information that has all of these guidelines. You go to the guidelines section, and all the guidelines are in there that you can download, share, what have you. So we'll help give you the link to that later. Yeah, absolutely. We're happy to share them. It's in the App Store and the Google Play Store. Stay Current Pediatric Surgery. Stay Current in Pediatric Surgery. Okay. So the only other thing that I really wanted to show, and this is from Canada. So shortly in 2011, shortly after that AAST study was published, the Canadian Pediatric Surgery Group got together and basically did develop some national consensus guidelines for their recommendations on clearance. And so this is another place if you want an example of a guideline for how to think about clearing patients. They have guidelines for both reliable and unreliable patients. It's obviously very hard to see that on the slide because they're pretty small. But the guy, and they basically walk you through that process of, does the patient have an abnormal neurologic exam? If they do, you obviously can't clinically clear them. Those patients need an MRI if they have an abnormal neurological exam. If they are reliable on exam and they have a normal exam, you can walk through clinically clearing them. If you are unable to do that because they seem like they're in pain, they have tenderness, you know, any of the other findings that you might go down, you can either move towards x-rays or in the rare instance CT. We obviously don't do CTs that commonly in kids for cervical spine injury because they're not deemed to be necessary and most of their injuries are not going to be bony. They're going to be ligamentous. And so we move more towards MRI if you think you need cross-sectional imaging. So we can share these with people. But I think that's, in the unreliable patient, you a lot of times can come back and re-examine those patients. So you leave them in a collar. You wait until they calm down or the anxiety passes or their, you know, pain's under control or any of those pieces. And then you may be able to actually examine them and clinically clear them at that point. That was awesome. Awesome. I still think, you know, this is unfortunately quite still a bit of variability at different institutions. Absolutely. And I think the biggest recommendation is develop, you know, use the existing pathways that are out there, whether that's, you know, from this Canadian paper or from the AAST or from, you know, institutions that have them and develop a guideline that people follow because that allows you to be more consistent and standardized in your approach to examining these kids. And the particular challenge are these really young kids, the three and under children. And by the way, if there's anything that we talked about today, just email me, tponski at gmail, and I can get you and connect you with the faculty here if you have a specific question for them or we can send you the guidelines or get you what you need. We really want this stuff dispersed. So if you didn't get it here, email me and I will get it for you. And these, I just put up there, Todd, this is the one I was referring to. So these are the Cincinnati Children's ones. There are obviously lots of other guidelines and options. This is just ours, but, you know, you can use many institutions, and we're happy to share them with you if people want to use them. I'd just like to put in a plug. APSA on their website has an area where they are making protocols and guidelines publicly available. So if you have a good protocol, please send it to APSA so they can put it on the website so it can be shared with others. Now, I have a few questions. Does someone vet those? What if it's a junkie protocol? Number two is how do they send it to APSA? And number three, where do they live? So I think, is it Megan Comerford? I don't know what email they should send. We have to figure out. So the one we used last year is think at eAPSA.org. Can you write that in there? And this is if they have something to submit to APSA, or is that a... To the PDC and for the review of it. So I guess I would send it to David Powell and then have him forward it to whomever it needs to be forwarded to. But they are trying to take... They want institutions to share their pathways that they've created for DVT prophylaxis, for sepsis, for cervical spine clearance. Because there are so many institutions that are interested in developing pathways and developing protocols. So if you have some that are available to you to review and to look at to help you and your organization make your protocols and make your pathways, that's the purpose of that. So I don't think that they're, quote, vetted by experts. I think it's put out there and then it's up to you to decide if you like it or you don't like it. I love that. And so, again, we're going to try to provide you as many resources as we can throughout the day to get you access to what is current. Okay. Okay. Awesome. Thank you, Mira. All right. So we'll switch gears to pylon idle. We have a 17-year-old young lady who presents with a history of pylon idle disease. On history, we find out that she's had two previous abscess drainages, both INDs and the emergency department, within the past six months. And her exam shows this picture, as you can see. The question we have is, what is the most appropriate management for this patient? Laser hair removal, minimal pit excision, unroofing and marsupialization, wide open excision, or excision with flap closure? Laser hair removal, no longer. So what do you guys do? We, well, that's interesting. So as this comes in. So currently, we are about to switch to, we are just switching to the minimal pit excision. At our institutions, what we've been doing is the unroofing and marsupialization. So that's what we currently have done. But there's lots of good evidence that the minimal pit excision may be the way to go. So this was presented, and this is another one that we're glad we're presenting again. Out of all of the topics that we've probably ever done with the update course, this one was the most rapidly adopted one. I think because people were looking for something different. Right. Aaron Lipscar presented something similar about the GIPS procedure. And we, I have switched, that day I switched completely to the GIPS. What about others here? Is there, I see everyone nodding their head. Really in history, it must be one of the fastest overnight changes because everyone was so eager for something better to do. The, the GIPS, and you're going to go into that, I'm assuming. Just a, yeah, just a little bit. But, and in this case, we would choose minimal pit excision. And this comes in the face that I, we were one of the authors advocating unroofing and marsupialization. So we've, we've also adopted a new technique. So based on that, on that video from the previous years. So I think the bottom line for this is really less invasive techniques are better. That's the bottom. The minute, the least you do, the better you're off. And whether that is a, a, a pit picking technique, whether it's the GIPS procedure where you excise the, the, the, the sinus tracks and then clean on underneath. Or what we used to do is unroofing marsupialization, which is a little bit more, we just unroofed the sinus cavities and cleaned it out. Whatever those are, whatever the minimal technique is, that's probably the most, that's, that's the best to do. First of all, that's the easiest to do. You can often do them in the clinic or as an outpatient basis. And then they've led to clearly improved outcomes with respect to healing times, recovery times. And most importantly, they've really decreased the, the need for additional operations and recurrence rates. So the unroofing and marsupialization, we unroof the cavity. And what we found with that is you have just a significant amount of granulation tissue. You also have a lot of hair underneath and that just really needs to be cleaned out. But the GIPS procedure or the minimal's pit excision does the same thing and does it with less invasively. That's why we're switching. What, what it is, it's the trephenes or really punch biopsies to really excise the track. And then you really core out everything underneath and clean it out. And I think that's exactly what we were accomplishing with unroofing and marsupialization, but in a less invasive technique. So we would, yes. Do you guys, one of my partners does a lot of this. He's. Nelson Rosen. Nelson Rosen. Yeah. Does all of our, most of our pilonels along with two of our other partners. And they, he does sinus endoscopy when he, so after he does the, you know, pit excision with a punch, he actually uses a cystoscope to like look in and be able to identify other things, sort of getting at your point about the hair and the granulation tissue that you can get out with marsupialization. He actually uses sinus endoscopy to try to make sure that he's completely cleaned out the cavity to allow it to best heal and not have that sort of hair still stuck behind. I think that would be, I think that just may add a little extra time and cost, but clearly as long as you clear everything out, that's probably the most important thing. I don't have experience with that, but I think that sounds like a very viable option. I don't know, does that, the surgeons in your group do that as an outpatient or in the clinic? So the sinus endoscopy, I think he only does when he's in, when he, on those kids that he takes to the OR for, for their gifts and not a, you know, a lot of them don't need to go to the OR. So for the ones that don't, I think he's just doing exactly what you're saying that with the punch biopsy, but, and then, sorry. And then using the, like using gauze or something on a hemostat to, to really try to clean out that and get most of the stuff through the gifts, through the punch site. So, I want to spend another minute or so on this to make sure everyone out there totally gets it. I'm going to repeat what you said. So, either in the office or in the OR, I always do them in the OR because I'm a wimp, you prep it out you take these trophines you have to we had to order them i mean we had to get them so they're punch biopsies and you get a pack ours are green and they have a little pack and you just core it out pull it out take a mosquito or whatever and get it some people put a scope in i found that it's just all red when i look and it's hard to see much but um and then uh lip scar taught us about using hydrogen peroxide i don't know if it really does anything but it makes us feel good when it bubbles and then um and then that's it uh is that right is that exactly how you do it that that's pretty yeah if you excise all the pits they tend to lead to a cavity and i think that's the key is with the multiple pit excisions even though they're small you can access that cavity and really clean that out i think that's the key if you leave stuff in there uh you will have a little bit of a recurrence but most of the time it's the hair coming out and you can either repeat that procedure or you can do the pit pecking pit picking technique where you just actually pluck the hairs out um and that often works as well oh so minimal things i think just for me as well i you know as we are switching over we've done our first few in the operating room just under sedation and locally i'm not required general anesthetic outpatient procedure after like one or two we're switching to the clinic so it it does depend on how invasive how um the extent of the disease but but i i would recommend if you haven't done it just do the first one or two in the operating room get the technique down so you're not fiddling around in clinic and and so forth and it is very easily uh very easy to learn and easy to adapt steve can you comment on the role if any of the use of sclerosing agents like for example phenol or or things like that in this situation uh i don't know do you have experience using that because we have not used any of those we we occasionally will use hydrogen peroxide to help clean it out but we have not used any sclerosing agents certainly been described especially phenol uh some people have filled the the pockets or the sinuses with the phenol and and that's helped in sclerosing some of that uh granulation tissue and reducing it probably is the same the the same concept of really trying to get rid of that granulation tissue we found the easiest is just to scrape it out uh and and the most minimal way is with the with the minimal pit excision or the gipps procedure so we have a couple comments but that paper there was another paper on phenol again published in this issue of jps so that's happening uh a lot internationally are people using little crystallized no because i have this crystallized phenol uh so um it's an interesting thing it scares me a little bit i don't know what kind of skin injury you may get but has anyone here used it okay um dr rosquero i'd be interested in the panels what specifically do you use to scrape out the cavity and how aggressive do you get it trying to remove the granulation tissue yeah we use we use caret to scrape it out and we're very aggressive we'll also use the gauze to to rub it and so forth initially uh it's a mosquito or any kind of clamp to really pull out all that hair in there but once all the hair is removed then you really need to scrape out all the granulation tissue that's left behind i just want to make the comment that uh you started off sort of with what's the right procedure and we've now had a dozen variations in our discussion about what's the right procedure somewhere along the line somebody needs to like show a video of the perfect operation because every every one of us have said well i add this or i do that so uh we're a great topic todd yeah um i think i'm going to disagree well i think that for the most part we're all the big thing is that it's minimal surgery that's the agreed upon thing it's not the big wax we used to do these huge it's the minimal less is more yes there's variations we'll probably get to the bottom of that and beat it to death like appendicitis but right now at least it's minimal procedure yes um so question from the audience they noticed that the skin closes faster than the cavity and pit excisions and asked do you have any maneuvers to keep the skin open so that it granulates from within good question that's a that's a great question um i don't have any tips for that that's why we did the unroofing and marsupialization because we wanted to heal from the inside out and we left the skin incision bigger the downside to that was the time for healing was roughly four to six weeks for complete healing i think the key aspect um for this is one is during the time this heals is make sure that you continue to keep the area free of hair we've we shave once a week we have them come back with one week follow-up if they start to close too early you often will see some granulation and in the clinic you can you can kind of reopen that up and silver nitrate that around the side to keep the the incisions open that's what we've done okay any other tips from and anyone else who has no um i've always wondered that exact same thing about should we put a vessel loop in uh to keep the hole open i haven't had a problem we've tried that to to that point of keeping loops or or a drain in place for that and that just caused a lot more pain and seemed to develop more granulation tissue along the track so we've stopped doing that i think if you clean out the cavity well enough and you have enough drainage points it'll heal fine mira did you have a question for kasar so alex do you want to comment on the the pilonidal study that you're starting to work on with the midwest pediatrics consortium uh so we are actually about to start our recruitment for a multi-center study the cohort study of pilonidal disease with the midwest pediatric surgical consortium and we will be doing pretty much any largely invasive procedure compared to minimally invasive procedures sort of trying to standardize the gibbs and medical management that's also with standardized recommendations uh we're doing everything surgeon choice and the reason for this is so many pediatric surgeons are unwilling to randomize their patients right now because they are very very supportive of one technique over another i was very surprised to hear that half of the hospitals or in half of the surgeons in the consortium had never done a gibbs or never seen a gibbs so part of this project is actually going to be education and implementation of minimally invasive techniques uh and another one there's going to be an overlap with a study that's the nationwide is conducting for the laser hair removal and their their data is looking really good so what outcomes are you going to be looking at alex like what are you going to be following these patients uh so our primary outcome is going to be recurrence or i guess non-recurrence uh at one year and we just got funded for that by app so this this may congratulations uh but the other outcomes that we're going to be doing are time to healing uh quality of life uh we're doing cost uh we're doing use of antibiotics uh narcotics days of pain uh days where kids are not able to perform activities return to school return to sports uh so we're going to try to do a good analysis on just patient-centered outcomes i think i'm glad you mentioned the nationwide i think i think laser it's going to be gips plus laser i think is what we're going to find is going to bring it but that will help answer max issue of the standardization problem um i think everyone can agree that at least theoretically laser should help this procedure a lot the problem is that it's not covered by insurance and patients can really just not afford it yeah uh but hopefully uh when the data from this nih or picori funded study comes back uh we'll actually have some push to get an insurance companies to cover it uh so their patients can do better okay um really quickly on to the um the skin healing faster than the pit i want someone from the audience um said rock salt works as good as silver nitrate to keep the skin open another variation what are you talking about matt we all do it the same somebody just also asked what is the role of antibiotics in uh minimally invasive palinidal sinus surgery um antibiotic stewardship personally um unless there's an abscess uh but for the for this i don't use them because you're leaving the the wounds open and they should drain so there's no need for even perioperative antibiotics for this i have a question for people doing gibbs in the audience so the initial uh gibbs technique paper uh does gibbs even in the presence of acute abscess even if that's the presentation he didn't do inds he did the gibbs cure it the same way you mean he didn't stage it he didn't stage it right so the question is would you if in the face of an abscess instead of just making a nick would you just take them at that time from the er to the or and do a gibbs procedure as your ind so go ahead so so i've done that and it depends upon how obviously if they have a lot of cellulitis if they're sick it then you're going to probably do more of a formal abscess drainage but what i've done is then use the vessel loop technique right so do your gibbs and then put a vessel loop in for the the abscess cavity to really allow it to drain better i think i think it makes complete sense that's how tony sandler does it in dc um i think it makes i don't know why not uh the question is would it have a higher failure rate if you do it in the face of infection that's the question what would hopefully you'll figure that out but um yeah i think it depends if you have to go to the operating room or not if you're doing a local drainage in the emergency department with that much inflammation and infection often you can't really get enough uh of a clean out during that time so i would just in that setting i would just drain the abscess i would also advocate draining the abscess off midline so when the cavity does that track does form it'll be off midline but those would be the things that i would do if i go to the operating room then i think you can adopt what just liz just said awesome all right any comments we're going to move on then uh thank you dr lee all right we're going to move to all right we're going to move to dr islam we'll be changing or shifting gears a bit and this topic was chosen after the recent uh apse meeting in boston in may where uh this has come up as an issue which surprisingly uh pediatric surgeons are interested in and we'll see what we mean so we'll start with the vignette so that is of a seven week old boy who presents the emergency room with a three-week history of projectile emesis weight loss and dehydration he's had three trips to the emergency room in the past few weeks and been sent home each time the ultrasound that was done this time around reveals hypertrophic pyloric stenosis um you admit him for hydration because he's severely hyperchloremic metabolic alkalotic and he has to have three days of this hydration uh before a pyloromotomy can actually be performed safely or before anesthesia will take him to the or so the question of this is common common disease common presentation which of the following factors may be playing a role in this infant's delay in presentation and result in severe dehydration for pyloric stenosis is it the fact that it's a boy that he has commercial insurance for his uh health care public insurance for the family caucasian in race because maybe he's an asian asian uh ethnicity or maybe it's because where he lives residential zip code so as you wait for it it's either it's a boy is it because of commercial insurance public insurance he's a caucasian or white uh colored race individual asian ethnicity or is because where he lives well while we're waiting can i ask you a question what did you rehydrate this patient with that's a great question actually we hydrated with normal saline sir uh no but uh space learning number of boluses before you uh number of boluses yeah the saint saint peter study uh that looked at a good algorithm that we presented a few years ago on how to know how much fluid to give um and i don't know it off the top of my head i think it's 16 17 18 is the cutoffs of the you have to look that up i don't remember the numbers for the chloride uh for the bicarb but it's basically we can find that for you we'll write it down but it's a a nice algorithm tells you exactly how much fluid to get it probably goes by how what's the percent dehydration and it calculates the amount of water or and sodium and chloride requirements yeah so what they did is they retrospectively looked back to see based on what parameters ended up correcting them and the main cutoff was chloride i believe and i think if it was like less than 88 you give three boluses before checking is less than like uh 96 and it was two boluses and like between 96 and 100 you give one bolus before you check okay so that's that's great i mean um uh you know question is why did they need that many boluses and why do others need just one bolus or none um and so the answers here on the on the um uh survey uh 23 said it's because the child may have had public insurance 11 think it's because they have commercial insurance whereas the majority thought 67 thought it was where they lived had the biggest impact so the answer is actually the fact that this child had medicaid or public insurance and the data on this this relates to and it's an example of what we call the social determinants of health or the non-disease part of it which impacts substantially on the child's outcomes and their ability to seek care as an example um there's multiple studies out there that have now shown that race and ethnicity so if you're african-american or black um and or hispanic that um you tend to have poorer outcomes disease severity for disease severity being equal when compared to caucasians in the united states yeah all these studies in the united states for now and then similarly if you look at those who had public or or limited or no insurance those also had poorer outcomes they have decreased access to care they have um and they have decreased ability to necessarily get the appropriate care that's needed and there's multiple studies so these this is just an example there's studies that have been looked at appendicitis uh they've looked at uh traumatic injuries they've looked at all kinds of different uh diseases that pediatric surgeons take care of and in fact they've all showed a strong and pervasive link between uh either black or hispanic race and outcomes as well as poverty so poverty in and of itself and so public insurance is basically a a marker for degree of poverty and so poverty has a big deal uh to explain so i think it's it's it's been shown in these studies that it increases the perioperative length of stay you need to get hydration longer a study that we did showed in fact that their chloride levels for those at medicaid tended to be about eight to ten lower than those who had commercial insurance to the pediatrician in the last month or last two three weeks they had gone the commercial insurance patients had gone to the pediatrician and been seen by a pediatrician three times more often um so they they're just many different markers for how um patients are treated differently so for years we keep publishing this right we had a paper we showed that there was disparities in appendicitis what are we have still not i am not aware of any changes we can make that will show a measurable difference in this it's a great point and i think that was the next thing to discuss is that first off is this even our lane right with a lot of talk it talks about you know hashtag stay in your lane and so on so forth is this our lane and i'd have to say convincingly yes we need to address this this is firmly within what we need to be doing and as you pointed out every single study has said there's a problem but we haven't done the next step which is what are we going to do about this problem right and what should we do about right i think that as pediatric surgeons right now what we need to do is first off and perhaps these studies have helped with this is we need to universally recognize and agree that social determinants of health matter so the first thing we need to do is we need to acknowledge that this is a problem the second thing is we need to get involved we need to get involved in advocacy so the second a would be advocacy we need to be aware of what the current efforts are on a statewide basis on federal basis on an institutional basis so the aap or the american academy of pediatrics is incredibly uh involved with all these efforts at a regional level at a district level at a state level and certainly at a federal level and they have they have tremendous advocacy outreach programs that we can link into so it behooves us to kind of get involved with that find out what's going on and how can we help in that third we need to educate we need to educate students we need to educate residents we need to educate other faculty that this is a problem we need to raise awareness so we acknowledge we advocate and we increase awareness and finally i mean this is not going to get better unless something concrete is done right and that concrete is unfortunately going to cost money it's like what allocation of resources so those allocations could be at an institutional level maybe we need to hire more social workers maybe we need to hire more discharge planning people maybe we need to fund the schools of public health so that they can actually carry out more surveys and other issues where they can pinpoint areas that we can improve things and this goes down so far down i mean so we look at uh babies who are born african american babies or black babies uh if you look at their gestational age for gestational age counterparts they do poorly so being black as a premature baby is a risk factor where does that even start right that starts even before the baby's born so it's the prenatal it's the mom it's prenatal care it's the mom who's undereducated who who can't seek prenatal care who there's poverty in that situation right so we need to this is this goes beyond what we are talking about into societal norms and how society needs to change i just can't believe that i have not seen a study you may have where someone's reporting an improvement in this like we did go ahead so um not that i'm advocating one thing but in this being an internationally yeah the broadcasted um event i'm curious to see what other countries have faced with this because we did a study a number of years ago in the kaiser system where everybody has insurance and with risk with respect to appendicitis and we clearly showed that that's uh we eliminated those disparities as far as um education um income level and race that those patients all have the similar rates of uh perforated appendicitis so that's maybe one way um obviously we're it's far off from what we can do but the starting the process and that's just one one uh disease process that we're looking at so you're absolutely right i think if you look at from a international standpoint um you know it goes well beyond that is so it brings to for the global surgery and the global need for pediatric surgery and and what do we do about that and and if you eliminate all those things like you said these disparities it's it's about poverty and lack of resources and the ability to get those resources to those who need them i think one of the things that we use a lot in in global health and in global surgery that we don't use in the u.s and in our system is really thinking about community health workers and you know are there opportunities for us to take skill you know we we have community health workers in sub-saharan africa and other places that that go door to door right that help families with adherence to medications the medication rate adherence is actually significantly higher in those settings than it is in our resource-rich settings because we use those tools and are there opportunities in disenfranchised communities in places where people have less access to use that as a kind of resource and a way to help get people into the system more in a more timely fashion with recognition at a community level well at least pakistan says they have the same problem so um it's i think it's arturo rondo said this is basically going to be everywhere yes pakistan does have the same problem i can attest to that yeah all right that was pretty provocative so um thanks for talking about that again i'm just i would love for in two years for you to present we found it we found an improvement we were able to fix the problem another plug for this is there is a lot of interest in social determinants of health at apps this year and we up we updated that podcast where we interviewed that's right the speaker and we have the full-length uh presentation available so you put the link to that podcast yeah absolutely and that was amazing what were the names of the adam voss esquire yeah it was incredible they also apps have sent out a survey actually inquiring about which apps members are interested in this kind of thing and i think they're creating a committee and it hopefully will be continued movement in this direction okay from pediatric surgeons that's awesome that's great uh it is it is a gunshot wound but it's not it's not about it's not about gunshot it's not about the gun it's about coagulation right right guns don't it's not blunt trauma so so steve is distancing himself okay uh this scenario is a 13 year old male who sustains a transmenius dental gunshot wound and in the emergency room the child's intubated bilateral chest tubes are placed and there's some significant hemorrhage occurring so they've activated the massive transfusion protocol and have decided to go to the operating room because the child is having exsanguinating hemorrhage in the emergency room they have the ability to do a tag or a thromboelostography a point of care test to measure clot formation and on that test it's been reported to you as a surgeon that the our time is prolonged the question is what is the most appropriate next step in the treatment of this patient with this tag result platelets frozen plasma transic amic acid or factor seven so tag this is known as two different it's it's known by two different terms tag or rotem and they are basically the same test it's just the machine the way the machine makes the clot is just a little bit different and it is a point of care test so in other words um it can be done well relatively rapidly without having to actually send it to the laboratory the machine is it can be available in the operating room it can be available in the emergency department and what it looks at is it looks at the clotting cascade and identifies what might be the best product to use to help with abnormal clot formation and there was a there was a really nice there it is okay so this is basically the output that you would get from a tag or rotem and the thing that's the things that are important are um basically in oh it doesn't there's not a pointer but so the the first thing you look at is the r time and that's actually the time that it takes for the clot to start forming and that depends upon your coagulation factor so if your r time is prolonged you should give fresh frozen plasma the next thing that you look at is the k time and that's actually the time until the clot reaches its its its fixed strength and this is dependent upon fibrinogen so if your k time is abnormal then you should administer cryo because that's where most of the fiber engine is is available the alpha angle is actually the speed of fibrin accumulation and it's it's related to the kinetics of the clot and again it's re it's it's dependent upon fibrinogen so cryoprecipitate can be used to help with those issues the the alpha ang or the the maximum amplitude is the highest vertical amplitude of your tag which is the maximum strength of your clot and that depends upon your platelets and not only the number of platelets but platelet function so if you have an adequate number of platelets you may want to consider giving ddavp to help with platelet function or transfused platelets as needed and then your your your l30 is actually the the time the 30 minute clot lysis so in other words the the percentage of clot lysis 30 minutes after your maximum amplitude and that is related to excess fibrinolysis so if you have issues with that you should um you should provide the patient with transex tranexamic acid or amino caproic acid there are a lot of uh institutions that are trying to institute the use of tag in the trauma situation it has been commonly fairly commonly used in cardiac surgery and liver transplant surgery and i'm interested to see how many people are trying to use this at their institution for trauma so everyone has written no that they've never heard of tag in so far no one has written yes yet um so i just like to what about what are we doing what about the audience here we do we use tag um as part of our workup for trauma and we use it obviously in the operating room for for patients who have significant coagulopathy or in the picu but yes we do use it as part of our um and we and i think it does help you be much more directed rather than you know you guys were talking earlier about sort of one-to-one kind of transfusion it allows you to be a little bit more precise about how how you're responding to what you're seeing in front of you um do you think in this case you know transex amic acid was obviously one of the options would you give both i mean we talk about transex amic acid with the crash 2 study and stuff like that as a as something that's indicated in trauma patients with significant hemorrhage would you give both or would you just start with with ffp and see how i would start with ffp um how were you able to implement or get tag implemented into you we have it at our institution with transplants but we have not been able to adapt it for trauma or uh other aspects yeah so i i and i'm gonna hedge a little bit here because i'm not entirely sure whether we actually have the ability to do rapid tag in the bay but we can send tags um to the lab and get them back we use them for ecmo obviously as part of our ecmo program and and we've integrated it because of also the cardiac ors and and the fact that they use it from perfusion but all of our ecmo patients get a tag you know at least once a day if not twice a day if they're having quite up the issues so i need this dumbed down for me a little bit so uh let's go through this again so you get the tag you order tag the tag test it comes back and how do you get like what does the result look like and do you have to have this table in front of view to the result looks like that diagram down there so how does it depends upon your laboratory some laboratories will provide you with they'll say your our time is prolonged suggest ffp they'll give you the suggestion yes it depends upon your lab we're not that fancy you need to have you need to have a table like do you just know off the top of your head or do you have to look it up in the table something it depends on how frequently i've been using it when we've had a bunch of kids on ecmo it sticks more and then but a lot of times i do have to go back to it and re-remind myself okay wait this is that but as you use it more it it seems very complicated when you look at it initially and trying to remember each of the pieces but i think as you use it more it becomes it makes sense to me that this would be a simple thing to implement to have a result that comes back like that recommended uh would be blah blah blah would probably eliminate some error of interpretation um so this was and it comes back within an hour usually or it depends upon if you have rapid tag or not okay um it can take up to three hours to come back if it's not a rapid tag um rapid tag is about less than an hour 30 minutes to an hour all right it also depends on your institution and whether or not the machines warmed up how often you're using it because i know that was something for us at my institution when we first started incorporating it um we just didn't use it very often so we had to call the lab and tell them like hey we're gonna run a tag can you warm it up but when it is live uh if you have the capacity to watch the results as they're coming in you can get three of those four like key pieces of information within 10 minutes because really the only thing you're waiting for the full half hour on is the l y 30 so you can kind of respond in real time um and there's a great resource on uh we can put it up if you google uh for like life in the fast lane tag they have a great breakdown for analyzing uh these diagrams that you see here and then a nice little mnemonic based on like whether it looks more like a wine glass or like a tumbler um for how you should be responding so and then finally we just recorded a podcast on this topic with dr adam vogel from texas children so that's going to be something that will be coming out in the next couple months for people to have on their horizon um explain to me the trans trans dynamic acid or how do you even pronounce it trans trans examic acid trans examic acid talk to me about that when i don't know when you use that yeah so there i mean i don't know i'm probably not the most up to date on answering this question but there the crash 2 study looked study trans examic acid in adults particularly and in and life-threatening hemorrhage after trauma and demonstrated that it it had a significant benefit um and so the major counter indication to it is head injury and so you you can't use it in kids in kids or adults with significant head and this is also this is txa this is txa which is how people like me pronounce it yeah okay um and this is and this also was uh greatly discussed by notrica about the use of txa in trauma um in one of the previous uh courses all right comments questions i think that physiologically this really makes a lot of sense to use but it it's been out for a while now it hasn't really caught on as much as you would think something would in this nature even for ecmo i mean there's still we still follow the activated clotting time it's just much easier which quicker and and has the same random pattern that a tag probably would have to in this situation so i don't know why is tag not just become the standard of care at this point well that's why we need courses like this it it is amazing how this type of dissemination and and the point that appsa makes that doing it at everyone's conference you know if the same topic is presented over and over again at multiple different conferences you will see what we saw with gips that it was an overnight transit just a little point the the it used to be that when the first nissen was done the first laparoscopic nissen it was 10 years until it was adopted our adoption rate has gone down to about a less than a year now because of digital because we can now disseminate things much faster you can get other people's input and opinions on things that are usually what is necessary to get it to be put into practice they might read about it but not implement it now things are happening much more rapidly so i think that within a year or two instead of 10 years we're going to see this being implemented more um yeah the question that i think dr is almost pointing to is also just utilization and how we you know that one of the advantages to act's over the tag is how rapidly you can get them back so you're standing at the bedside and you're having a hard time figuring out what to do with your ecmo patient who's having circuit issues or whatever you get that information much more quickly whereas there there is a delay to tag i think the rapid tag helps a little bit with that delay because you can get that at least especially the initial information more quickly but you have to a know how to use it and and b have the infrastructure to be able to get it as quickly as possible so that does create some obstacles i think to implementation and probably perfect i think she just hit the primary issue is infrastructure yeah good point yep okay uh all right so yeah this uh case is that of a full term 3.4 kilo infant uh who has gastroschisis uh baby's on room air uh is stable uh you're at the bedside and believe that the patient can probably tolerate a reduction and closure immediately uh you go ahead and inform the family and the nicu uh team of your decision and as you're just talking with the parents you tell the family that you can either go ahead and repair it in the or uh via what you call a standard uh suture technique with fascial closure or you can just simply attempt closure at the bedside without sutures uh utilizing the umbilical cord partially to uh close that effect so as you're talking with them and you're you're discussing the questions and issues which of the the following is correct regarding the sutureless gastroschisis closure a you have to intubate them b what by doing sutureless repair your time to full feeding is reduced you cannot do sutureless repair c if a silo has been used d complications are fairly similar to a standard repair or e there is an an increased uh length of stay when you do a sutureless repair so let's discuss while we're waiting who here uses a sutureless repair puts tape on it one two three who who four five who does a sutured repair go to the operating room baby's born with gastroschisis you go to the operating room so you have to define what you mean by sutured repair so suture repair is it is it fascia closure or is it you're just suturing the skin together in a purse string fashion because that can also be a sutured repair ish but really when you talk about sutured repair you're talking about fascial closure fascial closure does anyone just close skin yeah i just close skin ah interesting i didn't know that okay so you do that at the bedside no you can do it at the bedside or you can just take the fascial closure anyone go for fascial closure one okay so it's a pretty split here between b and d yep so the uh answers here right now on the poll uh most people chose b in which that if you do a sutureless repair the time to full feeding would be reduced versus uh d that the complications are similar to a standard repair and the answer is in fact that the complications are similar to standard repair um and so when we look at the sutureless repair the whole idea of sutureless repair in the fashion that is being done now came about like most things in pediatric surgery by serendipity um i think it was um tony sandler was in iowa at the time and he had a baby who came with uh the intestines just so much of it out he couldn't figure out what to do it took him a while to get everything back in and once he got everything back in the wound was so big he just couldn't close it and so he figured he just uh flop flopped the umbilical cord over it and put a tegaderm on top of it and said we'll come back and fight another day and when he came back to fight in a few days more days in fact the wound was closing it was half the size and then he let it go and then it just closed up on his own so he was quite surprised with that and then a few years a couple years later he actually reported a series of these patients the first series had about 10 patients in it and it was his experience from iowa and he reported basically he didn't need to take him to the or they just uh closed on their own so that's how the whole idea got born the thoughts are that um well obviously you don't have a need for anesthesia you can do this at the bedside you don't need the anesthesia you don't need to transport to the or um potential to reduce ventilation days if the you know you require intubation there's a a chance to um improve other outcomes as well um in fact the data is somewhat conflicting um and so there's been multiple retrospective studies on this uh which have reported that yeah they they just they're way better uh they they eat quicker they go home better they they don't need to go to the or and therefore it's probably cheaper to to manage them this way too and so it was great um but when there was a randomized study that was done so this was a randomized study that was done about two or three years ago that was published uh in the journal american college of surgeons by brisoni and their group from stanford and they randomized babies at birth to either uh have sutureless repair which could be done with or without the silo or um to sutured repair where they close the fascia and what they found was kind of strange what they found was that um they found they took longer to eat um it they had a longer hospital length of stay in some cases and so it was conflicting data because it conflicted with all the retrospective studies and even a subsequent one which was done um with 98 patients from their partners in san francisco at ucsf which showed a benefit for all of those things so i think the jury's still out as to where sutureless repair lies um the take-home message uh as the slide says is that it's what it's taught us perhaps is that the the old adage that you must close the fascia for all these babies is probably not true you can just simply do some kind of version of a skin closure and that's okay you leave an umbilical hernia the data over five years shows that about 13 percent of them will need a umbilical hernia repair performed which is higher than babies who got a fascial repair but umbilical hernia repairs at about four or five years of age is usually a very straightforward operation so on that last point so i i love how you phrased all this because um there have been and i'm sure wit can attest to this there have been a lot of papers in jps over the last couple of years because i know we've done a lot of reviews on them uh looking at these two groups and i you said it perfectly they disagree they all disagree with each other the study by robert baird when he was at mcgill showed everything was better about the tape closure versus in fact in his paper they had a lower umbilical hernia rate uh which was really surprising uh but then you have the brusoni study which disagreed i think it's time for the midwest pediatric surgical consortium to do this the right way we need to get multiple centers together not single center it has to be prospectively evaluated so i i think one of the things that so we looked at our own data recently and found that obviously our length of stay had gone up since we'd started doing more sutureless closures and one of the things that we think is driving it is a fear of feeding right okay the kid doesn't have a primary closure of their fascia so we're hesitant to feed them because we don't want them to get super distended and eviscerate right and so i i that's sort of been our our thoughts we actually just recently with our nicu instituted a feeding protocol and so we have some more objective things if the repugl output is less than 20 per kilo it comes out if the kid is tolerating you go up by 20 per kilo each day and trying to see if we can push ourselves along to having normal things i think it's really hard in these studies to know what's driving your difference in feeding or your difference in length of stay is it practice patterns because of our own hesitations or is it really a difference in the patients it's totally yeah you're absolutely right practice patterns so in this in some of those studies they simultaneously introduced a feeding protocol and then they said oh they introduced a feeding protocol and so the key thing here is when what as todd mentioned if you're going to do a prospective trial is to make sure you compare apples versus apples because there'll be a natural selection bias that oh this one is easy and so and is more amenable to a suture repair i mean a sutureless closure and so those are the ones that are going to have a better kind of easier slower quicker outcome anyway so it's careful have to be careful that you're not selecting out patients who are going to be better if you will right off the bat so you have to make sure that you put equal emphasis on that so salim i was um interested in your figure of around 13 15 of patients who i think i understood eventually needed an umbilical hernia repair as opposed to actually who had an umbilical hernia but never underwent a repair so my question has to do with the mechanism of closure of the umbilical fascia so i think we all think that there's some contracting mechanism that happens at birth that we don't really understand that allows the umbilical hernias to close the teaching used to be that that didn't really happen if if you had an abdominal wall defect because somehow you interrupted that contracting mechanism so is there any more information about how or why the umbilical fascial defect actually closes in these babies who undergo the sutureless repair i think so i think it's uh each study that mentioned it the last one was the uh one from ucsf with 98 patients which was published in uh jama surgery i think last year or earlier this year and basically they they found they're the ones who studied them for over five years so they had five years of data and they the older ones were acquiring hernia repair 13 is what they found when they compared it to the sutured group that was historical control and so um they didn't comment much on that um but yeah that's an interesting uh thing that maybe need to be looked at there's other studies which have shown that when you attempt a fascial closure and try to bring it all together um without a silo so an immediate repair those patients tend to have a higher incidence of of umbilical hernias or ventral hernias whatever you want to call it requiring repair so so you know an interesting thing you get sometimes get pushed by your peers so i i uh really loved closing these with the baby paralyzed um i been pushed by my peers saying why are you still intubating these patients no one else does that and so now i've been pushed by my peers where i do it that way and i still think it's uncrew and unusual punishment to the kid who who does not love having their bowels squished in while they're awake i do it i my i'm wondering about risk reward on that i think my success rate's higher when um when i do it with them paralyzed but i know that that that the the recommendations are to do this with them wide awake so yeah i when i do minus and i do a variation of it like i said i do a suture i suture the skin closed with a monocle stitch and just purse string it around the umbilicus um and i don't close the fascia so i don't require them to be paralyzed but they are asleep and um and so they do get intubated from that standpoint that brings to the question of whether we believe that general anesthesia in this age group in fact is uh has a problem or not and i think animal studies say yes animal studies say that every single general anesthetic agent and every class that has been studied whether it's a volatile gas whether it's an iv whether it's ketamine or an mda receptor block it doesn't matter all of them in rat studies and mice studies and sheep studies have shown uh that um they all cause increased apoptosis and and pervasive developmental issues when you look at humans though they've been now two or three very well done trials including the gas trial and the panda study the gas trial now has five-year data showing no difference in neurodevelopmental outcome in babies randomized together either general spinal uh their ingrown near paired under spinal or general anesthesia arguably using the dumber gender males um as their as their higher population and comparing them to females back just to make an obvious comment that we all understand but i'm not sure we said it out loud you you hinted at it salim and that is the heterogeneity of this population makes a huge difference in the results we're talking about now there are some where the the flap closure works easily a little tylenol in the bottom and shove the one or two loops back in but then you've got these complicated cases that need a silo and need to go to the or need other things so right now we have one prospective randomized trial correct where they didn't take into consideration the heterogeneity all those other trials are biased by this one i can do this way but that one is really hard and so we just as we go forward we need to figure out how to sort that out that's all absolutely one size certainly does not fit all no and and there has to be um horses for courses mark walken so i was going to say recently uh one of my fellows talked me into taking a larger defect and we couldn't wouldn't close it with the umbilical cord all the way across and we just spiral it around and even that works i mean it's uh you just love you as long as you have enough cord so you know i mean it's interesting i think that i think the technique is still evolving and you know again to mac's point we're not sure what patients this is going to work best in and which ones it's not you know but one of the things that is a theme been you know through this all of these presentations this morning is that less is more and you know one of the things that you know i'll say you know you know way back when this course used to be all about you know how to do a thoracoscopic tef or a lobe and it was all about mis and you know i'll say that minimally invasive surgery is a concept not a technique and you know this is just taking that concept to gastroschisis and you know i do think that as we think about things that we do a lot of things that cause more harm and you know whether it's interfering with the abdominal wall's ability to close up that umbilical hernia or not by messing with it who knows maybe salim has the answer where you just close the skin i don't know i like that but it's uh there's a lot of uh you know i think there's a lot of questions still to be answered so a couple things uh tony sandler um says that he i think i think i'm right about this he does not even use the umbilical the umbilicus anymore the umbilical cord anymore or you don't need it you could just that's not as important as we once thought i think it just sort of sits there uh so that's number one um number two some people will put a silo on reduce it with the silo and then put the tape so even if you can't get it back in it doesn't mean you need to immediately tape the kid um we we have just and and before we get to steve so um maria uh varela from argentina says that they currently take them all to the operating room for a general anesthesia uh for fascial closure number one she says they see umbilical hernias in this population yes and she's very intrigued by this discussion and and and uh maybe she should try to try the other way so see so part of the uh at ucla we have a uc fetal consortium where we actually standardize the care for gastroschisis and all of them are attempted without general anesthesia without intubation even minimal narcotics um and we've you know also identified antibiotic protocols feeding protocols and so forth the um and what we found was it very interesting was the fact that the length of stays did not decrease even with this strict protocol what we did find was the use of antibiotics the intubation days and the opioid use significantly decrease so uh one of the partners also was able to uh even open the defect reduce everything back down and still do a skin closure or sutureless closure with that and that still works very well with great outcomes just a question for you so if you have patients with complicated gastroschisis so they have they're out the door they don't fit the pathway so do you but do you close them initially or do you take those patients to the or and and address their atresias or the complicated like if you have a patient with an atresia that you can obviously see when they show up we've closed them and addressed them later on that's what i do too unless it's the only ones that we don't it would be the those that are perforated i think next year we should do that as a topic because i know that you aaron taught me some stuff that you do with when you have an atresia best way to manage an atresia with gastroschisis and we've had like five in the last two months so be an interesting thing to discuss um any other here's a question from the audience related to i'm asking about whether some of these different factors will influence uh what technique you use to close in terms of thickness of the peel on the intestines and whether the patient the baby was born via c-section or vaginal delivery so rudder delivery usually doesn't make a difference at least in the way i look at it um they should all be if unless there's an obstetric indication or or something like that they should probably all be delivered vaginally i think that's that's pretty much the consensus from from studies so there's that the the other issue is the degree of peel so the degree of peel was tried they tried to kind of quantify that using what's called the gps the gastroschisis uh prognosis prognostic index or prognostic score and they the canadians did that during using capsnet and they assigned a score based on the degree of peel the degree of bowel distension matting and they gave it a score i forget what the scoring system was on a scale of one to ten or one to five and they used that as a proxy for to see if that would help and and in kind of telling these are really bad ones these are really good ones the gps in the long run didn't seem to really matter as much uh it it was a good idea but it didn't really end up mattering that much but most of us would say that if you have one which looks really bad with a very thick peel very destined lots of and lots of bowel loops out then you would uh probably not want to consider uh an immediate closure those will all go on the silo and and you'll try to reduce them and and get them done at the end of a silo you can always do a sutureless repair that's fine but you wouldn't try to do an immediate closure in that kitchen um so in those studies uh what what is the rate of conversion from sutureless technique to surgical closure and reasons for the same did they discuss that um they didn't uh they did uh talk about how there's been a transition like todd mentioned that you know basically everybody said this is the way we're going to do it and people were dragged kicking in or screaming or both uh into doing it and so they converted in 2013 their group converted and so they just pretty much all do it sutureless um the question when you talk about suture repair again you have to be you have to you know talk about what you really mean by that so uh if you're just using sutures to close the skin because you you somehow that's too wide a defect to bring things together um versus you're actually closing the fascia so i think at this point we've we've understood that there's no real big need for fascial closure in in no matter what the size of these gastroschisis defects um that if you can get skin closure alone in some way shape or form that's probably adequate so they didn't mention much about that but again those which they're unable to close you can always just bring the skin together question from india um they want to know if matted bowel plays into your decision about what to do for me it doesn't i don't so if it's really badly matted then you can't do an immediate closure necessarily you won't be able to be able to push everything back in you'll probably end up putting a silo on and using a silo to reduce and once it's reduced then it doesn't matter you're right you can do a sutureless repair at that point it's completely fine you can just cross the skin okay and so that yep so matting matting doesn't really matter let's go to break because i think the highlight this year we each year we try to highlight one deep dive topic and this year we've had a lot of requests for uh pediatric germ cell tumors so uh this year we have uh two absolute experts in the field uh dr deb billmeyer and dr fred rascorla who are going to talk to us about germ cell tumors so i think deb you're starting us off yep okay we have a variety of locations and age groups to talk oh perfect so we're going to um start with a 15 year old boy otherwise healthy comes in to his primary care physician for his pre-football physical which is when we find a lot of things out about teenage boys he has a right scrotal mass of unknown duration and on exam he has a 10 centimeter firm smooth non tester non tender right scrotal mass you can't feel the testis separate from the mass he has no inguinal or supraclavicular adenopathy and he's tanner stage 4 pubertal development so first question is what should his preoperative evaluation include alpha beta protein beta hcg scroll ultrasound those along with an abdominal pelvic ct scan and question d which certainly is seeming to be the most popular at the moment so so yes he should have all those things done ahead of time sometimes people may wonder why you need the scrotal ultrasound and the ct scan so the ultrasound is good for distinguishing pair testicular from testicular masses the tumor markers are clearly important and for a germ cell tumor histology and the reason to get the ct scan prior to surgery is that we have concerns regarding any reaction to surgery that's done that may cause enlargement of the nodes that's reactive rather than due to the neoplasm and so getting the ct scan ahead of time lets you measure nodes in a baseline state before you've done any manipulation so here are the findings from those studies here is the scrotal ultrasound showing a encapsulated mass within the testis the ct scans are negative and all the markers are normal so the next question is what should be done um thoughts here from people in the audience any comments about what you would do here would anyone do a trans scrotal biopsy nobody would do an inclinal incision control of the cord and the nucleation of the mass okay so keep getting 100 percenters on this one yeah so oh there we go and this is really the point of this question um because things will differ depending on how old the patient is so we see at least two groups of patients little kids under the age of five and then everyone else and there's a lot of current discussion about whether adolescents are actually a separate group compared to adult patients so in the very young children the kids under five and most of them are under two years of age eighty percent of the testicular tumors are benign benign and are very amenable to testis sparing operations and when they have um malignancy it's always yolk yolk sac histology so the little fellows just need alpha fetal protein and the imaging to decide what to do once you get to puberty the um spectrum of tumors changes quite a bit the majority of overtly malignant ones are mixed histology but even the ones that have teratoma with negative markers over 85 of those patients have abnormal parenchyma with intra it's either called tin or ig tcn but basically it's intratubular germ cell histology and that is the cell of origin for these tumors so for the adolescent male and definitely for the adults the answer a is the correct answer inguinal incision and control the cord and radical orchiectomy not to do testis sparing operation and again transcrotal biopsy is is never recommended i think sometimes there's a concern regarding a very large tumor can you get the tumor out uh through an inguinal incision and the answer to that is you make your inguinal incision get control of the cord and then extend it down in a hockey stick fashion if you need to to get the larger tumors out okay so we're going to go to the next case dr wascorla so the next case is a 17 year old girl who presents with weight gain and about an abdominal mass he's had an ultrasound that showed a likely ovarian mass and the ct which accompanied this uh slide is what you see tumor images on the ct scan and the question is what is the best way to handle this well this is still great um it kind of brings up the controversy about cog staging which i think deb and i would sort of advocate for all lesions but i think they're can they're very good minimally invasive techniques and one of them there's this no spill technique uh described by shizu back in 2001 we use this fairly frequently you can do it through a fairly small incision as shown right here maybe a three and a half centimeter incision plastic bag glue with endermill or dermabond or whatever your favorite adhesive is make sure it's very dry is the key you can deliver it out and then we did a partial oophorectomy this turned out to be a thick coma unusual tumor for this age child but uh partial oophorectomy is very adequate um does that does any does everyone in here do that or have is there anyone here there who does not do that bag glue trick or do something else dr harmer just emphasizes that it really has to be dry and we've had them come off as well but i would just go back redry it get gauze around it so no peritoneal fluid or other fluid leaks into the area and often you end up gluing the um gauze onto the bag with uh onto the cyst with the bag so but our main point was that large ovarian cysts can be aspirated with leak-proof technique and then pediatric surgeons historically have been performing too many oophorectomies for benign disease and this is the reference that we used it's a phys database about a thousand patients i think this is becoming old that i think pediatric surgeons are improving in use of partial oophorectomies but we just wanted to emphasize that again that um if it appears to be benign markers normal you should really be considering a partial oophorectomy talk about um and maybe you are about the how how from a technique standpoint so the way i do my partials i sort of score it and um shell things out uh do you do a different way no i think the same thing um score it with the bovi yeah you can do it laparoscopic or open i think the main thing is to get it done and i think if you feel that you can't do it laparoscopic i would just make an decision and do it open because i think it's much more important to preserve the ovary ovarian preservation is very important for these children when it's a girls big thing filled with fluid how do you do that laparoscopically and and not spill fluid so you i don't i think it's pretty hard and that's why i choose this other technique because you do this down on the pelvis you know actually i did this on the wrong side we thought it was a left ovary turned out to be a right ovary but it still was pretty easy to deliver it out you know you make it sort of close to the midline a small transverse incision very low yeah you do everything through that does anyone do it laparoscopically okay we do it i think just when it gets to be this big it's hard it's pretty hard to do it what about when it's not that big i still don't know how people can safely aspirate the fluid laparoscopically that's always been interesting i don't think you probably can go ahead you can you can make a little and i mean i guess it's widening one of your ports if you have a bigger port site depending on how thin the patient's thin you can still bring something up to the abdominal wall and through the umbilicus yeah and then a lot of times um i'll do these through a through a like a gel port or something you know some one of those multi uh ports through the umbilicus almost do it with the sipes i see dr harman mac is uh giving me a thumbs up there so i think that's a real nice technique for these because then you can do sort of a combined laparoscopic open but i do think it's important you guys are the experts but if you don't if you aren't sure what the histology is you have to be really careful not to spill fluid because potentially you're going to upstage the patient and even with marker negative patients you can still have malignant disease you can have germanoma you can have embryonal carcinoma you can have immature teratoma which absolutely will have increased risk of recurrence if there's any spill okay so that was the phrase that i was wanting to know about so even if it's just an immature teratoma and you spill you have upstaged them or at least a higher risk of recurrence yes that's a very important point okay and and what are things that you might see preoperatively that could suggest that it may be a higher risk teratoma is it the amount of solid component or size anything like that you know i think it's hard i think fat calcifications and the markers are good indications but i think you know deb and her one of her prior studies from the cog group really showed that a very high percentage of malignancies have cystic components it's very hard to determine how many had cystic components but i think just the presence of a cyst should not lead you down the benign category great because in my brain it usually does you know if i see a big cyst i think i don't do anything different but i usually think in my head more than likely um but it's not necessarily true okay yeah in our last study um where we looked at the imaging appearance of the ovarian malignant tumors half of them had teratoma in them so most of them had a mixed cystic and solid appearance it was only 10 percent that were purely solid tumors so most of the time you're not being able to tell by looking okay okay okay so the next child is a five month old otherwise healthy girl she presents for a well child checkup and she's found to have an abdominal mass she undergoes a ct scan confirming this large abdominal mass which is pretty much everywhere and it's felt to be unresectable she has an alpha fetoprotein drawn which is over 4 000 chest ct is normal so what procedure should be done for this child so i thought we should have a question that didn't have a correct answer either okay so i think either one of these answers is fine i put the peritoneal fluid sampling in there on purpose because at the moment the standard of care for malignant germ cell tumors in the retroperitoneum at any stage is surgery and chemotherapy but on our current open protocol we've previously demonstrated that definitely for tested stage one tumors can be managed with surgery and observation we have early data and some support for that for ovarian tumors but for extra gonadal malignant germ cell tumors we don't have support at the moment for a surgery and observation only but on the current protocol that is one arm of the study to see if we can manage definitive stage one tumors at extra gonadal sites with surgery and observation only and we have recognized that sometimes kids who seem to be stage one either in the ovaries or in the retroperitoneal tumors can have positive malignant cytology in their peritoneal fluid there's no way to disseminate this new requirement that we need people to get peritoneal flu when they're doing a retroperitoneal tumor but we won't have any patients able to be continued to be entered on that non-chemotherapy arm unless we get some peritoneal fluid okay so let's say it again to make sure everyone hears this so when you have an ovary as usual and any kind of intra-abdominal germ cell tumor please get peritoneal fluid sampling on entry to the abdomen and send it for cytology okay that was the goal of this question that's very important uh and you can see the small number of people that were doing it so um the other thing i just would like to mention in this situation is sampling error is really quite a problem for almost any germ cell tumor so many of them are mixed tumors and you may have a sampling error with the biopsy only and sure for a child of this age the alpha fetal protein may be in the normal range and not have come down from the newborn levels yet so there's some concern about what the net histology might be so now i have to back up it sounds like right i have to back my back up yep okay so she actually had a biopsy showing immature teratoma but was presumed to have a component of yolk sac tumor due to the high alpha fetal protein and had two cycles of chemotherapy with a plan for four and resection but after two cycles the uh alpha fetal protein has dropped very nicely but the mass is getting bigger the child is short of breath and can hardly eat because the abdominal mass is so big so now what should we do continue your chemotherapy as planned to you've completed four cycles advance to second line chemotherapy for germ cell tumors or do multiple biopsies to look for other mixed histologies or attempt to complete tumor resection so let's ask people to write a b c or d in the chat if you could just say which one you would do a b c or d so what if it's a simple cyst that's less than five centimeters first i would ask why they're operating at all uh secondly i will tell you that uh in our review of our imaging data we did not have any malignant tumors that were purely cysts with no solid component whatsoever okay so i don't know if you would want to comment on that's a that is a great great point yeah so you have never had uh so if it's pure it's always some solid component if there's something there if it's malignant or in the in the review that we did i can't say no one has ever seen one but i can tell you that we looked in over over 100 patients didn't find any simple cysts so yeah we're 60 percent um on b 20 a and 20 d oh it's changed a little bit but so so mixed yes mostly b most say advanced to second line chemotherapy so this is um a unfortunately somewhat common scenario for a rare disease and it's always a painful decision to need to make but the the points i would make are are two one is the biopsy showed immature teratoma which is not a chemo sensitive histology and um secondly multiple biopsies probably won't get you anywhere so the the painful correct answer is actually d and although many times these seem to be completely unresectable they're often kind of wrapping around vascular structures it can be quite challenging to do there's certainly a risk of injury to structures while you're working so you have to be prepared for that but if you don't resect it you will not have a surviving patient okay so our next case is an eight-year-old girl that is awakened at 3 a.m with acute onset of abdominal pain and vomiting she gets to her primary care later in the day then referred to an er and she gets a ct of the abdomen at about seven that night which shows a cystic mass in the pelvis thought to be an ovary and there's thought of torsion she was transferred to our hospital got there a little before midnight we had labs that we obtained afp and hd were normal the rest were pending we obtained an ultrasound which may contribute we had thought we had no flow in the right ovary and we had a six centimeter cyst that we felt was a simple cyst so we took her to the operium and she indeed had torsion so we detorced it and this is what it appears let me stop you before you go any further because i want to harp on this point a little bit we we definitely hit on this last year and uh so torsion so you had good flow and all good doppler flow on ultrasound of the ovary right yeah we had no flow no flow sorry okay that's the point but but the point is if you did have good flow would that have stopped you from going to the operating room right so dopplerable flow on ultrasound should not sway you one way or the other if it's no flow it even encourages you to go even more but even if there was good flow you absolutely can still have torsion um and so what are your criteria before we get into this because i know we're getting off topic on germ cell tumors but i think it's a good option to talk good thing to talk about what takes you to the operating room for torsion anyone here um what are your criteria that you're concerned about torsion mark well i mean i think that uh ultrasound probably plays some role in it but like you said you can't hang your hat on no flow is there a size you use of the cyst to say no not necessarily i think you have to look at the history and the pain you know so the history and physical right so i mean if it's an acute onset um and it's uh you're not getting better and the patient's tender i think uh with you know some secondary signs whether even if there is flow based on the ultrasound it's never going to be if it's a normal ovary with good flow you're not going to go but if there's a big cyst or something like that uh you suspect it i think it's worth a laparoscopy okay pain in the pelvic mass yeah is indication for me yeah because you know some if it's a four centimeter cystic mass of the ovary they have pain the ultrasound shows no uh good flow do you go or not could this just be that it's a painful ovarian cyst um uh so how do you know so a lot of debate about that so and in a chart review that we are in the process of doing we looked at all these patients and half the time we are wrong when we went to the operating room there's no torsion there so our goal obviously is to get that negative laparoscopy right down but the challenge is making sure we don't also have misses when we do that what did you find in the patients who didn't have torsion i was frequently like a ruptured cyst so it either was a ovarian cyst or a ruptured cyst but it was not a torsion yeah um and so but you're better off doing that than having 50 percent of the patients have a torsion that you missed for now we're not changing anything but the point is years ago we had a very high negative appendectomy rate because our imaging wasn't good our imaging has gotten to the point where we have a two point something percent negative appendectomy rate across the country our hope is that we can that was from a 30 000 patient review um but our but the uh hope is that we can this was the setup for the next study is that we have thoughts about how to drastically improve the diagnostic ability for torsion to lower that negative laparoscopy rate substantially maybe maybe not one of which is artificial intelligence and image recognition so we believe that we can pretty accurately use ai image recognition to improve our accuracy rate so all right so here's the question uh what do you do you have a mass primarily cystic and torsion you've just detorsed it what should you do in the operating room detorse alone do an oophorepexy partial cystectomy partial cystectomy and pexy or just an oophorectomy we'll wait a little bit time any comments from anyone and thoughts on any of these you know one of the things i'd say i think one of the hardest diagnostic uh challenges is the hemorrhagic cyst because especially if it's been going on for a little while it'll look like something with some cystic and solid components and so one of the questions i'd throw out there is for folks is like what would you do so you get in there you have a torsed ovary there's something that looks like a hammer you know there's it could be a hemorrhagic cyst or it could be a tumor you don't know what it is you know what are you doing what do you do in that situation what does everyone do here so go to the operating room there's a hemorrhagic ovarian cyst or with questionable mass you know you don't know you don't know what it is although the ultrasound probably showed heterogeneous right uh yeah uh detours detours do you you don't uh evacuate the hematoma or anything like that no does anyone do anything other than detortion does anyone do a cystectomy would anyone laparoscopically open it and try to remove the cyst so everyone here would just do detortion no the question was is there a role for apexi i don't think so in a case like this i mean the point i'm making is that detours it leave it alone let it settle down re-image and see if there's really a mass there or not and then see what happened because there there may it may be just a simple cyst that bled into itself it could just be or it could be a tumor so you ever had one retours because you left the big because whatever it is that caused it is still there yeah i i've not uh i've actually not seen a retorsion okay all right so obviously i uh you can see what the audience said here but i uh i do do a partial sexistectomies when they're this big when i think it's a simple cyst that's what i did and uh i wish i hadn't but i did i did the torsion partial excision of the right ovary evacuated the cyst finished it middle of the night the rest of the markers all came back normal but the pathology showed some lines suggest it's a dermoid cyst most shows marked ischemia hemorrhagic necrosis and edema so uh maybe if i just asked the panel up here my two partners are here what would you do now go back i think i think i'd do watchful waiting okay so that's what we did yeah i'd do the same especially since the tumor markers are all negative yeah but the tumor markers are usually negative negative unless you have a tumor a tumor right so you right but you still have a teratoma in there right but that but you can i mean my thought process was if the tumor markers are negative it's less likely it's not 100 but it's less likely to be a malignant tumor and you can wait to wait and see what happens to be coming and then i suspect there's i suspect there's benign small benign teratomas out there that we never know about right yeah i'll just say what i just so it's i'm different from everyone else which is always dangerous but i would i would have gone back made a tiny incision brought it up and done a um i would have enucleated the mass and put the ovary back in an ovarian salvage immediately the next couple yeah i wouldn't wait i wouldn't wait i mean i wouldn't do it that day but i would wait i would do in the next couple weeks yeah i think what todd describes is perfectly fine um so we waited but we had a clue the next day when radiology spoke to me that on both imaging studies they saw fat so in retrospect what i didn't have in the middle of the night was that they had a clue that this was a teratoma right off the bat so they had fat on both imaging studies as demonstrated here so we followed the kid for a bit she developed another cyst with some fat in it and we took her back and did a laparoscopic partial oophorectomy taking off the teratoma as a mature teratoma and we'll continue to watch her i think the real teaching point here for all of us is really that we have to do a better job of sparing ovaries and this is one study from 22 children 20 young girls who had unilateral oophorectomies for mature teratomas so complete oophorectomies over 20 showed up with a con a metacronous tumor in the other ovary within the next four years and so i think it really emphasizes that we should be doing partial oophorectomy for all teratomas right off the bat that's a great point to say it again for those of you out there who may instinctively just remove the ovary realize that 20 percent of the time they'll get a tumor in there that sounds very high but that's it this is one of the highest in the literature most are a little lower than that but still it's not zero it's a real number and so uh the the recommendation here is uh is to do a ovarian salvage procedure take out the tumor with leaving the ovar okay i think the other part of the recommendation is to um make sure you continue to follow them over time so that how do you follow them so we follow them with ultrasound and um how often i will get my first one probably a month after as my new baseline and then i would probably get them every six months okay and then you do that for i do that as long as they're willing to come back because they're not really in their childbearing time of life yet when you first see them and so if you just follow them for a year you're still not going to protect them from ending up with a loss of their remaining ovary or the remaining portion of the ovary over time so i think it's worth following them so fred let's do the let's try to do the fifth case but let's do it we'll just go through it not necessarily we'll go fast there's a 13 month old girl presented with constipation has a sacral fullness as the scan is shown and her afp is 79 000. so elevated afp she has a big sacral mass what is the best thing to do complete resection rectal sparing resection post-op chemo biopsy and neoadjuvant chemotherapy or biopsy chemo and radiation i think it brings up the issue uh for discussion about what you do uh we would tend to argue for biopsy the uh child has a yolk sac tumor which is extremely chemosensitive and so i think we would really advocate not doing anything that puts the child at harm or potential risk of normal uh resection of normal structures and this just shows on the left at diagnosis and on the right post chemotherapy and our afp is normal and it was a very simple posterior resection of this so i think it just uh kind of advocates uh that uh initial chemotherapy is fine and when we looked at this retrospectively through kind of the intergroup study kind of the cog's predecessor there was no difference in survival between initial resection versus delayed resection and overall there's a 90 resection in these children with malignant yolk sac tumors in this region you still have one more case right is that right or let's do it okay okay so this is a 13 year old girl she presents with an abdominal pain and ct scan reveals a large pelvic mass her markers are all normal she has a laparotomy with finding of a right ovarian tumor and multiple peritoneal implants the pathology on the ovaries pure germanoma multiple implant biopsies all mature glial tissue consistent with gliomatosis and she undergoes chemotherapy with four cycles of peb with a good response and residual pelvic implants on ct imaging as expected because they were clearly too numerous to count and too numerous to resect but all fairly small so what should be the oh so she does well she's followed oncology clinic stable imaging at her three-year visit ct scan reveals increase in the size of the pelvic mass and a new lesion in the liver once again all the markers that we measure are normal so what should be the next step for this young lady treatment with platinum-based chemotherapy again second line chemotherapy stem cell transplant percutaneous biopsy the liver lesion or laparotomy with attempted resection of pelvic mass and multiple biopsies i'm glad you're presenting this case because i have a patient exactly like this do you followed for years and it was really challenging yeah the patients that have gliomatosis which which is defined as mature neural glial tissue not immature implants mature glial tissue generally do well generally do well but um sometimes they are trouble and so they all need to be followed and there there is continued like uh lack of definition about how often should you image and what image should you get so i'm not even going to try and answer that i'm just going to say that you have to follow these people so the question of what do you do when you get the imaging and there's still a mass there or it's bigger yes so um i will tell you that this this also would be a um i think there's two potential correct answers here and um they would be d and e which are percutaneous biopsy the liver lesion which would be the simplest thing to do and may tell you what you need to know or laparotomy with attempted resection and multiple biopsies this young lady turned out to have primitive neuroectodermal tumor and so the point of this case is really twofold one is that they need to be followed regardless of what your initial histology was and when any type of germ cell tumor either mature teratoma immature teratoma or any of the other malignant histologies it can recur as either a somatic malignancy which can be almost anything most often pnet but also rhabdo other kinds of somatic histologies or can it can recur something called growing teratoma syndrome which will not be sensitive to uh any kind of chemotherapy is going to require resection so at least you have to get some kind of biopsy to direct whatever kind of therapy you're going to plan to do and unfortunately for most of those non-malignant germ cell histologies you're going to need to do uh attempted resection if you can to obtain control of disease so i just want to ask a real quick question is there any role for hypec in that kind of patient or not or is it not chemo sensitive enough so it's going to depend on what um what histology you find so at the moment for immature teratoma and teratoma hypec has been used with kind of mixed results i think there's very little else to offer and so i would certainly consider it for the pnet we do have chemotherapy regimen which potentially has efficacy so i would start with that first i'll just run into the question of how often do you have to biopsy it if it's still there and you biopsy it and it's it's not a new different tumor is it growing i guess if it grows you biopsy it if it doesn't grow so we we actually have a bunch of questions but we're only going to ask one because we don't have time for the rest because we're already 10 minutes behind so the question is what is the role of staged like multiple resections for non-responders to chemo is there any role for it staged resection i'm not i'm actually not sure i understand that question sorry does it refer to a specific site or so why don't we have i think they're asking you about two or three times and try to keep getting tumor out if you need to yes i would because i think you have very little else to offer so all right but i think hypec is definitely a reasonable question to ask yep because that will be about as aggressive and total of a section as anyone could achieve so rather than you doing little bits repeatedly probably referral for hypec would be better perfect so what we do when this happens when we have more questions and we have time to get on the air we might ask you both we'll show you the questions and have you chat a little answer in there um so we're going to move on now to dr von allman who's going to talk to us about intussusception great thanks todd so dr wolkin and i are going to bang through a few quick hit topics um this one in particular uh talking about intussusception i was at a apps case presentation session several years ago that dr harman was doing and presented a case of intussusception and i was really struck by the heterogeneity of the practice patterns for how we actually treat intussusception and it's something that i think is trained certainly dramatically since i was a fellow which was way way too long ago but even just in the past uh several years there have been this ongoing change in how we manage in a susception so i'll be very interested to hear from our colleagues across the country but also internationally uh how they manage this relatively common problem so if you start with a standard case a two-year-old who presents to the emergency department with colicky abdominal pain a little bit of bloody stool and a palpable mass in the left upper quadrant on exam is hemodynamically stable actually relatively comfortable with no peritoneal signs so how how would you work that patient out and how do people what's the next test that you would get or conceivably would you take that patient his kid with classic intussusception would anybody take them directly to the operating room so who here who gets plane films what's that who would get a plane who would get a plane film right that's a good question because i've never had a patient that didn't have one so right but the question is you can't rule out in a susception on a plane film right so does it help you or not and i guess that's one of my pet peeves is we get lots of tests that don't really help us but we get it just because we get it and i'm as guilty as anybody else at our place um the radiologists will refuse to do an enema without a plane film to rule out free air so there you go so our our faculty here our radiologists will just take them for the enema and they shoot they shoot a flat plate basically in flora right before they start and they use that as their substitution in in the in the flora suite but not a separate did i miss that you got an ultrasound so that was exactly my next question is get the ultrasound you're saying going for the enema but how many people how how many people would get an ultrasound to confirm the diagnosis what test are you going to use to confirm the diagnosis so who here would not get an ultrasound would anyone not get an ultrasound to confirm the diagnosis looks like looks like you're going to get those two so most people are going to get an ultrasound which is what we would do for sure is get an ultrasound in a in a patient with a great history and all the classic physical findings would still get an ultrasound to confirm the diagnosis before then going to radiology for a therapeutic intervention and i'd be very interested to know from our international colleagues in particular do people do ultrasound uh saline reductions under ultrasound or do either contrast or i think in most places here uh at least in our institution use air as the contrast to do uh reductions uh with air so alex tell us what we found when we asked that question online so this was kind of sparked by a randomized control trial that came out of china uh within the past couple years where they compared directly the uh ultrasound guided saline enema versus the air contrast enema um and found that the ultrasound guided had like a 96 success rate compared to like 83 percent for air contrast enema so just asked why we weren't doing these ultrasound guided ones and um posted it to our facebook group and everywhere that wasn't the united states said we are doing these ultrasound guided saline enemas what are you talking about so um it seems like it's pretty much just a us specific thing that we're doing the air contrast yeah and it's sort of so maybe that plays into the next question which is being answered here as we speak which is how many attempts at reduction do people allow the patient to have uh before proceeding to something more invasive like surgery and in that study that you quoted how many attempts were made to get that 90 whatever percent reduction rate i don't recall how many they had made but i know that their the sailing group had um a lower interluminal pressure compared to the uh air contrast enema group it was like 88 millimeters mercury compared to 120 of the air contrast 120 is what we use uh which dr gotegall just informed me before uh our radiologists use 120 as their pressure line but how many i'd be curious from the people here how many the poll says 62 percent say three attempts uh two attempts and a quarter of them and ten percent would only do one attempt let me hit even while we're waiting for that on the basic assumption that uh three years ago uh we presented whether or not you do that at all um a few years ago our institution in akron i work at two institutions uh in akron they would not repeat it if it did not reduce i was going to the operating room and after this being presented multiple times on this forum we now repeat it and i think i would say we do it about three times is there anyone here that is in an institution that does not do us another attempt at least one other at least one other attempt our protocol in cincinnati is three attempts three attempts mac just a comment there uh two a two ways the first reduction fails one is you move the antisus septum all the way over mid right colon they can't go farther they're not going to go farther and you know there's still an antisus septum there the second way they fail is they actually reduce the whole thing but it doesn't reflux up through the ileocecal valve so the patient is completely reduced but that doesn't meet their criteria criteria for being able to say it's reduced and so when you repeat the animal one time you're trying to really reduce what was left and another time you're just trying to confirm that they actually did what they didn't if confessed to do in the first place because you need the edema to to settle out whit i also think that you've got to see progress with the attempted reduction before you would persist on with another one or two that is if if you try the reduction and it doesn't really move then there's no in my mind at least there's not a real indication for trying it again just to add what mac was saying is if you do reduce it all the way and don't get reflux those patients will typically their symptoms will go away so you you know that you've actually clinically you can safely watch those patients or you can just get another ultrasound to confirm that so i think that radiographic criteria of of reflux in the terminal ileum for full reduction doesn't really need to i want to challenge you on that so i just i'm not challenging but make sure i understand you keep oh hold on keep so uh so if the child if they do a contrast enema an air enema and it gets to the ileocecal valve but no air refluxes into the small bowel you would just follow symptoms you would not need a confirmation other than that or ultrasound that they've successfully reduced the child that's correct we actually studied that and initially in our early series we repeated all those contrast enemas and they were all normal at that time the next day what we found was really the symptoms if you bring them back they they continue to have that crampy abdominal pain was the key now it's easier with the ultrasound that you can check so the key statement you made is you bring it before you would bring them back the next day for a kind so how long do they have to be symptom free because patients with inus susceptions as i presented this child can be essentially symptom free and still have their inus deception what we found in our study was that they continued to have very similar recurrent colicky pain as if we didn't do anything to the inus deception we did reduce it partly but we didn't get it all the way those that we reduced all the way uh and didn't see the reflux those patients were completely asymptomatic so um chuck bro from um grand junction colorado um has a question are the three attempts all like they do it it doesn't go and then they do it again right then are you talking about like a time lapse between the reductions and how long is that time lapse we usually have a time lapse and we let them for an hour or two an hour or two and then redo the study yeah we do i think the time lapse is it depends on what time the first one was done if it's three a.m the next one will be at six yeah and i have one of just true confession i think early on in the laparoscopic approach to inus deception i think many of our early successes i certainly remember in my own experience you'd go in and you'd sort of grab the terminal ilium and sort of pull it towards yourself and go ah it was that was look at that that was easy but instead those all fall into that second category i mentioned it was already reduced they wouldn't call it reduced so we operated on them and wrote papers about how great laparoscopic surgery was for inus deception in singapore they say in singapore they say they give another shot if it's progressing so um you were going to say something i was just going to say to dr harman's point how many people would do this laparoscopically and how many people do it open and that's the next poll question oh okay so wow while people are answering this uh we did have a question from the audience is there any role for an an enema under laparoscopic like direct laparosc or laparoscopic like view so i know i know someone who does that jeffrey lucash describes that when he'll go in and when he does laparoscopy he'll put the scope in so see when you do it laparoscopically you have to sometimes pull which is what we've always been taught not to do so what he does is he has him do it he does an on-table air enema laparoscopically and that helps the operation substantially get it to almost to where you need and then he can pull a little bit rest of the way so it's a combined combined lap it's not just to look and see whether it's reduced no because if you're going to do that we should learn how to do ultrasound like everybody else in the world do them with ultrasound guys right no this is that they've failed he's going in to do it and he uses the push to help him laparoscopically reduce it which is i thought a really smart idea um what i have found i do it laparoscopically but what i've found is my success has gone way down since the success of radiology has increased so as they've gotten better these cases of going in and going are over that by that if i'm going to the operating room they have given it the little college try and these are often ones that are pretty challenging to do so the only comment i would make is that if you i still think it's worth putting a scope in and trying laparoscopically because if you open everyone then everyone gets an open operation right right where's the wisdom now because i think it's worth trying but i agree with you i think that radiology has gotten a lot better so the easy ones uh they took all the easy ones away from us sounds like namwin and artura aranda both use on-table air enema during their laparoscopic reduction really interesting i was just saying dan like i wonder if the laparoscopy versus laparotomy is also about access to laparoscopy that many of the people who are doing laparotomies are probably maybe in places that don't have access to laparoscopy yeah good point from someone who just came from a location like that okay and i think todd you alluded to the technique laparoscopically if it's a pull instead of a push and i think it's an interesting concept to do both with on-table uh yeah air okay or maybe saline we should be using it sounds like saline may work better yeah yeah i wonder and that study i just looked up they there's three attempts for three attempts so good all right so now to the to the last real issue i wanted to discuss because i think this probably been the biggest change in practice at least for us and for me is what do you do if you reduce this do you admit the patient overnight uh observe them for 12 hours observe them for six hours uh observe them for four hours or discharge them immediately and this was i think one of the points of the session i mentioned early where i was really struck by we were at that point still admitting everybody for uh at least overnight and uh okay keeping them npo so we know what you do what do you do in indiana do you admit them overnight or send them home from the emergency room so i think there's some variability and there's not only variability among the partners but one thing we have to cope with is that we have most of our kids come from another place two to four hours away having had a ct scan as the initial study and if they have any symptoms when they go home they will go back and they will have another ct scan at that outside facility so sometimes our reason to admit is because of the local resources available to them and i think that since we've gone to air reduction rather than contrast reduction they actually have more crampy pain in the first few hours after we do the enema i think they're more distended with gas than they previously were and so there's a little bit more symptoms and the third thing i would take into account is how symptomatic were they before they came in and how challenging was it so i think there are some good candidates local kids not too bad easy transportation back they're great to go home i'm so glad you made that point uh just like it sounds like this is the theme of today is that it's a tailored approach uh that you can do one or the other but it's a patient by patient uh plan fred do you agree with that i would pretty much observe four hours on almost everybody okay um and let them go i think in the er you keep them in the in the er yeah and then don't admit them okay um but i think that is a good point that you have to have a tailored approach to some children so what are you doing atlanta yeah we observe them for a little bit in the ed and po challenge them and send them home okay anyone here other comments to make this does anyone admit them overnight routinely here okay yeah huh not anymore and if i did i'm not admitted anymore because i keep so our protocol is is that a four-hour observation um followed by a po challenge and then discharge home i think the one the it can be a challenge sometimes because that requires that there's capacity in the ed to have the patient sit there for four hours that's right that's another and that has been a if if we run into a barrier to that it's a capacity issue in the ed not because we don't want to use that as our plan so i want to do another variability assessment we're we're definitely behind as now we're going back to the way these courses usually go uh what number do you well actually i'm gonna start with you alex because you're the ones that see them in the ed before what number do you quote the parents and we're going to go down here as their chance of recurrence um say uh 10 9 to 15 what do you say i'm going to show you two slides so i won't say all right fine well well sorry this is a pre-test it's a pre-test i'd say five to ten percent five to ten about ten percent everyone here in that range ten i see ten i see six percent definitely you're right yeah five percent okay all right all right so just to move along uh to talk about a couple of studies that looked at the four-hour observation primarily uh this was a study that where they looked at 51 patients i think 52 patients and bottom line uh is there was no difference in recurrence rates however their recurrence rate was 15 and 16 respectively for patients admitted overnight and patients observed so a little bit higher than most people suggested here i think that's actually a little bit higher than most people would quote um there was no difference in the time to uh recurrence no difference in adverse outcomes and that was with a four-hour observation obviously if you do that your length of stay is going to be a lot shorter than if you admit the patient overnight so their conclusion was there was no increase in adverse outcomes with a short observation uh for an uncomplicated hydrostatic reduction the other and this was their protocol which we won't go through but basically it's just that if you're able to reduce it and confident that it's reduced observed for four hours and po challenge and discharge this other study was a systematic review with a meta-analysis um it looked at there were 10 papers where there were they had enough data to compare the two they also found that there was essentially no statistical difference in recurrence rates or return to the ed or need for operative intervention or mortality and obviously again a decreased length of stay the recurrence rate in this study was six to eight percent so much more in line with what most most folks had suggested in the room so the key points are outpatient management uh after an interception after a reduction is safe there's no difference in most of the outcomes that we measure but you significantly reduce their length of stay and a cost and everything else do you do with um like a small bowel small bowel interception that uh you see incidentally if it's incidental i would observe it if it's a patient who's post-op i would operate i would put a laparoscope in or operate on but we see them all the time i mean it's not uncommon with a ct scan or something for them to call that and i wouldn't do anything with that because i've never found that i had to do anything about that you could probably give gastrographic we can talk about that later okay all right um so that was great um of course the things we all deal with the most get the most discussions and that was great we've had some bad experiences with this with uh with patients through our esophageal center of patients who have had really really significant injuries from button battery ingestion so we just wanted to uh briefly talk about that again i'll go through this quickly but button battery ingestions are uh more becoming more and more frequent the national data suggests that there's increasing numbers of of emergency department visits for this uh part of the problem is that button batteries are absolutely ubiquitous they are all over the place now they're in greeting cards they're in uh you know remotes and that sort of thing so case and this is an actual case a nine-month-old who was brought to the emergency department at 10 o'clock at night with a three-day history of retching and respiratory symptoms and they got this chest x-ray which demonstrates the finding on the film there and the question is what would people do then for management what the key finding is when you see something that looks like a quarter but it has that line around it it is not a quarter it is most likely a button battery so we don't have the ability to show you with a pointer but um but if you look around the edge of the circle there you'll see a ring and that is how you can tell that it's a button battery so i just wanted to make that that point again and i think the what the poll is suggesting is that people would take it out emergently which is the right answer and it's uh 50 50 right now as to whether people would do that with a rigid scope or a flexible scope and i think that probably relates to who takes it out whether it's gi or whether it's surgery and whether and how you were trained so i agree with those results however uh i've had a couple of occasions over the years that we couldn't get to the operating room very quickly uh and there was a short duration of uh symptoms so as as many of you know we like to use the foley catheter technique and so we did it in those two patients and it worked fine the key points are it wasn't three days of history when you're likely have a perforation uh uh and there was a reason we couldn't get to the operating room because the operating room was uh was tied up and it was early in the morning so anyway just a little caveat that the foley catheter technique may work and um in just a limited uh uh limited reasons or or for reasons that you can't get to the operating room very quickly did you look electively when you had more time since it was a button battery or they didn't have any yeah we did we did look i'm not sure we didn't look like four hours later but we kept them in and watched them and then we did a little uh esophagoscopy on them before they uh before they left so i'm going to skip a little bit of this because it's a complicated case but um this case in particular demonstrates some of the complications in this child when the button battery was removed there was a large tracheoesophageal fistula noted and on follow-up endoscopy the child ended up with a severe esophageal stricture which started them down a path of multiple operations and complications so just the point that these things can be quite difficult and create lots of problems one of the things that i actually have learned and i'll be very interested on on the other comments from the folks in the room as well as online is what so you take this even if you just you see the button battery endoscopically you have a history of a day or whatever and you take it out um what is the follow-up management for that how do people what other tests should be obtained what would folks do mark so as many of you know naspi and the gi uh group put together some criteria and some uh some guidelines around management of button batteries with zero input from surgeons which uh i find very fascinating and uh i i'm in two hospitals one of which gi mostly takes them out the other one of which uh pediatric surgery mostly takes them out and there's a lot of discrepancies in how we manage them but as we've gone through this one of the mandates of these multiple MRIs and watching these kids because everybody's afraid of a vascular injury so i'm really curious to hear what you found there are a few papers and case studies out there but we find ourselves sort of with these kids handcuffed to the bed with these serial MRIs which if they truly got an esophago aortic fistula i'm not quite sure how we manage that on the floor of our hospital so the point you raise is exactly the issue that i think is is pertinent for this discussion and as with many of the things we've discussed there probably isn't a correct answer but uh this is uh data that came from a study from colorado uh that first of all the number as i alluded to the number of ed visits has doubled the rate of significant complications has increased almost seven fold 90 of the serious outcomes in these are in these 20 millimeter to 25 millimeter batteries those are the ones that cause the problems part of the issue with them is that they are lithium batteries and they tend to be three volt batteries as opposed to one and a half volt batteries and the pathophysiology is is not erosion of the mechanical of the battery itself or even the electricity it's they that it's a caustic injury from the hydroxide ions that are created that raise rapidly raise the ph in the tissue and it causes a caustic injury the complications are esophageal perforation stricture tracheoesophageal fistula as this child had interestingly there are a number of cases of vocal cord paralysis not associated with perforation or anything else is presumably local effect of the of the um caustic injury and then what you alluded to which is aortoenteric fistula it's the most common cause of mortality in the big national data bank that follows this it was accounted for 46 percent of the mortalities and there were another 29 percent where some sort of vascular compromise was identified as the as the etiology so when it's bad it's really bad and the problem uh that i was not personally aware of and is the issue that you alluded to is that this can happen up to two weeks post removal of the battery and so um the uh the authors of that paper uh who presented i think 16 different cases and there were several who died from aortoenteric fistulas was to get an mri study after removal of the battery get an mri to look at the uh potential impact on the surrounding vasculature again what are you going to do about it i think that's an issue when it happens and i've seen one it is very hard even if you're standing there waiting for it it's hard to do anything about it and you're not going to do anything preemptively presumably except be ready what does that mean it's so it's a difficult challenge as to what do you do and if you see irregularity in that area then what is the follow-up for that so the nasa guidelines have these serial mris but without real clear criteria on what to do based on the findings so we're actually piloting a study to look at you know if you have a clean mri on the initially post-op you know will that lead to an injury do they all seem to get better uh so i think that this is something another opportunity for a multi-center trial and uh i know that some of our guys are trying to put some things together for this so hopefully we can get some participants in it so we can answer this question yeah it's one of the challenges is it's not rare but it's rare enough that it's hard for a single institution to get significant data so i just want to make one comment and we had a kid a few years ago that had an unrecognized ingestion and probably 10 days of symptoms went to an outside hospital had a hematemesis with the battery coming out and then got him into our gi service i was asked to see the kid the next morning for access when he was exsanguinating and clearly it was too late to do anything then but that prompted us then to look at a mechanism to get these kids to the oar faster so we currently use our trauma one system so if we have awareness of a button battery call or person arriving that goes out as a trauma one page wow that means that the or doesn't start a case if they have a room available it means the x-ray comes immediately to the emergency room to take a film and the entire trauma mechanism is activated and it reduced our time from hitting the door to hitting the or from an hour and a half to less than 30 minutes that's great that's a great idea yeah i like that so if you have a trauma one mechanism available to you it's really a good way to reduce your time to or and then just finally the question of what happens if you you get one of these kids and the battery is actually in the stomach where presumably there's much less risk that it's going to do anything bad and the again just for the sake of time the authors of the paper advocate that you should scope the patient anyway because they had patients who had significant esophageal injuries but the battery continued to pass on so that you can't rule out an esophageal injury just because the battery's in the stomach so just to be clear that completely flies in the face of the actual recommendations from poison.gov which say correct you do not need to do that that's correct so and that's exactly and they make that point that's correct that it is controversial which is why i put that on the slide it is controversial as whether you need to actually do anything about that or not but some people would advocate that even if the battery makes it to the stomach you still need to scope them to make sure that they have not had an esophageal injury let's say you okay i want to make sure i put this all together now if you do your esophagoscopy so the coin's not a problem the battery's not an issue anymore now you're going to look to see if there was injury and you see that there's injury what are you going to do what do you do for that patient do you put an ng tube down like to step to give you what do you do when you see that there is a burn to the esophagus yeah i think it's a great question i think it depends on the extent of the injury if the injury is relatively minor mucosal injury i probably wouldn't do anything and follow them symptomatically if they have uh circumferential uh erosions and it looks bad then i would probably re-scope them to look for a stricture formation okay so there's something that might say that patient needs an mri okay so when i said bring it all together that's what i was actually because yeah because i wouldn't do that and this is where i finally we have a debate uh so i wouldn't do that because i don't think that changed your management at all so what i would do is if they got symptomatic i would do an esophagram and see if they had a narrowing or a stricture but the esophagoscopy didn't help me it didn't help me unless you're going to either put something across it or get an mri or do something the mri is independent from my that's looking for a different but you problem but so i would suggest if you believe this paper you should get an mri so wait but that's different than evaluating the ongoing injury to the esophagus where you might find a stricture and the difference between a swallow and a scope and i agree you can just send them to radiology and get a swallow that's fine but the advantage of doing a scope if it's bad is you can reassess what it looks like you can also dilate them if they are but you would not so but you're not going to do that unless there's in other words if you get the esophag the esophagram you don't even need right now anyways because i would wait a couple weeks and if they're symptomatic maybe get an esophagram at that time and if they are then you could figure out if you go dilate them but if there is an injury then maybe you would get an mri so that might be the only reason if you're going to do it routinely is get it into whatever so dan you you mentioned the uh recommendation of doing the endoscopy uh to evaluate for esophageal injury in a button that is in the stomach the question is do you need to remove the button in the stomach at the time of the endoscopy it's also uh you will find papers on either side of that i think that if um typically if people look down there and they are capable of removing the battery endoscopically they would people would advocate removing the battery because you're already there yeah that's i would think you're already there you might as well remove it right but some of us might be doing that esophagoscopy using a rigid esophagoscope in which case you may not yeah yeah i think there is some stuff out there in the gi literature about you should remove it from the stomach if it's one of these 20 millimeter batteries or not but i could because it may or may not pass the ileocecal that i don't know 25 it's 20 20 to 25 is the millimeters are the batteries that are the ones we worry about the most yeah um the uh my concern about doing the scope is that i think you're going to i'm worried you're going to take something and make it worse if you don't have to do anything if there's no reason to scope the kid i would avoid it because i don't think there's only a chance of causing harm i don't sure there's i so agree there's risk to every procedure um but it again it depends on how severe the it's like any other cost of congestion basically yeah so i just want to make one final point about trying to mitigate the degree of injury that you have because you look at these things and they're terrible and you just wish there was something you could do and there's some evolving work in animal models using agents that you put on the area of injury and i think it's quarter percent acetic acid and so that's what we're going to plan on doing in our or when we take them out and say any evidence of injury to neutralize it amazing i had no idea that's yeah you you you have to get we're working on that as well and we're talking to the pharmacy and it's yes it's not just like you can order it it's not something off the shelf so i see but that would that will change things a lot that's great to know so bottom line is it's emergent get them out as soon as you can they're bad awesome thank you uh but sorry one question dan for lie injury or any esophageal injury that's circumferential do you ever put something across it so that if it closes you can get a g-tube in yes okay um just a line just a line how many people get a consult for it's we just need a line so uh so this is a real case a 13 year old presented to the pede service with hemolytic uremic syndrome it's very proud of myself for getting a hematologic slide on there uh and then you know it's posted by your partner who was on call last night you're the sow you're just back from seeing a trauma they brought the patient back to the or before you can get by to see the parents you say hi to them and you are tell them it's all going to be okay and then you know you go and you review the chart the peds note says to or in the am for vascaf for peritoneal dialysis what does that mean in turn consented for a vascaf nick you gets a head you got a potential ecmo coming in the patient's asleep what do you do do you put in a temporary dialysis catheter in the right ij do you put in a peritoneal dialysis catheter do you call the peds team do you call the intern who consented the patient like what do you do so what i did is we called the team the primary team and they said no we want a vascaf so we put in a right ij vascaf turns out nephrology apparently everybody was debating this they really wanted a peritoneal dialysis catheter but we did this for a couple days because usually we do peritoneal dialysis for h us because we questioned that and then two days later we were back putting in a peritoneal dialysis catheter okay it's an incredibly common issue for us or has been and we've tried all sorts of things to mitigate that about what is the right catheter before you get to the recovery room have you put the right catheter in yeah at the cleveland clinic there is issues with line placement all the time and so now there's like an actual anytime that a patient's getting a line there's a separate form that they have to fill out where they specify exactly what type of line that they want how many lumens uh all of that we also have that form and just last week when i was the sow which for those of you aren't familiar stands for surgeon of the week it's not an award yeah i know it's not an award i had to call the service to say we have three dip this you know the pre-op information says three different things what do you actually want yeah so we have a very similar mechanism with the google line request form that has to be filled out specifically though one of the things is who's the attending responsible and what's the number so when you we've used that multiple times so if it's a nephrology service we're not calling peds we're not we're calling the nephrology attending um but and we actually won't book the case until it's that line is actually in the patient's chart we we have it scanned in and a physical copy of it so it has to match yeah so we actually have a uh an order set in our we have an order for it in epic this is a paper version of it that i put up there and at the bottom is uh this latest revision has who is the uh the resident and the attending you know and everybody responsible for that patient with their contact information so we can get it right away because i know for us this is a really it's a pain in the rear problem this is a great everybody has and what i'm trying to emphasize is that it's just all about communication because there's so many combinations and permutations of the just a line and does your form say what we also have them say what line every line that was there in the past so we we have that on our thing so we know what's available we we don't have them putting every line there but we can get that pretty easily out of epic okay um so here's here's another case uh this is a pretty active 16 year old that has sickle cell but has complications of his sickle cell and is on a transfusion protocol this kid probably today and i actually don't know if he's gotten one would probably get a bone marrow transplant in our hospital for a sickle cell but has a history of multiple lines mrv shows again again like my hematology slides yeah like i got the sickle cells um his mri supposed to be the next slide um well basically the whole upper system is an mrv that's with the both subclavians and both ijs clotted off there's reconstitution of the superior vena cava with the azagous which is what you usually see in these kids that usually that stuff usually doesn't clot off so what do you do would anyone here uh do a saphenous vein cut down i would yeah because there are some people that would you can do a broviac or a you know cuff central venous catheter in the femoral with the saphenous vein cut down even though they're active you could do that nope there's that's popping up some there too it's just because todd would do it people are jumping on the bandwagon that's probably that's how people don't think so just two weeks ago i had a similar case and we have a really great ir guy and we went to the ir suite brought the whole or team there and did uh managed to get above and and took a long time but eventually got a wire than a catheter hold on hold on hold on oh sorry yeah we got we're gonna well i know what you're gonna say you're giving the answer oh so nine percent so see mac started talking and all of a sudden people want to poke the heart so uh yeah so i'm gonna go so this is what we did um and this is actually a video we presented a few years ago with uh kurt kentz who's in tennessee and matt clifton who's basically what you can do is and what we did is under thoracoscopic guidance we put a needle in the right neck and went along the course of the superior vena cava and you can see it scarred down up in the superior mediastinum but just track along the mediastinum and get into the superior vena cava right where it reconstitutes with the azagous vein and then get a guide wire and then just it's just another line that you can uh dilate up one of the keys is that you need a longer needle than comes in the kit so we used a spinal needle we did not do it with ir but you know i guess you could do with ir we just did it under thoracoscopic guidance um and it worked really well it worked well enough that this kid actually kept that line for about a year or two and then something happened to it i forget what it was and we came back and we did it again and it was sort of just the same thing over again so i think marcus jarbo reported doing this essentially we're using ir using radiographic guidance or ultrasound guidance as opposed to thoracoscopic yeah but it's the same sort of thing and my guess is that you can just probably just as far as i know you can just keep doing this we've done you know maybe half a dozen of these when they've come up but it's not uh again it's uh it's a pretty straightforward technique once you're doing it everybody gets a little nervous but it's pretty straightforward so you were not in birmingham i just i recall um in our case what we did actually the clot went in the upper atrium and so we had to get into the distal atrium then we balloon dilated the clot to make a channel that wasn't just going to thrombose right away that's why we had the whole or team standing there cheering i think i was scrubbed in passing things to him so a little bit different so uh next case uh five-year-old needs just a single lumen cuff cvl for treatment of alll how do you approach this and what i don't actually don't have on here is subclavian using ultrasound and there's some folks that are using ultrasound for subclavian sticks which we're not doing yet i think it's a different approach it's a super the super clavicular approach the the new and in the papers on that the pneumothorax rate is still higher than the ij um and then there's some mixed data about higher in fact there used to be some some data that you get a higher infection rate with an ij stick although that's that's very mixed data and that doesn't really pan out in a lot so most people are going to do a right ij stick using ultrasound and that's what we would do uh currently um but you know there's there's a lot of papers out there about you know what is the you know the intravascular complications based on site uh subclavian you get a little more uh pneumothorax ij question whether you get more infection but the bottom line is it's really not a whole lot of difference in all the in all the uh different uh routes that you go and many of the final recommendations all say you know basically write ij ultrasound or you could do a or or you could or ultrasound i should say ij ultrasound guided or a subclavian stick so i uh it was sean st peter's paper out of kansas city that convinced me years ago to switch to this when they showed that using ultrasound guidance and an ij had had better outcomes um i don't remember oh there it is so uh that yeah and then the other person carolina milan is a pediatric surgeon argentina who came to spend some time with me and actually she taught me a ton more than i could ever teach her and one of those is how young i could go with percutaneous sticks um i was always a little hesitant to do this and then in the newborns uh i did cut downs and uh since she came now i even do them in that age as well yeah i mean we we do percutaneous sticks and almost everybody the tiny little micro premiums we still do uh a cut down yeah okay but actually in that that i didn't even cover that and it was in those kids i don't ligate the jugular vein i just poke it with a needle and then thread thread a catheter through it so you don't ligate it that's interesting you can get it back again the other thing the other trick that i someone taught me i think it was oliver sold this this idea of a micropuncture needle do you have that as well we do okay we do have the micropuncture needles okay so you have a 16 year old trauma patient and he's a central line for pressers you place the line in the the right subclavian using landmarks and that arrow is pointing to your catheter so what do you do people here in the room between the last two who would um try again at the same site who would go somewhere else so who would try at the same site i would probably try it it depends if it if you put a big dilator in there then you might have a hematoma right and that's a that's you know that's my point i'd try again at the same site but i wouldn't persist very long um i'd go to the other side okay is what i is what i would do but again this is one of those things that you know you want to look with fluoroscopy too because you don't want to have you know you don't want to end up with a hemothorax on one side and a uh and a pneumothorax on the other sorry we have a ton of questions that um we'll answer but uh faiza heider who has been coming on to these events for about eight years or seven years uh she actually she's in bahrain and she said that they do external jugular uh access back to the original thing does anyone here use that as their primary site ej if it's there and big i did for years yeah i get a lot of used to's yeah i used to so so mark rowe taught me how to do that when i was in i was in pittsburgh for a year doing a critical care fellowship he that was like his primary go-to and he talked about it and how you could you know but there were all these tricks he had and and they it's not as easy as you think to get to the junction of the ej and the ij things can get hung up and stuck and go the wrong way yeah you use the facial vein that's yeah facial vein cut down we used to do those too that's what i used to do too all right next okay so so he's going to present a case that we saw at akron recently um so this is a three-month-old male in the nicu he's got intestinal failure um and has a femoral broviac in place for long-term iv access for tpn and he's preparing for discharge in the next few weeks but still needs that iv um and at the time of uh rounds one day we notice uh this so the outer sheath there is is now broken so there is some debate amongst the group about what the next best step would be and thought it'd be great to bring to the update course so um so damaged broviac and patient broken sheath on the broviac is going to need central access at their upcoming discharge what would you do so my question is why did you put it in the femoral in the first place because like if that that might influence what you would do if there was a reason that drove you to put it in the femoral he had also had a hemodialysis access site previously so the femoral was the one that was selected for his i think he had the hemodialysis line in the broviac place at the same time pretty much good question i don't know the answer why does he still need the line he's still a intestinal failure patient and needs it for a tpn yeah i don't know if you all can see the variability but a lot of variability but about half will repair it with the kit some people talk about exchanging it over a wire placing a new one over the new site so the debate that the reason i asked alex to present this so i came on as sal and i'm a repair kit person one of the other surgeons said that you know if this patient is going to need very long-term tpn they would rather replace the line um my argument was that's exactly the reason yeah why but then the question is well how many repairs can you do so we debated it eventually was repaired with the kit but the question was would you ever not do that so it sounds like most people here but it is impressive how many other people would not do that so we saw um one study that was looking at um complication or infection rates comparing the repair versus uh placing it a new site um and uh they had like 36 patients um who um had a broviac in place and looked at how many ended up getting a repair and i think there was like 96 repairs and only one of them ended up getting a central line associated bloodstream infection so the one percent risk for infection uh with the repair and most of them had multiple repairs um the median was 1.5 repairs per a patient and um some of them even had like 10 repairs on the same line yeah you can keep repairing them so you have a a six-year-old with aml that has positive cultures for staph arias through central venus port so what is the single most important way to prevent central venus catheter infections because i figured that we can't talk about central line complications without talking about the most common central line complication which is central line infections all of these things have been shown to impact central line infections including dental care especially in your hemont patients so we actually have dentists who sold they're there to prevent central line infections in our hemont patients preventing mucosal barrier infections and things like that we talk about mbi clapses and non-mbi clapses but it really is all the above there is a lot of data to support this and it's really hard to pick out if it's any one of these things that does the most in this patient or whatever it is so these are this is just a pitch for the central line bundles that we all have and to follow them and this is the kind of thing that for those of us in leadership positions we're constantly harping on this and you know making sure that people don't forget it always amazes me when i start to see hand hygiene fall off and uh you know then we have to have a little new foam up foam you know foam in foam out campaign and those sorts of things but you like it's a never-ending it's a never-ending battle and it's really something that should be on the forefront of our minds because to remember the most common complication of central lines is a central line infection when you get an infection what's your initial treatment so that's so i so i didn't go into that here then um but if it's if it's staph or something that's treatable we'll treat it through the line um so antibiotic antibiotics well so in high-risk patients actually in our high-risk patients we're doing antibiotic locks so in patients that are short gut and some of our hemat patients we do uh we're doing ethanol locks for uh to to help there's some evidence that those help i don't know if everybody's doing that or not are you guys doing that as well yeah it looks i've seen lots of nods about people doing that and we don't do that in every patient though just high-risk patients what i was telling i think alex was on rounds with me yesterday two days ago and i was telling the team that when i was a resident or a fellow we were taking out lines a lot and i don't think i i can't remember the last time i take out in fact i mean it's very rare we take out infected lines now because we can treat through almost all of them almost all of them so so gram positives you have about a 90 percent chance of clearing them gram negatives it's closer to 50 percent fungal it's it's it's really hard so if you know so that's sort of you know depending on the risk of the patient and what you need and what you need to do it but usually gram positives we can clear the others you a lot of times have to take it out just want to make a comment about a standardized dressing what the surgeon thinks is the right dressing is not what nursing thinks is the right dressing that is true and so what happens is you put on the dressing in the or that you think is the right dressing for that line and as soon as they get to the floor that's not the hospital approved standardized dressing and it gets taken off uh-huh that's how the line gets pulled out that's how the line gets infected so i'm encouraging everyone to work with their nursing leadership to come up with a standardized line yeah so so megan durham one of uh one of my partners uh has uh spearheaded this and and she uh and some of the other folks they actually took pictures of what the standardized dressings are and put them up in the operating room so that we can see what we're supposed to do but and if a lot in our case we found that the recovery room nurses or the pacu nurses were change or like you do all this stuff and it'd be all look nice and pretty and then you go and they'd be changing it just because it wasn't the standard dressing we had the same problem and we all the other problem we had that we had to address is that the standard dressing changed every three weeks and no way you're communicating that to everybody was a challenge so we've done the same thing on our central line cart we have pictures of what the dressing supposed to look like and that is the dressing and unless there's there's evidence to change it to something else that's the dressing we i think all now recognize the importance of the opioid problem and certainly in our earlier polling it even seemed that it was a very high rate of people doing the right thing however when you actually look at data that's been published in recent years not everybody is plugged in so i do think it's worth going through again this was two days ago for my buffalo news newspaper the opioid crisis may be over according to a county administrator but the experts disagree uh you do a laparoscopic appendectomy for acute appendicitis five hours later you're ready to discharge what do you send them home on all right i'm going to move on that's because we did it the first part we practiced right this question's irrelevant so is that so okay are you really a hundred percent with that our our group is because we we had an intervention we really did with someone who wasn't uh no no no we just as a group got together and decided we were going to do this and the question is then they're going to come back and you can't call in the narcotics so what do you do say that again the the question has been in previous years when we talk about opioids that if you risk the chance of sending them home with nothing you're going to get the call in about four hours or three in the morning that you have to write them a script and you can't do that right is that what you're saying i'm saying it's well it's it's harder to do that now it's a pain to do that right it's hard to come back to the hospital you say come back to the ed i guess but we have not had that problem for acute appendicitis the same question about umbilical heart do you put them on schedule yes every four hours alternating alternating yeah when they're awake alternating acetaminophen and ibuprofen so um so let me julie rios is going to be giving a talk here and actually i was looking for your title to introduce you but i'll do it later um but she's one of our um gynecologists here at cincinnati children's you take care of adult patients correct what about is what's happening in adults are you giving less narcotics to the adults i give less narcotics to the adults um so i also use try to use acetaminophen and ibuprofen and then i will send them home with a few of the narcotics separate so it's not linked to the ibuprofen kind of as breakthrough so if you get that call in the middle of the night they have something that they can use as breakthrough but it's only for one or two days so you give a few i give a few and it's just the oxycodone by itself so i let's uh people chat in the group i'm very curious what people are doing in other countries with narcotics okay let's keep going can i ask can i ask a question how how many people are using toradol in these kids like give them a dose of toradol before they wake them up i always do i'm a big fan of toradol i have some data on that too a little bit later so sorry no no thunder stealer uh looks like for umbilical hernia repairs it's either just acetaminophen or the combo but the background here is over the past 18 years 9 000 children and adolescents have died from this mortality rate has increased threefold mostly males but even in kids zero to four there's a seven percent death rate from kids getting opioids and 25 of those have been homicides 81 are adolescents the heroin death uh death rate has increased 400 485 and opioids almost twofold this is a uh uh 2018 publication mac kurt heist just wrote kurt heist for those of you don't know from atlanta has talked to us before in this event about era about enhanced recovery he says the rts what's rts the return to system that's total atlanta term because i don't think the return to system or coming back to the hospital or callbacks are the same for those with or without opioids if the tylenol motrin doses are scheduled and given in advance kurt thanks for that that's uh thank you kurt uh so here's some data again not just audience so here's a study looking at 06 to 14 again maybe we've gotten past that now but 68 of those patients were prescribed opioids uh and the adult general surgeons tended to give more than the pediatric surgeons uh and the opioid group has uh increased ed visits for constipation and i i know i've seen that so some data for our umbilical hernia reflect rethinking back to our own uh results i'm sorry that's small this is 12 to 15 data uh 4 000 umbilical hernias 52 percent received post-op we go it's as opposed to our data which was zero zero in our vote right here right oh here here in the vote yeah six years old or older were tended to get a get more opioids than younger kids and southern u.s was more problematic than northeast and again the durations less than three days was 50 percent four to ten days was almost 50 percent and greater than ten days four percent so again recent years have shown this to still be a real problem um this was a a small study led by david rostein and sarah cairo at our place in buffalo uh just published uh earlier this year where this is the intervention todd so we we looked at how much pain medicine we gave for simple things like appendectomy and then we did an intervention where we educated everybody including nurses anesthesiologists the whole hospital and then we re-measured again after the intervention this is more of a you can do it slide so here is our early the first post-op orders use of ap ap is acetaminophen again ibuprofen ketorlac morphine and then a combination of hydrochloro and acetaminophen and um but the blue is after the intervention you can see that uh dramatic increases in non-opioids or narcotics it was interesting that morphine didn't change yeah i saw that is that recorded because it was given in the operating room like by that was given by anesthesia probably no this is post-op get surgeon ordering okay you can imagine maybe an early post-op one dose or something like that uh then this just sort of restates those same information and shows p-values to what was significant in their change and this is now at discharge pre-intervention and post-intervention so pre-intervention 84 of our patients got narcotic at discharge for an appendectomy down to seven percent uh 31 got acetaminophen up to 94 percent 58 got ibuprofen went up to 86 percent miralax automatically at discharge dropped from 77 to 47 as we had less problems with constipation it's amazing so um kurt uh uses gabapentin too do you guys use that at all uh i don't but i anybody in the room because anyone here is gava i'm interested dan von allman uh from cincinnati let's pass it around von allman from cincinnati says that uh we use gava here this is mark wolkin we use gava extensively uh in atlanta uh you know kurt kurt got us started on that but it's uh really remarkable how it's changed the pain management for the kids and even for the kids that have had major operations when you give a dose preoperatively and continue it post-op the it's really remarkable how well they do can you tell us how it's dosed so we're using basically 300 milligrams tid in uh in the in the bigger kids uh and then uh i i want i i i don't i'm not going to say our dose publicly it's in the order set so i don't know what it is for the smaller kids i i kurt kurt kurt can text it in or type it in so dr uh highest respondent for the gabapentin dose in the younger kids five milligrams per kilo per dose tid for three to five days what about in kids who are npo you continue to give it to them even if they're npo well as part of our eras protocol we have very short npo times you know they're npo if they want to be i mean one of the challenges with gaba though and some of the younger kids it's it's a large volume in the liquid form to get the right dose in but it hasn't been a it hasn't been a terrible problem has it helped in operations like pectus repair and have you seen a decrease so i i think but we're doing multiple things in the pectus patients we're also doing uh doing intercostal nerve blocks and some things like that we just we just now i think we i think we finally got our cryoprobe i don't think we've used it yet uh we're going to do some of that as well but for example in my bariatric patients we you know it used to be the first night they're usually kind of miserable and we went from post-op day one discharge about 20 percent of the time till now 50 plus percent of the time we can get them home on the first post-op day fred riskorla and we use gabapentin as well it's mainly with our pectus eras protocol and found it to be helpful but there are multiple other aspects of the protocol just out of curiosity does uh are you using that in adults julie uh like did you change the way you manage patients post-operatively or not formally yet i don't know if we formally did i mean most of mine is laparoscopic surgery and so most patients go home the same day fully is out before we leave the or so trying to make sure the patients are doing well from a open standpoint if i do an open case i've used a lot of tap blocks um with anesthesia and most of my patients go home post-op day one tap blocks who here is using uh can you explain what a tap block is because so essentially it's a um medicine that goes in uh intrathecally into the um they essentially give numbing medicine and it's a catheter that stays in that essentially numbs the abdominal uh wall and essentially allows them to get up move um they'll pass gas that same day because they're not really using any narcotic medication and we just schedule ibuprofen and tylenol with it uh and we have a question uh from dr gray fabian gray anyone using ivy tylenol and are you having trouble with your hospitals letting you use it occasionally and yes i use it we use it quite a bit at least in akron and cincinnati i don't know here too i'm getting the nods about here too yes i'll zoom in come here i want to make that so you're really pretty ivy tylenol is is is very expensive as everybody knows and i know i'm involved with i guess i'm one of the ivy tylenol police in our hospital along with our p and t committee but we have what we where we've loosened up is in places where it's appropriate in our cardiac icu and the nicu and some places like that but the reality is that it's no more or less efficacious than per rectum tylenol so unless you if your patient has a rectum then and it can be administered that way i mean it's it's it's literally cents versus a lot a very well it's a lot of money but the the other piece the other confounding factor is that we've actually softened up on a little bit because it is now much cheaper than it was it used to be hundreds of dollars a dose and i think it's maybe 20 or 30 dollars a dose but the reality is that it's correct and works just as well with the same bioavailability prospective randomized trials i i don't know i i don't know max calling me out on whether it's class a evidence i think i think it's good yeah yeah yeah well i know there's some pharmacokinetic stuff that the pharmacists show me in the in the pharmacy in the pharmacy literature about bioavailability yeah so this talk is it's sort of in two parts just a general technical discussion about for laparoscopy how we access the peritoneum and then at the end liz is going to focus on a particular particular problem that we need to be aware of and and figure out how to address the process so just uh get started for a 10 year old with appendicitis what does dissection clamp passage mean that's what you do clamp passage your hemostat when you pass your hemostat down through the unbiblical fascia pass a clamp and then you take your clamp back out i see you come back in yeah yeah yeah yeah yeah the needle right yeah but i don't do that in a 10 year old by the way okay that's only in while we're waiting for the answers to come through i only do that in four year four week old pylorix once they're older i do various needle i do various so you would have you would have picked uh b i would b all right b or if i do a hassan it depends if it's an extirpative for a gallbladder i'll do hassan so just polling the other people in the room mark b so we're just various needle through the fascia in a 10 year old that's what we're talking about with a open a section okay you want to vote no how do you get what do you do how do you get access how do i get access yeah uh i just do direct entry with uh visualization in my adults so optiview optiview okay does anyone else here use i did it for my first time uh last last week uh you use optiview quite a bit right okay it's a good thing to use if you're not going through the umbilicus yeah i did it through palmer's point yeah this past week yeah all right but i varus first i varus first to make my oxygen safer to distend the abdomen yeah and then i did it one option that you didn't have on there and i'm shocked is sills okay or forget all that other stuff would you have done a single side approach either the sipes which is the left bottom left picture or a tula which is where you pull the umbilicus out of the umbilicus out of the appendix out of the umbilicus and do an apodectomy on the outside so what what do you say then put the scope in and do the rest of the after that so uh i do it uh uh two different ways so i'll do an operative laparoscope through the umbilicus or put the camera and a grasper through the umbilicus grab it pull it up but either way classic tula the second one is i do extra extra corporeal single incision appendectomy so you make dan happy because you're the cheapest appendectomy in the hospital yeah we don't know what percent of the total population voted for the sdoe now a lot of it depends on the body habitus wouldn't you say no it depends on the surgeon okay surgeons are very committed to their one or the other okay i would disagree with that but that's okay we've disagreed before i want to hit on what wit just said so i will adjust what i do based on several different factors some say always do the same thing no matter what i will if it's based on if they're large body habitus i will do a three-port appendectomy i won't even try single and we publish papers on you can take the ob 90 90th percentile and above pediatric population and do sipes appendectomy just as well as three trocar so wound issues all that stuff it depends if you're doing an intracorporeal or an extracorporeal single port appendectomy not if not if you have a wound protector it's the same in fact it's better if you have a wound protector that type of trocar we use has a plastic lining so it the appendix never touches anything as it comes yeah so this question was when it's time to pass your needle in your trocar do you pay attention to the direction it's going do you try to go in and up toward the spleen in and up toward the right in and up toward the left straight up or do you go straight down i go up i lift because i lift up on the umbilical stock and then i poke superiorly superiorly in what direction you mean left or right yeah superiorly straight up oh that's the wrong answer i know what you're getting at but i still do that all right any other comments about this i i learned from keith jorgerson to go in and toward the spleen so is that right that's what i do so well that would that's the natural inclination for a right-handed person if you're a right-handed person stand on the right-handed side of the in fact even if i'm going to help a resident or fellow i oftentimes stand on the right to put the first stroke card in and then we move to yeah just to let them side of the patient well i know i'm going to do it safest okay so straight down that's not i would say that's not really what we want it's amazing in it especially in some uh bigger obese people and teenagers the distance between the posterior fascia and the umbilicus and the aorta is about this far and intestines lying on top of that so i think a lot of this is just how you insert your varus i i generally do not go more than a millimeter like that get that loud audible click for me it's that i have a loud varus needle because there are different brands of varus and i like the ones that make a very loud audible click after you pass the paradigm i agree with that and i hold the needle at the bottom so do i yeah and you ever helping helping a resident or fellow and all of a sudden go oh they went in too far you don't have that that's why i do the hassan technique that's what i do too yeah say that again mark i'm sorry like a dart yes very close to the tip all right i think you you uh touched on the reasoning for not going straight down but it's because in whatever direction you want to go to outside of straight down you've got much more space to insert the the trocar and the cannula yes and if you go straight down when you put your telescope in the first time oftentimes i notice people start looking around and i poke a hole in something you know scott bollinger my partner in akron made a quote once that i think is very true all these things are great all these things are important the the key to success is that when you keep doing the same thing over and over and over again is how you minimize it's when you start trying new tricks and techniques is when you end up getting injuries so when you put your thing in a different location than you normally do that's when you cause problems if you do the exact same thing every single time you usually are safer but there are areas in the abdomen that are safer right if you're if you're poking straight down the thing that's there like mac mentioned the aorta the most frightening thing are the iliacs right you get the iliac vein and you're gonna have a really bad mass and there's no iliac vein in the left upper quadrant yeah but it's okay i mean i just it's very rare that i'd be putting the varus needle in much more than a couple millimeters if it is i would do a hasan but i felt like it's someone i couldn't if it's not a very thin patient that i could know that i'm just a couple millimeters in and hear that click then i would do a hasan i don't do the varus unless it's a an easy varus but the question is not just the varus but it's the port the trocar and the candula oh which direction you insert yeah yeah okay and just to comment on your if you do do it the same way every time how do we then ever innovate so i i guess there's migration to to what you would call a safer technique i'm talking about the cases i've heard about people getting injuries is when they have done things um like insert them in the left insert them in different places where they're not used to and know the feel of it um when they've got an injury if you're trying to modify the technique to make it safer like which angle you point it in i think that that's probably not going to cause much harm if you use the sheath varies needle approach do you insufflate before passing the trocar i don't use sheath i you don't use a sheath not first well we we we're not using the step anymore but it with the open hasan i would just put the sheath in without the varus and then put the cannula through the sheath and not before and then insufflate yes so if you do a hasan you can either make the incision on top of the umbilicus right through the umbilicus or under the umbilicus at our place we generally make a vertical incision right through the umbilicus except in the neonate now and what do you do in the neonate well we're i try to make an infrabilical incision okay liz what do you do through the belly button see the peritoneum and see that you're actually in the abdomen so you okay so you through the umbilicus skin incision through the umbilicus skin incision through the umbilicus and what and and through the peritoneum and then put the wait sheath in so you're cutting down through the you're you're assuming that in the babies in the babies so in order if this is some if this is 16 year old yeah then they they're getting the cells we don't we do how do you make your how do you get how do you get access to your cells how do you we make an incision through the umbilicus it's open yeah it's a mini linia alba midline incision it's a dpl incision right when we were doing diagnostic peritoneal lavage back a thousand years ago yep it's the same thing no one knew what that was right so the dinosaurs are roaming the earth okay now we're focusing on specific patients so a two-day-old with duodenal atresia the same question we asked at the start about how you would get into the peritoneum duodenal atresia i'll do an infrabilical incision because it's gonna it's gonna be a newborn with a wet umbilicus and you really need to be careful you don't cannulate the uh umbilical vein and then how do you so you make an infrabilical skin incision and then how do you get into the belly i put a varis needle through out a sheet without a sheath yeah you know i i think that uh the those the step trocars are not designed to be placed with the sheath in because it's a big step off a big change in diameter and i really worry that you'll deflect the abdominal wall and injure something so i think if you use a step you should always put the varis needle in first safely insufflate then put the varis needle with the sheath in to insert your sheath i do the same so i've never heard of that yeah i do the same it was a stevenism just never heard of that yeah it's a much more it goes much more slick and smooth when you put the varis without the sheath the sheath adds that little obstruction to it huh that's why i won't use that trocar because i can't stand that step off now i've never tried just putting in the first first because that's what i do anyway yeah so mark a real technical point here we can get in the weeds a little bit do you think you can make that infrared umbilical incision and still come at an angle with your various needle that you could get the vein or do or now we're back to going straight down and you're not going straight down a centimeter below the center of the belly button so and with a little baby you can actually something remember keith used to do this all the time you can grab the umbilicus and just lift it up you want to use do the towel clamp trick you can but i think that if you cut you remember the umbilical vein is going to come up through the center of the umbilicus if you go below you shouldn't be hitting that orifice i think the danger isn't that you're going to the danger isn't that you're going to you know somehow go in the belly and then cannulate the umbilical vein i think the danger is that you're just going to go through the orifice or the the obliterated orifice of the umbilical vein which is the base of the umbilicus so if you go below that you should be in theory outside of the umbilical vein so um along this is what's interesting i'm thinking now what it what are the risks that get you into the umbilical vein which we're going to talk about but that's what i do exactly every time and this is why i go superior so i grab the umbilical stock with a coker or snap lift it straight up and i go try to go perpendicular to now the fascia instead of flat is like this and i go perpendicular to that every single time and that's what i do you do the same yeah i do the same with just a varus without the shot yeah yeah high five on that okay be on the highlight clip oh yeah 50 50 don't need to worry about what we're talking about right because they do it but see i worry about i worry that a quarter do dissection and clamp passage into the peritoneum and then it varies because i worry that you can open up that that open up the umbilical vein but i think for those that do that you just need to be careful and know that you're popping into the peritoneum well i think the important point i think liz may get into this a little bit more is that at least from my knowledge until about a year ago i didn't know about any about this potential complication and maybe that's my ignorance that is of of either cannulating the umbilical vein or getting co2 in the umbilical vein you're going to talk about this and and so to me it's it's it's really interesting that we've been doing this for over 20 years and this devastating complication is really just coming to light or or just becoming knowledgeable so so what dr holcomb's referring to just to say it because dr byerly is going to go into depth on this is that in the last year there has been a lot of recent discussion among some of our colleagues uh who have seen a lot of they've heard of a lot of cases or seen cases of when the access was made there was entry and air entry into the umbilical veins causing an air embolism and that's what we're a co2 embolism a co2 or or air or air uh which is a big problem and that's what we're gonna that's what i'm stealing dr byerly's thunder but that's essentially a big reason of why we're talking about this right that's where we're going and which point was that why is it that i have never heard of it before this year you've never heard of it before this year and now all of a sudden everyone's talking about it so it was a hot topping at ipeg that that's where it came up dr rotham going to percent it right but 12 cases but why did but we didn't hear this from steve until about a year year and a half ago when he started talking about it before that i'd never heard of a case two or three years ago is the first one and i've heard of three or four or five more since then and he's he says 15 that he knows about right yeah all right we'll get because we're way behind now okay i'm sorry we'll hurry ahead how about a four-week-old with pyloric stenosis same question about access anything different here two-day versus a four-week chords a little better i'm d here but i'm i'm not d sort of i am i am dissection past the hemostat and then put a port in okay you make the hole big enough to just drop the port in okay so although there's no prospective randomized trial on this at what age do we think we don't have to worry about the umbilical vein yeah the umbilical vein being problematic it's a great question steve says two months i don't know where you got that i can tell you where he got it out of his back pocket sorry steve well look at that that's amazing there sort of a four-way split interesting all right here's the case as you access the peritoneum for a pyloromotomy in a four-week-old male with pyloric stenosis the patient becomes bradycardic hypotensive and drops his end tidal co2 you you immediately worry about i hope this answer is straightforward so just a 30 000 foot co2 embolization is a rare event it happens in adults but it's not usually the umbilical vein it's just like can you imagine a very very senior the umbilicus and somehow you get just into the venous system and blow co2 clinically significant embolization results in a mortality of 25 some people have discussed trans esophageal echo urgently to try to help figure out what's going on treatment immediate treatment options that people try are immediately desiflate put yourself in trendellenberg a central venous line to suck out the gas gas and i know of several cases who have gone on ecmo emergently and at the start of the pyloromotomy so be aware don't we don't really know the incidence in babies but the impression is that it's real and deadly pediatric surgeons should be working on a technique that lowers the incidence and thus the reason for these discussions uh i believe now when i put i use a sheath but i always put the trocar in before i insufflate look with the telescope make sure i'm in the peritoneum then then put on the insufflation but i have to say steve rothenberg who's worried about this believes that you can get co2 embolization without necessarily just having your needle or trocar in the vein he believes somehow there's a way to damage the vein on the way in and insufflate into the peritoneum like you're supposed to but have the co2 rush back up and go through the vein and so the open technique may be the safer way a la what wit is described as the inferior facade well so and i don't know this information but does anyone have any impression of is is this occurring with a variety of techniques or is it maybe one technique that's happening but i don't know the answer to that well again steve because he and i have discussed this a lot would say anybody who's not doing an infarumbilical incision doing a hassan approach straight down all the other techniques are at risk is his opinion right and i don't think we know what's right okay so same thing um basically you have a baby that you're starting your lap pyloric on and all of a sudden the end title co2 has become non-detectable and the child has a cardiac arrest so the question that we pose is what is the most likely cause of this arrest during laparoscopy gas embolus unrecognized hemorrhage to the trocar site pneumopericardium from extraperitoneal insufflation monitor error and inadvertent endotracheal extubation yeah your person your question was much better than max i agree but now everyone knows the answer so we've made i did give the we've made glorious progress right actually actually the most the most likely cause is e yeah because this happened the gas embolus doesn't happen very very much correct i mean i think that's correct but hopefully you will have the wherewithal to have gas embolus at the top of your mind on your mind yes and not you know it's very convenient to blame everything on anesthesia we all love doing it right it's rare but the mortality is high um one of the things that's that's actually interesting is that it's nitrogen and the air embolus that causes the most problems with hemodynamics so one trick that you can do is you know that the insufflation tubing has a large amount of air in it probably 40 mils if you run the co2 through the tubing and you before you hook the tubing up then you'll minimize the amount of nitrogen that you actually put in that's interesting so there are some there are some people that think if you run the co2 through the tubing that you'll decrease the risk of really having a significant gas embolus wow didn't know that i that will be a change i have not done that before um management again take out the cannula desflight the abdomen put the baby in trend allen barge um inotropes chest compression um some people talk about aspirating the gas through a central venous catheter and um obviously ecmo or hyperbaric oxygen that's a great slide because these things are not things you could look up you kind of just have to hope you remember what you just showed uh it's very you know when we were in training for general surgery we were all taught how to deal with an air embolism right never heard of it right and i don't think maybe any of us ever saw it right but we were all it was you know bammed into our heads of the things that you had to do if it happened yeah and so i think that's probably where these dictum come from or these ideas come from that was awesome actually that worked out all right so i'm gonna present on the mundane topic of perforated appendicitis um and i'm gonna go through a few articles some from our place and uh some from um other institutions and so here's the first question um and i realized that in reading this question we don't do a lot of ct scans but i just sort of thought the information was was kind of interesting so i developed a slide around the uh the information in in the paper and so you see a 12 year old child with signs and symptoms of appendicitis uh he's been symptomatic for 36 hours you think his appendix may have perforated in this and decide to order a ct scan so the question is how accurate is the ct scan in diagnosing perforated appendicitis there was this uh paper that came from uh our place i was not a part of it but my colleagues were and i just thought it was interesting information uh and it was in the journal of pediatrics surgery in 2010 and so what the paper's about is there were 200 ct scans who were reviewed by six surgeons two of whom were fellows and two radiologists so eight people uh the reviewers were blinded as to the diagnosis uh there was a lot of experience among those viewing the scans and you could argue that the the fellows probably had the most experience because they're looking at those every day and the reviewers were then asked to diagnose perforated or non-perforated appendicitis and on these scans there were no abscesses and so what was found was that the reviewers were correct in 72 percent of the ct scans which i thought was was a pretty interesting figure uh the sensitivity and specificity are as you see and the positive predictive value and negative predictive value are also seen but anyway i just thought that was kind of interesting because on first glance gee i would have thought it was 90 percent uh but it's really a little better than two out of three or two-thirds so you said there were no abscesses or did you eliminate cases that had abscesses yeah there were no abscesses yeah cases were excluded were excluded if they had an abscess thank you so anyway i just thought that was kind of a an interesting um interesting information all right all right so um you operate on this child and think he has perforated appendicitis in the operating room how accurate is your visualization of the appendix in determining if it has perforated or not okay so i think this is important because this this sort of gets is going to get to the idea of of papers in the literature on perforated appendicitis versus non-perforated versus suppurative uh versus gangrenous uh because most of the papers um they just mentioned that the patient has perforated appendicitis and i i always wonder that that the dying that the um there's no real definition of perforated appendicitis and a lot of us have differing uh ideas of what a perforated appendix looks like so in this paper this is from uh dr pondsky was the lead uh author inner uh inner observer variation in the assessment of appendiceal perforation uh and this was in 2009 and so what dr pondsky and his group did was uh there were 110 surgeons uh involved 62 attendings and 48 fellows these were adult surgeons as well as pediatric surgeons um there was a cross section of surgeons they were you know from university hospitals community hospitals and children's hospitals and among the attendings the agreement in defining an image uh as to whether the appendix was perforated or not was 27 percent so if you notice the um the uh answers i think they were either 90 or 70 percent and and in point of fact there's a wide variation in what each of us thinks is perforated appendicitis so i thought i've always thought this was a great uh you know one of the great paper so we we took one image we showed people images and some and there was the agreement among surgeons was no different than chance alone and whether or not was this perforated or not they were not agreeing but the funniest is we took one of the images turned it upside down and flipped it to the left and even people didn't agree with themselves and they saw the same picture later on in the study so inter and intra observer variability was close to chance alone yeah i think that this is a i personally think this is a real problem and uh when we talk about perforated appendicitis because we can't come up with a definition so um at our hospital uh we identify perforated appendicitis as a hole in the appendix or a fecal in the abdomen and and that's it uh if we don't see the hole or we don't see the fecal uh then it's not perforated and dr um saint peter came up with this um definition for one of our prospective uh trials uh in the early 2000s and i and we still use it today uh and i think it's i think it's a nice definition that i i would like or i would hope that uh we all might be able to use when we're talking about perforated appendicitis so we all think we're talking about the same disease process i think that because of your paper i do think that at least of the places i've seen have adopted what you what you all have shown um but what's controversy is is is everything else in the acute appendicitis group or is there a middle no bucket it's one or the other right and there are a lot of people who would put gangrenous into something else so what we're going to get into that all right the way sean explained it to me is in the it when they grouped stool in the abdomen or a hole in the appendix when they took all those patients that didn't have either of those the incidence of abscess was less than five percent that's the way sean explained to me and why why that grouping happened is that and and that's why we why we that that's what we care why we care about is who develops a post-operative abscess yeah so the data from this uh paper uh are right is right here so in that paper i just showed for the two years before a definition was used we did 292 uh non-perforated appendicitis and had an abscess development of 1.7 percent and we did 131 perforated appendicitis and we had an abscess development of 14 percent and then we applied the definition for two years uh and the abscess rate actually dropped for the non-perforated appendicitis uh and it rose for the perforated appendicitis and so what that tells you is in the two years before uh we were treating some of the non-perforated that were probably perforated uh and the per some of the non-perforated were perforated uh in the uh in the two years before and then you got those out of the denominator and so the abscess rate went from 14 to 18 percent after the definition so anyway i think uh this is the only paper that i know of talking about definition of uh perforated appendicitis and i would just uh i just think it's a really uh simple and easy definition to use and it's uh at least been validated in this one paper all right um and as todd said uh it really identifies those patients at risk or not at risk for developing a post-operative uh abscess all right the next uh question is you find the patient has perforated appendicitis and your resident asks you if irrigation of the abdominal cavity is beneficial well i think there's uh probably a lot of uh controversy uh out there on this uh on this topic and i'll just show you uh from our uh hospital uh that dr st peter was the principal investigator on this particular study um comparing patients undergoing irrigation and suction versus suction alone uh during a laparoscopic aphodectomy for perforated appendicitis and uh we use that standardized definition of perforation uh in this trial there are 110 patients in each arm uh the surgeon in the arm in which irrigation was used the surgeon had to use 500 cc's of irrigation as a minimum the average uh was about 850 cc's that was used there were no differences in the patient characteristics at presentation and the results found that there was no difference in the abscess rate between the two groups the length of hospitalization hospital charges or operative time and so our conclusion was there was no advantage to using irrigation at the time of laparoscopic apodectomy for perforated appendicitis now what that doesn't say is that there's no necessarily disadvantage to using it so if you still believe that you want to irrigate it's probably fine to do that there's just no advantage to uh to irrigating can i stop you yes some of the criticism that report has been that the both of the incidences of abscess formation are higher than some other studies the 18 and the 19 so any thought about that i'm sure you've heard that before yeah so i would say that's because of the definition that we used okay it was a standardized definition so all six or seven surgeons were using the same criteria for perforation and we were we were not putting non-perforated appendicitis patients in the cohort who were listed as perforated so therefore the abscess rate is truly reflective of perforated appendicitis makes sense and that's why that's why i brought up the idea of the definition was there a debate about how much irrigation because there are surgeons who do leaders and leaders and leaders and leaders right say that makes a difference right so i've got a recent paper on that great um so here's a um a paper from um our uh colleagues in um minneapolis at the university of uh minnesota that just came out this year on standardized irrigation technique reduces abscess formation after appendectomy in in in in reading this study um i would say there are a couple of problems that i've identified it's a retrospective study but there was no definition of perforation mentioned in the paper and there was no standard antibiotic usage over the study period which was 10 years from 2007 to um 2017 uh 432 patients uh 432 patients now of those 432 patients 105 of them were perforated which is about 10 patients per year with perforated appendicitis um and so the study was about a standardized large volume irrigation by one of the surgeons uh somewhere between three and 12 liters uh in small focus directed aliquots uh comparing that to surgeon preference for the other surgeons for the irrigation uh and the results were that of patients with perforated appendicitis if you used this uh standardized large volume irrigation the rate of abscess development was zero uh versus uh about 19 percent if um if it was surgeon discretion or surgeon preference used uh so although it's an interesting study i i would say that there are a couple of problems uh with the study design so i think you are you need to take the information with a little grain of salt zero versus 18. true it changed my practice this study and i maybe what did you have comments about it or no yeah more just um for uh in general i think one of the issues is that no matter how good your data are you can't beat a good rhyme um so the solution to pollution is dilution you have to come up with something different so my idea was um potentially uh the inoculation for contamination is aspiration so yeah just put that out there i like that so i i be sure to interview at our point uh there you go so i um i don't do nearly as much as he did you know the way this study happened is apparently that they were all teasing him that he used so much irrigation so they studied it to show him how crazy it was oops their study showed his abscess rate was much i can do the same study at my place what's that i can do the same study yeah really yeah yeah so um so anyway i think i think there's a a lot of a focus on this uh particular paper and um just wanted to try to present the the details of it for what it's worth there is a meta-analysis uh that came out last year uh looking at irrigation versus suction alone for um laparoscopic uh uh appendectomy the uh there are a few problems with this meta-analysis and i hope everyone realizes that just because it's a meta a meta-analysis doesn't mean it's necessarily a higher level of study because the the meta-analysis is only as good as the component studies uh which are being analyzed but there were three randomized trials and two retrospective observational studies uh 2500 patients most of them were adults though four-fifths of them were adults uh and the authors did not find any difference regarding development of an abscess wound infection or length of hospitalization so the authors came to the conclusion that there was no advantage to irrigation when compared to suction alone it's a good topic that we could do every year right we can keep doing this this so uh any comments or questions from anyone who does something different than what dr holcomb recommended uh i mean there's a lot here do we so do we irrigate or not uh the answer is we don't have an answer the the best quality study said no difference the more recent study that was uh uh not as a well-designed study did show a difference i think we can go by and see uh so alex in your practice when you're in it when you're a pediatric surgeon what are you going to do irrigate or not i don't know don't know you don't deal with it i don't deal with this okay liz no irrigation but but do suction out visible costs so so alex's aspiration rhyme right same aspiration yeah localized aspirationalized aspiration that's different i'm talking about localized puss too not not four quadrants so let me make one point about that study that disagreed with with yours is that this person did a tiny amount of irrigation push suck push suck push suck so we never irrigated the whole belly it was a focused push suck push suck push suck so 100 cc's at a time so i have modified since that study i never irrigated after yours for years and then when this came out now i'm now i'm irrigating so uh i don't know do you irrigate no no for von allman fred selectively yeah so the the comment from dr bill meyer is that it there's different situations if the appendix has been sort of walled off and protected by the omentum uh that's a different situation when there's pus everywhere um one interesting about pus everywhere is that in in their study um that was one of the findings that was in the group of no of very low abscess the pus everywhere didn't seem to correlate you know when we see the exudate but not actually a hole or not actually stool that exudate did not seem to pose a risk for abscess which was probably one of the biggest changes for me do you irrigate or not no mira no so it's a mix here sorry we can't give you a definite answer there's a comment here about a study from montreal that grades the degree of contamination and correlates that to the abscess rate so it's not all perforated perforations are created equally oh interesting from dr baird but i think i think that there rob baird robert baird okay i do think it's it really would behoove all of us if we came up with some standardized definitions so we're all talking about the the same disease process yeah well we'll get there eventually in the next 30 years okay okay so my next topic i've got uh just a few slides uh just to preface this the reason uh that so both of these presentations that you're presenting with are presentations in which your data disagrees with someone else's data would you agree with that statement uh for the first one i'm not sure it disagrees for the second all right we'll see at least by my reading of it go ahead it's todd go ahead so it's about meconium plug syndrome uh and i think it's important to realize this is not meconium ileus so we're not talking about meconium ileus we're talking about meconium plug syndrome and this is the newborn presenting with a transient large bowel obstruction uh that is relieved by the passage of meconium plug sometimes with a contrast in of a sometimes with some rectal stimulation but it's not meconium ileus and i did not actually know this todd but this uh syndrome was first described by uh william clatworthy uh in ohio state wow i did not know this in 1956 and so i've shown the the title uh page of his uh report and they described nine children uh one of the nine children uh developed uh or was found to have hersprung's disease um so our paper was um 2008 and this was a retrospective study uh and we looked uh over a 13-year period at newborns who were documented to have meconium plug syndrome from 1994 to 2007 and there were 77 babies and 10 of those babies were subsequently found to have hersprung's disease uh which was the uh about the same as the clatworthy paper no baby had cystic fibrosis uh a lot of early literature seemed to suggest uh well not necessarily a lot but some early literature seemed to suggest an association with cystic fibrosis and meconium plug syndrome and our conclusion with uh was that babies with meconium plug syndrome and abnormal stooling pattern should undergo a rectal biopsy a recent paper uh that just came out was from um uh dr lautz and colleagues at northwestern and this came out this year in the journal of pediatric surgery and it was a fist database uh study so fist is the public health information systems and that's really a database registry for hospitals participating in the children's hospital association in the united states and there are about 50 hospitals within the children's hospital association so this is a fist database study from 50 children's hospitals in the u.s it was over a two-year period and they found 373 newborns 43 of them had a hersprung's disease on an early rectal biopsy and a total of 57 or 15 percent were ultimately found to have hersprung's disease and so at least from my reading todd the in these three papers the instance of hersprung's disease is somewhere between 11 and 15 percent so that's why i'm not sure i i think that there's a lot of difference in these um these papers okay so that's because we had okay so we're all in agreement then do you have any comments that were there's some limitations in this paper and i mean the retrospective database study and that they didn't have uh a good code to identify the rectal biopsies so they used a whole bunch of different uh cpt codes and procedures and diagnostic codes that may make it a little murky for analysis but okay yeah i think that uh database studies in general suffer from a lot of the you know same problems and this was uh no exception but a but it comes out to a similar a relatively similar um instance of hersprung's disease so uh mac do you biopsy all of your meconium plugs i was about to ask you a question okay go ahead is the controversy that a 10 to 15 incidence means warrants that all these kids get a biopsy right that's that's the yeah how do we interpret the data yeah yeah so so what do you do i've done both okay wait what do you do so we uh generally if there's if there's abnormal stooling pattern then we'll do the biopsy but we do not biopsy every now they're not that many but every patient with meconia every baby with meconium plug syndrome did any of the babies the question is that 10 to 15 percent that you don't biopsy that come back to find out has it ever you know have they gotten worsening enterocolitis because you wait you know in other words can you afford to wait and see or is it are those patients getting sick and it's worth doing it and even though 85 percent of them are going to come back negative liz what do you do uh we biopsy you biopsy all of them yes sir okay uh out in the audience here do you the question is do you do you routinely biopsy babies that have meconium blood dan von allman says yes wolken says no selective okay mir is agreeing with dan selective okay selective based on how they're doing clinically okay okay all right this topic of article fertility was something that um which i'll tell you this is what's interesting let me tell you a little background on how we designed the these update courses so the group of the course directors get together we look at the papers that came out over the past year in jps or in other journals we sort of decide what are some things that are highly controversial some new ideas things that we think there's some gaps recently apps of pbc has come on board to join us where they have their method of coming up with their gaps what is fascinating to me is that this year how many overlaps there were when we completely independently came up with our list uh so umbilical access complete independence both of us came up with that uh c-spine was one that we both came up with and and now this is the third one that we both came up with uh that we felt was important to talk about and that is uncle fertility and we absolutely have an expert to talk to us about it dr julie rios is uh our uncle fertility expert she's a ob-gyne here in cincinnati children's and she's going to talk to us about uncle fertility so i just um went back to kind of what you guys i think we're doing this morning with some cases so this was an interesting case that we just had in the last month of an 11 month old female that had a three month history of constipation diarrhea recent visualization of a vaginal mass so she underwent a exam under anesthesia cystoscopy vaginoscopy and biopsy of the mass which revealed both urethral and uh urethra and bladder involvement so looking at the mass um both urology and my partner in pediatric gynecology said we think this is a bladder primary and rhabdomyosarcoma was the final uh diagnosis so we had a pet scan that was negative for lymph nodes so the treatment plan is going to be um this d9803 which is vincristine ectinomycin and cyclophosphamide and so we look at dosing of chemotherapy by how what the equivalent is to cyclophosphamide so that's what the ced means cyclophosphamide equivalent dose and it was 30.8 grams per meter squared anything over 15 in a pediatric patient puts them at high risk for ovarian failure in the future she was also going to plan for gu radiation for local control so our oncologist read her treatment plan and we got a risk assessment of the primary ovarian insufficiency risk is high she's planning to undergo laparoscopic lymph node dissection um for further uh staging so what would you offer this patient for fertility preservation let's look at this so it looks like there's your answer it looks like everyone is saying ovarian tissue cryopreservation let's throw up a yes no the question is have you heard of fertility preservation yes or no yes you've heard of it no you haven't yeah so i'm just going to go to the next slide just to kind of go through our answers so she's got two things going on she's getting chemotherapy which will affect the ovary she's also getting pelvic radiation which will affect her uterus and her ovaries as well so ovarian transposition or ovarian transphosition can preserve ovarian function from radiation damage but the patient's receiving high dose highly toxic chemotherapy also in 11 month old young patients we may not actually get enough anatomic different distance if it's a pelvic radiation to really prevent that scatter so that's always a question to talk to the radiation oncologist about and to get the sim to see what the scatter is going to be to those ovaries if we moved them um gnrih agonist therapy was something that we did a i mean i would say not within the most recent years to try to decrease uh fertility uh or increase fertility preservation during chemotherapy it really has not demonstrated any clear preservation for patients there is some benefit in older patients with breast cancer potentially the studies conflict for that as well um but again if we don't recommend this is our first line asco does not recommend this this first line um and so if they have another option available that's typically what we go with um so this patient was going to have another surgery so ovarian tissue cryopreservation it's experimental um it's followed by future ovarian tissue transplantation that can allow for about 30 percent of patients to have fertility in the future um most of the data though is from post pubertal patients but there have been studies to actually look at the ovarian tissue when we pull it out of the pediatric patients and there's physical visible follicles so there's lots of research lots of hope that this will be something that's useful in our pediatric patients as well and i just wanted to show a little bit of you know what we do so typically you can take a full ovary you can also take a partial ovary the tissue is harvested the cortex is then cryopreserved we typically do it within the same day to try to minimize any loss of eggs just from being out of their vascular supply and then later in the future it's an autologous ovarian cortical tissue transplant most of those go back in what we call orthotopic transplantation where it's put back where the ovary came out so you can sew it to the other ovary which is what we see on the bottom the very bottom picture is the tissue strips are sewn to the contralateral ovary that remains um there's also a newer technique where you can just make a peritoneal pocket near the fallopian tube where you remove the tissue put the strips so that the cortex where the ovaries will rupture from their eggs will rupture from near the peritoneum and they'll just rupture right through the peritoneum so there's different techniques and um it shows about 37 to 50 percent of patients that had a transplant um had a live birth 30 to 40 percent of people so some people had multiple transplants um so 30 to 40 percent of patients will actually have fertility preservation but 60 to 90 percent will have ovarian endocrine function so it's very successful in that restoration and that's data based on a meta-analysis so a couple questions not every place has their own uh gynecologists in their hospital how what could the these uh 900 pediatric surgeons do at their hospital they don't necessarily have gynecologists so if this is something that the patient i mean you have to have the whole process so even if you have someone that can remove an ovary you have to have someone that can freeze it because you typically freeze it on site um so there's lots of programs across the country and even internationally that do this this actually became very um i guess uh standard of care in the netherlands uh as the first place that did this routinely um so all over the world there's places that do this and so if a patient's really interested in this they can go for a procedure at a different hospital if they're stable enough so we have patients come in just for this procedure and then they'll go back for chemotherapy so for those of you in the room who may not have gynecology i don't know if you all do who does it at your hospital i don't know if you all have gynecologists or not um does everyone here have gynecology okay so i guess answer in the thread if you don't have uh a gynecologist who does your ovarian cryopreservation um what about boys what are we supposed to be doing do you do that i actually know i i don't do it but i know about it um so again for boys it's also difficult because um i didn't put on here egg freezing um or you know sperm banking would be the equivalent because until kids reach puberty you can't get mature gametes from the body um so sperm banking is really only an option if they have been are post pubertal typically tanner three and above is going to give us a better option for just banking sperm if they're pre-pubertal and they're going to get high dose treatment there are some places um university of pittsburgh um as has the protocol available but you can do testicular tissue cryopreservation okay yeah that's what i was essentially no one really does a whole orchiectomy okay so it's just a wedge yeah that's what we do here wow so we have the protocol here and we do it and then we ship the tissue to pittsburgh so any place can actually open this protocol um and then to you know ship the tissue okay hey todd can i ask a question so i missed uh about the uh transplantation at at what age is that done so we typically just do it for pregnancy because the graft is not equivalent to a full ovary so it only is going to last somewhere between two and five years is what the studies show so for hormone replacement we just use medication um for pubertal induction as well as you know hormones until they're ready to have pregnancy and then we put the tissue back in specifically to so it stays cryopreserved for whatever it is 20 years or however long yeah just out of curiosity is that cryopreserved here at the university of cincinnati or is there is that a private banking so we used to do the so we actually ship it off-site so pretty much every place now uses long-term storage facilities because they have the um extra i guess cautionary you know because you've heard about some of the instances of embryos or things being thought out in cleveland as well as in um california and so i think people like having that extra security so most of the long-term storage facility has three or four mechanisms for detecting tank dysfunctions so that that doesn't happen so ours goes to minnesota our tissue but we process it in our pathology lab here just say just explain what happened so there was a hospital that lost their power supply or something yeah and all of the embryos that were in storage unfortunately i think in a couple of tanks so it wasn't all of them but just one tank that's what that's why we need to maybe take some precautions yeah so who pays for it and since these are young children who will move up and grow move away how will they be tracked or how will they know where their tissue is stored so our team just um so who pays for it we'll start with that one so the patient does pay for it um typically for us we try to team this with a different procedure most of our oncology patients are going to get bone marrow biopsy they're going to get a central line port so if we place that together then the hospital fee and the anesthesia fee often can be covered by insurance because they're going to the or for something else oh the tissue storage fee that is the patient um so it is um income dependent so with anyone with an oncology diagnosis if they make under certain income it's 75 a year and then if they make more than that then it's 275 a year any other comments or questions okay
