PDC 2020 Practice Gaps

Uh, this is the PDC. So the PDC very similar to what I just talked about with that, uh, the fellows video. This is a session we've been doing for a few years, which I love. So, um, I guess I'm gonna open it to, um, Liz Byerly. We have Liz Byerly, who else do we have? Bob Cusick, Eric Skarsgard, and they're representing ABSA and they're gonna Talk to us about what the PDC has noticed have been the biggest um practice gaps among pediatric surgeons that have, have taken questions. And I guess, Liz and Eric, uh, and Bob, if you guys can explain PDC, explain how you get these comments, these uh questions and these topics, and then take us through these, these questions. So Liz, let's open it up to you. OK, so, um, what, what the PDC, what we do on the PDC is, um, look through, uh, a, a very long list of topics in pediatric surgery, and, um, decide what we think based on, um, expert questions and based on, um, based on hits to the NAT they're the, they're not a textbook. What seems to be the, the biggest practice gaps or the most um sought after information from our pediatric surgery community. And um we take the, the top 10 and focus on those and um not only in the expert questions but also focus on them, um, oftentimes at the AS meeting and through, um, this great platform that you've set up here. So, uh, Eric and Um, And Bob and myself have put together some uh scenarios that we'd like to go through and, um, open the floor up to questions and um have some fun. Awesome. So the, the first, um, scenario that we have here is a 14 year old girl with a body mass index of 45. And she has undergone an uneventful laparoscopic cholecystectomy for acute cholecystitis. Um, she's admitted to the hospital to, uh, basically for pain control, and that evening after surgery, her nurse notifies you that, um, while she's sleeping, her oxygen saturations have been dropping into the mid-eighties. So what do people think about this? She has obstructive sleep apnea because of her BMI of 45. OK. So what do you think that um would be the best choices of treatment for her? So the questions are, is, is this just simple obstructive sleep apnea or is she, does she need some uh Some fluid overload issues, or um is she perhaps having a DVT and PE? So this is why I love PDC. This is not something that we talk about all too often. Let's hear, we, before Rod tells us what the audience is saying, what does the faculty think? What would you, what would, Mac, what are your thoughts on this? I think she most likely has obstructive sleep apnea, and I would use positive pressure. Um, those other things are possible, but usually you don't sleep through a PE. Uh, and it's, uh, the, the big picture, Todd, is if this person showed up to my bariatric clinic, and there was a history of snoring, she'd get a sleep study and be on CPAP. The same patient shows up for a general pediatric surgery operation, such as cholecystectomy, and we don't think about that. So I, I do think there's an important education point here. This is, I'm telling you, this is why I love PDC cause this is where we learn. All right. So, um, Rod, what are we finding out there? So, that's a great question. So the, there are a few things that people are saying in the chat. First of all, they're wondering, was there an OSA screen pre-op? Did we do that? I don't think we really talked about that. Um, and then there's some people saying that we need some further workup. But if you look at the poll, we're actually at 57.1%. So most of the responders said CPAP, uh, And then the next most common one, still thinking about airway issues, we're saying about a third of them were saying supplemental oxygen from nasal cannula. So not a lot of people uh leaning towards the DVTPE. Not a lot of people thinking, uh, opioid overdose, hardly anyone saying naloxone. Um, keep it to the chat and let me know what you guys think. Tell me why you were thinking that. Yeah, good point. Todd, how about a chest X-ray? Chest X-ray. Uh, Liz. I, I think that would be a, a good first step, but, um, uh, but, uh, I, I think that I agree with Mac that this child most likely has obstructive sleep apnea. Yeah, yeah, I'm gonna, I agree with Mac. Uh, we, you know, we see this all the time in that when a patient shows up to our bariatric clinic, we do this big workup and, and we think about all these things. We also, you know, heparin bolus is on there. We do think about uh VTE prophylaxis and doing something like that. Uh, a lot of us have protocols in place that are followed to varying degrees. for that as well. But in this patient population, uh, there's that tremendous undertreatment of obstructive sleep apnea. And I think the onus is on us as pediatric surgeons because they're at great risk for post-operative complications related to their sleep apnea to, uh, screen them ahead of time and get sleep studies. So as to as to Mark's comment, I would be interested if people in the chat could put out how many institutions or how many people actually have a a a a venous thromboembolism pathway or program in place, and then what is the compliance with that pathway. OK. Let's go on to the next question. So, um, like we had a nice discussion, this, this child most likely has obstructive sleep apnea and would benefit from some, uh, positive airway pressure ventilation. Um, just a couple of points, um, as to, uh, Mac and Mark's comments. Um, there is, uh, there's an explosion of obesity, and it's not just in our country, it's all over the world, and in the last 40 years, the pre the prevalence of obesity has, has gone to over 18% of children. Um, Again, as, as was mentioned, a lot of these kids don't need, don't get or don't require actual obesity surgery, but we need to keep in mind, and we should actually work these kids up as if they were going to get obesity surgery, so they should have preoperative screening for obstructive sleep apnea. Um, obviously, uh, anesthetics and post-operative pain, uh, medications can exacerbate post-operative sleep apnea. Um, so, uh, you need to keep that in the back of your mind. And one other thing that, that we found in um when we were reviewing for this topic that, that we thought was interesting is that um kids who are, who are obese and who are getting therapy for uh DBT actually require a little bit closer monitoring of their 10A levels because they can have the potential for altered drug metabolism because of uh their obesity. So just uh some little interesting tidbit there uh to end that question. Moving on, the next child is 13 years old. He recently moved to your area, and he's presenting to see you for follow-up for esophageal atresia. And he had been on reflux medications until about 6 months ago when it was discontinued by his new primary care provider, and his symptoms of reflux had actually resolved. So his mother and him, he, the child and his mother are wondering um if he requires any further follow-up, if he can just be uh discontinued from all uh follow-up for his esophageal tricia. So what is your recommendation for this 13 year old boy? No further follow-up, yearly esophagoscopy, a barium esophagram. Esophagoscopy right now and the next available operative time, or esophagoscopy in early adulthood. So Liz, um, If it were me and he was new to me, I would do a barium esophagram as a screening study. Um, Assuming he doesn't have any symptoms and just as a baseline. So I'm assuming he doesn't have any symptoms since none were mentioned. No, sir, he's completely asymptomatic at this time. So you would start out with a barium esophagram, and what would you, what, what, what's your premise for that? What are you looking for when you order that, that study? Well, to me, he's been treated correctly or incorrectly for reflux. And so, I would wanna make sure that he doesn't have um an anastomotic uh narrowing due to reflux in the past. Uh, I wouldn't necessarily be looking for reflux, although you might find that, but, uh, but anyway, I just want, since he's, since he's new to me and I didn't do the operation. I would just want a little baseline for what his esophagus looks like because he's been treated with um With reflux medications. Hey, Liz, I, I, I agree with Wit completely, except I would vote for esophagoscopy because if you, what you really wanna know, and this patient will require long-term surveillance is if the child has Barrett's esophagus or any evidence of damage from the reflux. And if you do that and they have a stricture, you can dilate it at the same time. So you actually get more information, I think, from doing an esophagoscopy. Granted, that probably requires a general anesthetic. OK. Well, um, we would actually recommend an esophagoscopy based on, um, the current available data. And those current available data mostly come out of um recommendations of NASFAN and their European counterparts, and they've actually developed some guidelines for endoscopy following esophageal atresia repair. And um they recommend that whenever your, your anti-reflux medications are stopped, you should probably have an endoscopy. The second recommendation is a screening endoscopy at 10 years of age, whether or not they're on anti-reflux medications. Their 3rd recommendation is screening endoscopy in early adulthood. And finally, they think that these adults, every 5 to 10 years, should probably have a screening endoscopy. The reasons for that is because, as um Dan just mentioned, a number, a significant number of these children will actually have esophageal metaplasia or Barrett's esophagus, and oftentimes, the symptoms are Not correlating with the pathology. And so the big worry in these um adults is since clearly uh uh most of these children live long, long, long into adulthood now compared to the 1960s and 1970s, but the main reason is because there's a, a concern of not only Barrett's esophagus, but there's also a concern for an esophageal cancer risk. And the, the data on the esophageal cancer risk are, are a little mixed. Uh, there was a pretty good study out of the Netherlands that showed that there was a, that there was a significant increase in the risk of cancer. Um, there was another good study out of Finland, and again, both of these, um, These healthcare, um, systems are very good at following these children for an extremely long period of time, and there, there was also an increased risk of, uh, esophageal carcinoma. So I think that the reason that these recommendations are coming out from NASA again and so forth are, uh, because we wanna make sure that we don't miss an esophageal cancer. Any other discussion for this, uh, scenario? It's just interesting how the poll results, you can always tell it's a good topic when the poll results are all over the place. So, there's almost no agreement. It looks like a rainbow, every, it's all over the place. Yeah, so Liz, I think that's really um interesting. And um I'm glad that, that such guidelines have been, you know, promulgated because I think that that's always helpful, because at least in our generation of, of folks, that's not necessarily what would have been done. So, uh, so I'm glad you brought this, uh, this question up. And I, I think it's gonna be important long term to look at what, what happens with these recommendations, right? What do we really, what, what are, hopefully, we can glean what truly is the, the risk of developing not just metaplasia, but developing an occult carcinoma. Uh, next, you are starting a laparoscopic pyloromyotomy on a 3 week old infant who was admitted earlier in the day. And you bluntly gain umbilical access, put in your expandable trocar and instant installation is initiated. Shortly after starting in um your installation, your anesthesiologist is mentioning that the Nital CO2 is, is having kind of ups and downs, and they're not sure what's going on with that. And then, basically, shortly after that, they completely loseital CO2 and the baby arrests. So the most likely cause of cardiac arrest during laparoscopy is, is what? What do you guys think? Unrecognized hemorrhage? Is the entitled CO2 going away because of monitor error? Has the child become extubated? Is there a something called a gas embolus, or could there be a pneumopericardium from extraperitoneal insufflation? So, those of us who have been here last year know the answer because this was presented last year, and I know that this is a strategy of the PDC and I want to point this out. You know, we always want new material, but when it's an important enough topic, I, I know I've heard from the PDC that not only should many conferences talk about the same topic, but you should repeat it. Um, I forgot what that term is in adult education of keep repeating the topic to make sure it sticks in our brain. Repetition is the key to adult learning. What repetition. There we go. So the, the, so we recognize on the PDC that this this is a repeated topic, but as Todd mentioned, um, Studies would show that as adult learners, we need to hear this maybe 3 or more times before we actually remember it, um, or incorporate it into our practice. And Liz, to support that, the poll results. are all over the place. They really are. What does the poll think? I is it, is it another rainbow? It's a rainbow, Rod. It's, it's worse almost, yeah. There are a few competing ones here. About a third are saying pneumo pericardium from extraperitoneal insufflation. About 40% are saying gas embolus. And then the next most popular one is inadvertent endotracheal extubation with about 15%. Still, the majority is saying gas embolus, but it's, it's all over the board. Doctor Holcomb, you are correct. The answer is D. And again, this is, this is really rare, and I'm not exactly certain that this number is, is correct, because I think this may have happened to a lot more people than we realize that don't want to report this in the literature, right? So, if this happens to you, it's so traumatic, you're probably not going to sit down and write a case report about it. Although, um, Deb Bilmeyer and, and, and her colleagues sent out a, a, a poll. To, um, the pediatric surgeons in, um, the United States, and, and that's kind of where we come up with this number of 28%. And they, they think it's because it's secondary to the fact that uh the, the baby has a patent ductus and a patent umbilical vein, and this allows, um, uh, this allows a gas embolus to occur. So, entitle CO2 is the most sensitive detector of a gas embolism or an air embolism during laparoscopic surgery. So if that entitled CO2 goes away, the first thing you have to be concerned of is that you actually have a gas embolus, and not an endotracheal an inadvertent extubation. And the reason that this happens is that, so is that um That part of the problem that we think we what we think is part of the problem is that when you start your insufflation, there is a lot of air in that tubing, so the tubing is very long and it can have a significant amount of air in it, and air contains nitrogen. And nitrogen is not soluble in um blood, but carbon carbon dioxide is. So it's almost like the baby gets the bends when you insufflate all that air. So, uh, I'll talk in a minute about ways to, to potentially mitigate this issue, but, um, if this does happen, um, it's recommended that you put the baby in severe trendalenberg, um, put the, the baby right side up, give volume, give isotropes, chest compression. Um, ECMO, if needed. There are some reports of actually removing the air from the right atrium using, um, um, a central venous catheter. Prevention strategies, and I think this is probably the most important part of this. So make sure the baby is adequately resuscitated before you start your operation. There are reports of an infra umbilical port entry to avoid injury to the umbilical vein, but again, um, that's not 100% foolproof way to do, uh, you know, way to enter the umbilicus. Other people say that you should actually, once you put your trochar in, actually look in the abdomen with a scope. It's not insufflated, so before you insulate, put, put, put your scope in and look to make sure that you're actually in the in that you're actually in the peritoneal cavity. Turn your gas on and flush the tubing of all that air before you hook it up. And that'll decrease the amount of nitrogen and air that gets delivered to the baby. Liz. I don't. Do you have more? I wanna comment on what you say. So first of all. I know Max's gonna tease me, but this changed my practice. And so, I will tell you that, uh, when you presented this last year, I completely do it different now. So, this is what I love. I love when I find something that radically, I do exactly as you described. I now put the, the port in the way you described. I don't insufflate. I make sure I feel the air first before it's out and then connect it. I look with the scope before I insufflate. I do all of these tricks. Even though it hasn't happened yet, and I never had heard of this till you guys talked about it, but I want to address, uh, uh, some of the comments here, um, that, uh, we have, uh, let's see, uh, Chuck Bra and Mike Chen are talking about, and I know Liz, uh, Mike mentioned that you do a trans umbilical open pyloromyotomy. And I, I wanna go against you guys. I don't think this is enough of a reason to justify that. I think there's an article posted that Chuck posted from 2008, justifying doing it. I think they're all great approaches. I don't think, I think the frequency of this doesn't justify switching techniques to an open, or if you like it, that's fine, but I don't think this frequency is enough of a justification to switch to an open technique if you're used to doing it laparoscopically. Bring it on if someone wants to challenge me, but that's my thought. I agree with you, Todd, and I have had this happen, although, remarkably enough, the baby did not code or anything else, but I did inadvertently cannulate the umbilical vein. I was better lucky than good. And now, I still go trans umbilical, but I always put the scope in before I do any insufflation to make sure that I can clearly tell that I'm in the peritoneal cavity. And I tell the story every time to the resident who is helping me so that, uh, hopefully, they won't learn from my mistake. You know, Liz, I've got a a comment and a question, uh, for, for people. Um, you know, what I've changed also is this is part of my time out. So, if I'm doing a baby case, I make sure the anesthesiologists are thinking about this. And so, they recognize it earlier. And I, you know, kinda agree with Witt's comment from last year that probably still inadvertent uh extubation, uh, is very common and they need to think about it, um, you know, at this. Um, so again, I go through all these steps and, uh, the other day I was doing a lap pyloric, and I, um, saw a bunch of air along the, um, umbilical vein, um, umbilical ligament. What do you guys do in that scenario? Um, we had no change in our end title. Uh, you know, this topic has me afraid. It hasn't happened to me, but, you know, we're all very conscious of it. Uh, what would people do in that scenario? I, I proceeded with the pyloromyotomy and everything went fine. It's scary. I I would have continued on as well. I mean, you already had done the, you already had gone in. So, um, this is the part I don't understand. I mean, why is there no bleeding? Uh, uh, just the whole thing is so confusing to me. Um, and I saw Ian Mitchell put a question that he did a Hassan and had this happen. So, Bob, I, I agree with what you did. And Todd, let me ask, let, let me ask you a quick question though. This is a relatively recent. Observational phenomenon that is in the last 2 or 3 years perhaps. But we've been doing laparoscopy and lap pylorics for 20 or 25 years or so, uh, and we've been doing other laparoscopic operations in neonates for a long time. So why do you think or why does anyone think this is a relatively recently recognized issue? Are, are there different Ports that have been developed or they're, we're getting more, um, you know, not as cautious in our technique or, or, I mean, Bob and Dan have just mentioned this. I know of 6 or 8 other cases around. And so why is this all of a sudden happening, so to speak? I don't think it's recently recognized. I think it's recently reported. I, I agree with that comment, Dan. Yeah, I, yeah, I, I, I think that it's, it's happened, but just, but it just hasn't gotten to the literature and come to the forefront. This is the benefit of digital communication that we're all communicating much more now. We used to have to wait for a case report to come out, and you never knew what your colleagues thought of it when they saw it. Now we're getting instant feedback. So someone says, you know, I saw this crazy thing, and 30 other people say, yeah, I saw that too. This is a new phenomenon. of how we're better communicating. Uh, you know, I also think this is a culture change. In the past we didn't talk about our complications as openly. And, and it's a good culture change because we all, we all learn so much more when we, you know, are able to exchange these ideas. Um, all right, let's keep going on. This is great discussion. OK, the last, uh, the, the last one I have here is you have a 13 year old who has a transmedia style gunshot wound. On primary survey, um, you complete doing your endotracheal intubation. The child has bilateral chest tubes, and you decide to go to the operating room. They've started a massive transfusion protocol, and you send a tag, a thromboelastogram, which shows a prolonged our time. What do you do for this patient who has a prolonged our time on TG? What is the most appropriate factor replacement? Is it platelets, FFP? Does the child need tranexamic acid, or does the child need factor 7? So, while we're waiting for those poll results to come in, um, I'm curious what, um, any of the faculty here, uh, anyone, uh, do you use tech? Yes, I see Dan, I see Liz. I can't see all the faculties, so speak up. Especially in transplant, Todd, we use it all the time. Yeah, we've been using it for the last, OK, but you, that doesn't count. I'm talking about who uses it in the trauma for trauma patients or, or non-trans like do you use it? I, I know about Cincinnati, but what about other hospitals? So we've actually started using it in, um, you know, you have the, these former preemies who've had drains in their abdomen, and they, they have a bad liver, and they need an X lab, and oftentimes that's just a big bloody owie. So we've actually sent a tag pre-op so that we can correct whatever needs to be corrected, and it gives us some information for anesthesia in the operating room, what they can do to to to help us out. All right, so, um, Rod, what are we finding? Yeah, it looks like a little bit of a split here. So, uh, almost half are saying FFP, that's the leader. And then there's about a third saying transexamic acid. And then the, uh, the other two, factor 7 and platelets, those are less than, uh, 9%. Um, I will say some people in the comments, uh, Bargava Malaui, Doctor Malaui is saying. FFP in the chats and uh I will say that as a junior resident, we all got tag cards to put on our IDs. So when we're on their trauma rotation, that's one of the things we, we look at the tag immediately, we flip it over and say, oh, this person needs this. It's, I think it's becoming more mainstream. I think a lot of junior residents are getting used to it. Interesting. That's a cool perspective. All right, Liz, what's the answer? OK, well, this child needs FFP and primarily what I'm gonna show you is this. So this is a picture of a tag. And your R time is, uh, I don't know if this the R time right here is actually the time that it takes for the clot to start. And if that's abnormal, the patient needs FFP. The other important one is your alpha angle right here, and your alpha angle is actually the speed of fibrin accumulation, or your kinetics of clot formation, and this is something that if it's abnormal, you should administer cryo. This maximum amplitude right here, that is actually the maximum strength of your clot. So if your clot is weak, your patient should get should get um platelets. And if the patient has an adequate platelet count, perhaps they may even need DDAVP because the platelets that they have are not functioning well. This is a, uh, uh this chart is awesome. I wonder if we've shared this. If not, we gotta, um, maybe Rod and the students can help us figure out how to get this to everybody. And this is it's already gonna get tweeted out. We're tweeting it out, Doctor Bailey. This is probably the card that they have. The final most important part of your tag is the LY 30, and basically what LY 30 is, is lysis at 30 minutes. So, if this is abnormal, you are actually having excessive fibrotolysis, and this is where you would maybe give um aminocaproic acid or tranexamic acid. So, Ian Mitchell, go ahead and take a screenshot, cause uh there you go. There's your, there's your card right there. All right. OK, more top 10 to come. This was awesome. All right, so, um, Liz, awesome as always. Uh, let's go. I see on my computer, I see Eric next. Do you, Eric, do you want to go next? Sure. Uh, thanks, Todd. Let me try to get my screen share working here. All right. Uh, it's fantastic to be part of this group, um, both the PDC and then here on your, uh, panel here, Todd, I'm really grateful. OK. Um, you know, Liz described our process for identifying, uh, knowledge and practice gaps. And, um, you know, it'd be hard to have a session like this without congenital diaphragmatic hernia or some aspect of, uh, CDH care emerging as a, as a, a, a learning sharing opportunity. And so here is the The token CDH case uh from the PDC. And so this, uh, you know, we've, we've had some discussion this morning about the importance of standardization and the word protocol and, uh, um, guidelines have emerged. And, uh, it's been famously said that from the patient care delivery, I'm sorry, um, let me present the case first. So, uh, this is the case of a term baby who's had uh antenatally diagnosed, uh, probably a high-risk, uh, CDH based on ultrasound criteria. And, uh, I've got some vital signs here for you. Uh, heart rate 140. Mean arterial pressure is maybe a little bit soft at uh 40. Um, urine output has been better. It's starting to drift down. It's now about 0.5 cc per kilo per hour. Uh, the lactate is going up a little bit. It's now 3 millimoles per liter. From a ventilatory perspective, uh, the baby's on, uh, conventional ventilation and has been maintaining a PCO2 and blood gasses about 55 millimeter mercury. And the preductal saturation is 90% on a FO2 of 70%. And uh uh your cardiologist has come by and they've done an echocardiogram, and, uh, the echocardiogram shows a tricuspid jet. Uh, with estimated super systemic right ventricular pressures. Uh, a small ductus that has, uh, predominantly right to left shunting and a quite dilated and poorly poorly contracting right ventricle. And maybe I'll just stop there and, and see what, uh, what the faculty thinks about this baby and, and where, where he should be going next in care. Yeah, so it's a turb baby, um, uh, mechanically ventilated. Uh, ventilation seems adequate. The CO2s have been in a very acceptable range. Uh, oxygenating OK. You can see there's, um, you know, the lactate's pretty good. You know, there's, there's organ perfusion cause the, the baby's making urine. And, uh, you know, still on a decent amount of oxygen support. But I think, you know, we're surgeons, and I guess the question, and I've given you some echocardiographic data. And I think as surgeons, we, you know, we're always asked, uh, as part of a care team, you know, is this baby ready to have their CDH repaired? And so, let me just go to the, to the questions. And so, What is the most appropriate next step in the care of this baby? And, and, uh, should we just, uh, take this baby to the operating room? Um, is this baby's physiology severe enough that we need to be looking at, uh, ECMO? What about, uh, therapy with something that's going to try to vasodilate that pulmonary vascular bed? Um, or do we just maybe, uh, lack some, uh, detailed cardiac anatomy that would be clarified with a cardiac catheterization? So, uh, uh, Mark or anyone have any thoughts on this while we're waiting for the polls? I see that the rainbow is starting to develop. So, um, Any thoughts from anyone? Anyone do a lot of CDH? So Todd, for me, this baby is closer to ECM than CDH repair. OK. Would you, would you go to ECMO? Would you consider adding a pulmonary vasodilator? So Todd, as you know, in Cincinnati, and I'm not one of the CDH team, but we have a low threshold for starting pulmonary vasodilators. So my guess is here that's what would happen. And that's what I was gonna say is I think this, this kid needs a little more time before you run off and fix them. Uh, I, I, I would go with the pulmonary vasodilator at that point. I don't think the kid's ready for repair, but, uh, I, I didn't, uh, the numbers in front of me. I didn't calculate the OI, but I don't think the kid qualifies for ECMO. You know, one of the other issues, you know, Eric, is how, how labile is this kid and what do they look like? Are they just You know, some gentle swoons or is the kid all over the place. And yeah, even if the kid's OI isn't uh quite where you think they need to be to go on ECMO, if they're really labile and you're having a hard time managing, sometimes, uh, a short course of pulmonary vasodilator, but if that doesn't work, then you can go to ECMO. Yeah, totally agree. Um, Todd or Jarter, is it OK to, uh, have the reveal, or do you want to have more discussion about this? Don't reveal yet, Rod. Tell me what are we hearing from the audience? Yeah, it looks like the audience is kind of like what Todd was saying. It looks like the rainbow again. There are about a third of the people saying to go on with ECO and uh. About 30, 0, it's jumping, actually, almost 50% now are saying pulmonary vasodilator, so it's moving while we're doing this. And then the fifth are saying, just go ahead, do the diaphragmatic hernia repair. Um, in the chat, we have Tara Liu asking, Doctor Liu asking about prenatal measurements, um, and then what about VV ECMO? Right. Well, those are all good questions. And, and I think I wonder if the needle started to bump on uh pulmonary vasodilator therapy when Mark mentioned the fact that this baby's demonstrated some lability, uh, some physiological liability, and I think really what that is describing is this phenomenon of pulmonary hypertension. And, uh, so Eric, in the key, the key point in this whole Description or the super systemic uh right pressures. I mean, you don't want to take the baby to the operating room with those in, in that condition and the the vasodilator, I think is certainly the initial step, but, but, uh, that's why I don't, I've, I just wanna have the teaching point being that the, the right ventricular pressures are so high that you don't want to take the baby to the operating room with those pressures. Yeah, well, that's exactly right, Witt. It, it, I'll just, uh, take, put people out of their misery. And, and show that indeed, that, that is the recommendation uh for therapy here. Um, And uh, the, the points that I would like to kind of bring out uh with this question, which really, I think, underscore the importance of uh team-based care and CDH. I think that the, the learnings of the last 10 or 15 years is that the improvements in CDH care are based on what happens outside of the operating room, not what happens in the operating room. And it's been, uh, famously said that it's more important to do things the same way than what you think are the right way. And that quote goes to Brent James for, who's a quality improvement expert from Intermountain Healthcare. And there have been a, a, a number of groups that have sought to standardize CDH care, um, uh, and probably more on the way, uh, with, with, uh, um, guidelines and development. But the two that I'd like to highlight are the Euro Consortium, uh, group who've, uh, published an updated practice guidelines that cover the, the, the, the whole waterfront of CDH care from basically prenatal diagnosis to long-term follow-up. And then more recently, the Canadian CDH Collaborative, uh, which has, uh, similar guidelines, and I've just included a QR code that takes you right to the guidelines that can be downloaded onto a mobile device. So let me, let me actually, I wanted to point that out because you're gonna see a lot of that for the rest of the event. And Eric, thank you for doing that. For the audience out there who don't know this yet, if you have an iPhone and you just open your camera and aim it at that code that Eric just put on the screen, It will take you to the link. The rest of today, um, we're gonna have more of those QR codes. It's a great way to download articles as they're being discussed, and in the future, I would encourage all faculty to put these QR codes in your talks because they're a great way for people to instantly download the articles. So, uh, Eric, thanks for doing that. Yeah, no problem. Um, and so, and that's actually an app that you can, uh, put on your phone and you can use at the bedside. Um, it has the recommendations and links to the evidence, and it actually has some practice tools that you can, that you, you can use in, in, um, real-time care. Um, the the Canadian collaborative, uh, based on really, uh, evidence that you all know isn't the greatest, but, uh, consensus and discussion developed, uh, readiness criteria. Uh, and these are physiologic criteria that should be met before you take a CDH baby to surgery. And so, obviously, um, these include, uh, normal blood pressure for age, uh, urine output, and a reasonable serum lactate. That are reflecting adequate organ perfusion and end organ oxygen delivery. Um, an FO2 that ideally is less than 50%, and a preductal saturation that is around 90%. And these, this reflects that lungs that are adequately able to gas exchange and acquire oxygen. And then really importantly, and the focus of this question. Uh, and it was raised by a member of the panel that you really need to see a pulmonary vascular bed that is sufficiently relaxed, that you're not gonna have an acute crisis during surgery. We know that surgery is actually a stressor on the pulmonary vascular bed, and so we want to see whether it's a trend, uh, ideally a trend of, of the pulmonary artery pressures coming down, and they should be less than systemic pressures. And, um, you know, and I think this really underscores the importance of expertise on our care team that can bring this as a point of care, uh, tool to the evaluation of babies with CDH. And I think in, in many of our hospitals, that's cardiologists, but increasingly, it's the neonatologists who are trained in functional echocardiography. And I would, uh, uh, it's in the references, but I would highlight an article. I've taken a couple of tables from it here by Neil Patel, who's a neonatologist in Glasgow. And he's come up with some recommendations around Uh, standard, uh, echocardiography and clinical indications for emergency functional echo to really guide treatment decisions. And that could be fluid management, drug management, or timing of surgery. And just specific to this question and, and the options for pulmonary vasodilator therapy, and there's really, uh, there wouldn't be 100% consensus among the experts around this, but you can see that if you have Um, on your echo, predominantly right ventricular dysfunction. And so you recall in this case, it was a dilated, poorly contracting vent right ventricle. That's almost always due to increases in the pulmonary vascular resistance and your options are nitric, sildenafil, And, uh, increasingly PGE1, which maintains the duct, uh, open and allows a a pop-off vent for the right ventricle so it won't fail. Um, and I'll just I'll let people read other things. And always ECMO is uh your is your parachute if you have, um, right or left or biventricular function. And the choice, the question was asked whether it would be VV or VA ECMO. And I think, again, that's going to be determined by your echo echocardiogram. That's gonna show um the primarily the function of the left ventricle because, you know, if the left ventricles failed in CDH and that baby needs veno arterial support. So, I think the real take-homes here are that, you know, this is a complex disease, but there are opportunities to standardize at least some of the elements of care, and that our care teams really need to include people who are able to provide this sort of physiologic information about the function of the heart and the severity of pulmonary hypertension, so we can make best care decisions. Hey Eric, I, I just wanted to say, I just, I downloaded the app and uh just poking around with it there, and this is fantastic. I didn't know this existed. And I also want to point out there, I think someone said it on the chat group too, Todd. I know you and I both have iPhones, but, uh, uh, the QR codes work for Android also. Yeah, I got the app too now. OK. Um, and so this is, uh, uh, a, a switch in gears, and we're gonna talk about another fairly common. Pediatric surgical problem, and that's a patient with a spontaneous pneumothorax and some evolution in how we might think about caring for these patients. So this is a 16 year old healthy male. Who, uh, presents with pleuric chest pain and has on chest x-ray, uh, clearly defined with the little stars there, uh, left spontaneous pneumothorax. Now, his, importantly, his vital signs are stable. His oxygen saturations are about 94% on room air. And while he has some discomfort, um, he can walk without significant shortness of breath. And so as you're in the emergency department, sort of thinking about what to do, um, another chest X-ray gets done. He's been in the department for a while, and in 4 hours, he's really had no progression in his pneumothorax, nor have, nor have his symptoms changed. And, uh, so, you decide, you, you, you may have some awareness, some of the, uh, who are on this, uh, um, uh, group may have some insight into a recently reported randomized control trial that actually advocates for conservative management. And so that's the focus of this, of this case, is that you're going to offer this patient, uh, conservative management. And so, uh, the next step in the management of this patient, uh, using a conservative paradigm would be, uh, uh, would you admit him for observation? Uh, would you admit him and put him on, uh, nasal cannula oxygen at a high rate to try to wash out his, the, the nitrogen in his chest and clear his pneumothorax? Uh, would you aspirate, uh, with a pleural catheter, the pneumothorax, and then discharge him? Or would you discharge him with a pleural catheter and place attached to a Heimlich valve? Or would you just discharge him, do nothing, discharge him with a mild analgesic and arrange follow-up. So I, I guess, uh, what's not on there is, uh, is put a chest tube in and admit him, which, uh, I think maybe 10 years ago would have been the historic treatment. I think things have evolved from there. And any, any comments about this? So, um, This has been one of the hottest topics of the last 12 to 24 months. Um, we did a, we had a lot of talk with, uh, Chuck Lays and, and Dan Osley about uh some their, their aspiration studies. Um, and we've incorporated that algorithm, um, with, with the aspiration. I'm just curious what other people here have done. Anyone else use aspiration in the faculty? Well, I think that the, the pendulum is swinging uh towards aspiration versus um Versus a chest tube in this situation. And I think this, uh, there are a number of studies that are supporting that, that approach. When you, when you say aspiration, what, what, what are you talking? Are you talking about just, uh, like an angio cath aspiration or a pigtail catheter or what are, what are your, well, I think that, I think most people in the studies are talking about a, uh, Just needle aspiration. Others may use the term though to put a small little pigtail catheterter in. I personally think the pigtail catheter in the is just a smaller version of a chest tube. Uh, so, uh, so anyway, when I use the term aspiration, I'm talking about just aspirating. Yeah. So we, we would put in a, uh, a pigtail actually, um. And then clamp it, check an X-ray after 6 hours, and if it's not there, pull it out and send them home. If it's, so, I don't actually see that. Is that A, B, C, D, or either? That would be C. OK, well, so we're, we have a somatic issue. That's, that's not what that means to me. Well, uh, it doesn't matter if you aspirate with an angio cath or with a pigtail, but the idea that you'll send them home if you suck out the air and it doesn't come back, that it's, that the hole has closed and you could feel comfortable sending them home versus always admitting them. And that's the controversial topic for me. Um, but, um, and Todd, what you just described is, uh, what was developed through the consortium. That's, that's what the study was that Lias was the first author on, um, was to place a catheter that you then clamp. And the conversation initially started with just a pure aspiration like Witt was talking about, but people said, well, what if that fails and now you've got to do a second procedure. And so that was what people landed on was, let's just put in a catheter that you clamp, which mimics an aspiration. And then you still have it in place so that if you haven't made progress, you can just let it go of the clamp and, and then go down that path of, of managing the pneumothorax and if it looks fine, you just pull it and send it home. That's awesome. Rod, what does the audience say? And then we'll get Eric to give his answer and move on. Yeah, this is another one where they're a little bit all over the board. So let me, uh, and, and actually, there was a comment, um, uh, Sean, I would love for you to address this cause I know I've asked this to, uh, or I know Dan Osley addressed this in the podcast. Um, uh, uh, Iliana Gafar says, not my practice, but another missing option is straight to the OR for bat's pleurodesis. What are your thoughts, Sean? And then we'll get to Eric So what we've migrated to, what we've found is do or don't, but the path that you want to avoid is the patient that comes in and ends up getting an or ends up with a tube, and then you're following, uh, and then you try to put them on a water seal, and then that fails, and then they end up spending 6 days in the hospital before they get their vats. So, what we incorporated while we were part of the prospective observational study in the consortium was that if, if it looked anything short of perfect. So if it looks, if it looks fine, they go home. If it doesn't look fine, instead of going down the path of putting them on suction and seeing if you can manage it that way, then we go to the OR. So most of our patients, they either go, go to the OR the next day or they go home from the ED. OK. So, um, Sean and Eric and everyone else, can you please address a lot of questions in the chat? We're not gonna have time to get through because we're running behind, but Eric, what do we need to know? Well, uh, I, I'll caution my comments, or preface my comments by, by saying that we have to be always careful when we are making assumptions about the generalizability of evidence from a randomized control trial cause this question really came from a trial where, uh, for a select group of patients, um, but that included children, uh, as young as 14 who presented with, uh, unilateral moderate to large, uh, uh, primary, uh, spontaneous pneumothorax. And, and the trial methodology really sought to compare um observational treatment and we use conservative, and I think we can have different interpretations of conservative, but here it was truly observational, no intervention uh with patients who had some sort of intervention. And it was sort of what you were all describing, kind of a minimal approach with a, a catheter aspiration and removal if it didn't recur, but then down a pathway of, uh, you know, eventually leading to surgery if they had a continuing air leak. And in this study, the primary outcome of used to compare these two groups was full lung re-expansion, radiographic lung re-expansion by 8 weeks after the initial event. And I think the point has to be really clear that we're talking about a select group of patients here. Um, so this isn't something that we can necessarily go out and apply to all patients. These are patients who present who are minimally symptomatic, um, and did not require supplemental oxygen. And I think importantly, had unchanged chest X-rays after 4 hours in the emergency department. This wasn't a pneumothorax in evolution. Um, they were, the patients in the observational group, uh, were discharged with, uh, and really the, the, the, the paper makes a point that you really have to follow up with these patients. You have to can't sort of send them out and tell them to come back if their symptoms worsen, there had to be scheduled follow-up. And important to note, and it speaks to the fact that, that not all of these patients are the same, there was a 15% crossover rate in the conservative group, and meaning that these patients progressed and needed to go down the, the alternate pathway. But the results are, are impressive and I think quite surprising. Um, roughly equivalent lung re-expansion, that's the primary outcome by 8 weeks. Uh, you can see in that table, a high 90%. Uh, a 3-fold increase in adverse events in the interventional group. And so, these were things like, uh, bleeding. Uh, need for catheter repositioning, uh, air leaks continuing, um, uh, and so, you know, obviously things associated with instrumentation and intervention. Uh, a threefold, uh, increase in the length of stay of treatment. Probably not surprising since most of these conservatively managed patients weren't admitted. And strikingly, a two-fold increase in twelve-month recurrence rates for spontaneous pneumothorax. So, I think this is a, a really interesting thing to be aware of. Um, I think a question we need to ask is, is this completely applicable to our population? I mean, this is a, a, a mostly adult population. Um, but it certainly, um, speaks to the fact that a primary spontaneous pneumothorax probably is a spectrum of disease and that a one size fits all approach, treatment approach is probably no longer appropriate. I wonder if that, uh, are, are people surprised by, uh, by this, I, I, I guess, first question, people obviously had heard of this study, and, and has it, uh, changed your practices in your institutions at all? Um, well, I think it changes the thinking. So when we talk about the spectrum of disease, what we're really looking at, whether you're talking about placing a catheter and clamping it, doing an aspiration or observing, you're just trying to separate two populations, which is who has an active leak and who just popped a web and has a pneumothorax. And if you're just treating the pneumothorax, you can drain it or not. Um, but if they have an active leak, that's where you're going to have your crossovers. Those are the people who get admitted, and those are the ones that we don't encourage following for a long time to see if the bubbles go away. I, I think that is a great summary that it's just wanna know, are they done leaking or are they still leaking and uh how you manage the done leaking patients can be up to you. Uh, but the point is that that's a great, that's a great summary right there. I think we're way, we're running way behind. So, um, that was a great case and always important because that's a really big change in the last few years. So where do I go. OK, I'll try to move this along, Todd. Uh, so this is a 10 year old boy who's been hit by a truck and, uh, comes into the ED and he's, and he's should represent a multi-system injured, hemodynamically unstable trauma patient. He's unconscious. He's got a tachycardia with a low blood pressure, and he's got a spectrum of injuries that would lead one to believe that he's, uh, in hemorrhagic shock. Um, so, the, the question here is, uh, you give him 20 ccs per kilo of normal saline, and then what is your next, and, and he's still hemodynamically unstable. So, what, what would be the next maneuver in addressing, uh, this boy's, uh, uh, traumatic shock? You want to give him some more crystalloid? Uh, do you want to get, uh, type specific blood going as soon as the blood bank can get it to you? Uh, is this a patient who should immediately go on to a massive transfusion protocol? Uh, should he, we heard about TXA before. Should he get, uh, a bolus of TXA, uh, or is it appropriate to allow him to be hypotensive because that's going to reduce his ongoing bleeding? All right. So let's call on some people here. Any faculty that want to speak up. I know, uh, Uh, anybody can make a comment here. Bob Cusick, anyone? So would you give, this is a, a big question. You've already given crystalloid. Do you give more crystalloid? Do you give type-specific blood, which could be a while to wait for? Do you initiate massive transfusion protocols? So that's the question, when do you initiate massive transfusion protocol? Give TXA, uh, or implement permissive hypotension. Let, let the patient get hypotensive, which may slow down the bleeding. You know, the question is, when do you give blood? Do we give blood earlier than we used to give blood? So comments, questions, or should we just go straight to the audience? Rod, why don't we go? Oh, go ahead, yeah. How did the patient respond to the 20 cc's bolus? Yeah, good question. Uh, uh, and then I think really that's the key to this question. He hasn't really responded. This is a kid who's, uh, got probably a, a liver splenic injury, pelvic fracture, femur fracture. And so he's, it really didn't make much of a dent in his hemodynamics. Still unstable. All right, so Rod, what did, what did the audience say? Yeah, the audience is, um, a little bit mixed. So most of them are saying infuse another 20 cc's per kick of Chris Lloyd, give him another bolus, even though he didn't respond. And then the next most popular is to, uh, go ahead and hit the red button, boom, initiate MTP, give him 1 to 1 to 1. Um, and then the other three options, going type-specific or implementing permissive hypotensive, those are, uh, a little bit less. Oh, it's changing in front of my eyes, a little bit more people are saying MTP. About a third All right. And that would be correct, yeah. OK, yeah. And so, and I think that's, uh, you know, one of the things that we try to do on the PDC is be, um, uh, in sync with changes and recommendations for practice. Um, and I think this is a really important point, and you raised it, Todd, about what, what to do with crystalloid in these resuscitation scenarios. Um, I think everybody knows that this is still a major problem, major source of mortality in children. And uh what we're realizing now is that, uh, and this, this came up in the, in the um target, targeted uh resuscitation uh looking at um coagulation studies and uh rotate and rotem, tegan rotem. There's been a trend towards more hemostatic uh resuscitation and the recognition of the importance of limiting crystalloid uh to not more than 20 cc's per kilo. And that's in the 10th edition of the ATLS guidelines. Uh, it's, it's new in this last set of of, um, in the instructor's manual. And there's good reasons for this. If you give a lot of crystalloid, you end, you worsen the delusional coagulopathy, and you increase the metabolic acidosis. And so, uh, as is often the case, uh, uh, children, uh, trauma resuscitation is following, uh, the experience in adults, uh, which have really, um, sought to, uh, uh, use, um, transfusion practices that address this issue of maintained hemostasis. And so, um, the first paper that's highlighted here, uh, is a, is pediatric patients who are part of a large trauma database, uh, from combat operations in Afghanistan and Iraq. Uh, where they looked over a period of 12 years of an evolution in transfusion practices that really emphasized the importance of rapid institution of massive transfusion protocols. So this is just the percentage of patients who have children who were treated on massive transfusion protocols between 2001 and 2013. And the, and so this is the dark solid line, and correspondingly, the decrease in mortality um in those children over that time. This isn't a perfect study, and there have been others that have, you know, not shown uh convincingly that this is a direct relationship, but I think certainly, um, there is good data that shows that if you adopt an early balanced blood product resuscitation, uh, red cells, platelets, and plasma, Um, that you will, uh, lose, use less bread products overall, and a lot of your mortality and morbidity outcomes will be significantly improved. I think another important one that's uh, again, from evidence uh coming from combat zones is the importance and potential value of TXA. And so, again, this is another, uh, study from the military that looked at TXA use, yes or no, in trauma patients. And this is actually quite a, a rigorously conducted study that surely, clearly shows Um, a survival advantage, uh, from these forest plots in use of TXA, um, in trauma patients. I think I'll just mention to condemn the concept of hypotensive resuscitation as an intentional strategy. Um, there's really no evidence at all for this. And so, really, when we're looking at a severely injured child who comes into the emergency department unstable, we should be looking at limited crystalloid, 20 ccs per kilo, should move immediately on to blood products, um, in, in a balanced, uh, resuscitation manager, manage and, and, and then also, uh, consider early use of TXA. All right. Is that what, is that it, Eric? Yeah, that's awesome. That was awesome, uh. Very important points and I, I think we can summarize those for people um in the key point, uh, maybe throw those across the screen or later or tweet them out. So let's go on to Doctor Cusick. Um, Eric, that was awesome. Uh, Bob, uh, if you can go ahead, uh Eric will stop sharing his screen and you can share yours. All right, let me know when you've got it there. You got it. All right. That was a fast transition. Thanks, Todd. This is awesome. So thanks so much for including me. Um, Eric and Liz are always tough to follow. The PDC is a great group to work with, and, um, so it's, it's always a lot of fun, um. So let me. So, um, my questions are a little shorter and I'll try and go through them a little quicker to get you back on schedule. So you have a 12 year old boy who has deteriorating renal function from nephrotic syndrome and the nephro uh nephrology services requested the placement of a peritoneal dialysis catheter. Uh, the scope collaborative guidelines for peritoneal dialysis catheter placement includes all of the following except. A preoperative antibiotic, a lateral or downward facing exit site, no suture at the exit site. A lower abdominal suture sling. Um, so, this, uh, a lot of the membership has been concerned about kind of the knacker guidelines for peritoneal dialysis catheter placement. And, uh, as I looked into it, uh, there really aren't guidelines. Um, what they have started is the scope collaborative. And so, we're all being looked at for about 3 things, you know, when we put these catheters in. So, um, we got, it looks like, uh, the audience is like me. I'm not sure what you mean by a lower abdominal suture sling, but, uh, Rod, You know what we're seeing? I, yeah, there's, there's, uh, a lot of people saying lower abdominal suture sling. I too am with Todd. I would like a little bit more information on that. And then it kind of, uh, the next most popular one is looking like no suture at the exit site. Uh, and then the third most popular is, is make sure that it's lateral or down facing, uh, exit site. So I would just say that, that to me is the answer is DB cause I know the other three are what I've been told to do, that face down, give, don't put a stitch and give antibiotics. But I'm curious if I've been wrong. Yes, you know, the lower abdominal suture sling is something that I've gone to recently, uh, from some of my adult colleagues, and that's just, uh, putting a suture, uh, kind of down towards the pelvis right above the bladder absorbable suture to kind of help guide the catheter and keep it down in the, uh, in the pelvis. And, uh, that is not part of the scope collaborative, um, uh, although it is part of SA's recommendations. So you, you do this laparoscopic, like you, I don't understand how you stitch it in, intraperital, you mean? Correct, I do it laparoscopically. Um, I, I do omentectomies and so it's, it's, uh, the laparoscopic approach is nice to remove the omentum and then I'll put my, uh, sling down in the pelvis, um, and so I just kind of percutaneously, you know, just make a small incision, use a, um, a suture passer, put it around the catheter, and then tie it, uh, loosely in the subcutaneous space just to guide the catheter towards the pelvis. Cool. All right. So, the prevalence of uh chronic uh kidney disease is pretty common and so, um, uh, you know, this is all part of our practices. Um, uh, most of them are from neurologic abnormalities, but, uh, there's also some renal, uh, causes. Uh, failure rates are quite high. We've reviewed our institution's failure rate, and it's significant. If you look at the literature, it's probably 45% within two months for hemodialysis catheters and 30 to 50% of peritoneal dialysis catheters. So the scope collaborative is really trying to reduce these numbers by standardizing care. Um, uh, it was initiated by NAR, uh, to prevent, uh, infections primarily in peritoneal dialysis catheters, and, uh, they're really further along in their development of these recommendations with peritoneal dialysis catheters rather than hemodialysis catheters. Uh, so there really aren't guidelines yet for hemodialysis catheters, but those will be coming. Um, 3 elements are currently evaluated at each institution. It's preoperative antibiotics, uh, some gram-positive coverage. A downward or lateral placement, uh, of the site and no suture at the exit site. Um, and there, there's decent adult literature, uh, on these, each of these topics. Uh, in the pediatric age group, there's some registered data that's suggestive, uh, but, uh, no prospect of randomized trials. Um, so, uh, there are some adult guidelines, uh, that recommend the sling stitch, uh, so to speak, down, down to the pelvis, uh, but it's not currently part of the scope guidelines. Great summer. All right. I will, uh, move on to my next one, which is, uh, just, uh, changing this a little bit to hemodialysis. So similar patient, um, and which of the following would lead you to recommend a dialysis catheter as opposed to fistula creation. Um, the, the purpose of this question is I, I don't think we think enough, at least in our practice, about which patients should get a fistula, and we're just frequently asked to do dialysis catheters. So Bob, does the fistula first. Um, incentive that is popular in adults, is that being applied to children? Um, you know, I think through the scope trial, it eventually will be. Um, uh, I know as I review the literature on this, it definitely makes you wanna, um, be conscious of it early in the care of these types of patients. Hey Bob, I have a question about that because I'm not sure if I agree with that fistula first question on kids. A, the vessels are smaller. B, you do a fistula now in a younger child, and again, there's benefits of getting these kids listed in. Get transplanted much quicker than adults do, and the new allocation scheme that's supposed to come out in the in the winter is going to further accelerate getting kids transplanted because the organ allocation scheme is changing. The challenge that you do is you do an AV fistula now, it, it eventually will clot after a transplant, and then that site is lost. And for a 12-year-old, they are looking at at least 2, if not 3 transplants in their lifetime to hit 80. And so all of that translates to longer term concern for maintenance of access for dialysis and using HD line through an IGA for hopefully just a shorter period of time where the patient gets transplanted. May be rational given the challenges. Now, of course, if you place it in a subclavian and take out one of the outflows of an extremity, that's a very different question, but that's where all lines should be placed on dialysis patients through IJs. Yeah, I mean, that's great input. Uh, you know, Greg, as I look at the literature, there is some increasing, um, recognition that we should be thinking of fistulas. Um, let me finish the discussion. I'd like to get your thoughts again, Greg. Um, um, so, uh, the options are pulmonary dysfunction, aneuria, polyuria, and previous transplant, and you probably ought to be doing a dialysis catheter if you have cardiac dysfunction. Um, and so that's the answer. Again, uh, common disease, um. Uh, as Greg said, there's a high transplantation rate in children, but up to 25% of these kids will end up needing, um, renal replacement therapy again. Um, uh, analysis of a large international registry note that over 70% of children have, uh, a catheter placed and only 20, 26%, uh, recommend an AV fistula. Um, uh, there's multiple studies showing superior superiority over catheters in the primary and secondary patency rates. Um, and you can avoid things like, uh, central venous, uh, stenosis or, uh, the superior vena cava syndrome. Um, upper extremity, uh, location should be protected from IV placement, um, as much as possible, and, uh, as, as Greg mentioned, you should be doing IJs, not, um, subclavians in these patients, uh, who need dialysis. Um, and there's a couple of different organizations, um, that have recommended, uh, that we consider AV fistula use in, uh, children, uh, over 20 kg and, uh, uh, that are gonna require at least 12 months of, uh, hemodialysis. And so, Greg, in that population, you'd still recommend that we stick with, uh, uh, putting catheters in. I think that that is the, the, the, the question that is very hard to base any data on because you don't know the durability of a transplant. Obviously, a preemptive transplant is the most favorable and if you have living donor alternatives, you can get these patients transplanted before they um need dialysis. Um, and so, again, we would be cautious about going to a primary fistula in this population because if, if you do that, you, you know, talk about protecting an extremity in terms of vascular accident. You have really, um, uh, you know, committed that patient to, um, a, a different extremity down the road for the, for, for, for dialysis. Half-life of even a living donor kidney is only about 23, 24 years. And so if you're doing that in a, um, uh, a, a, a, a 5 year old, that means that patient is now 27, 28 when they're facing retransplant and. You know, again, trying to think about that strategically is the challenge. I, I don't question that there are benefits to primary fistulas. It's just the long-term consequences of that, uh, uh, it's very undefined at this stage. So what would, what would be your recommendation? When should we be going to a fistula? Is it your 18? I think if you have for us, the way we oftentimes think about it is if you have a teenager who is, uh, resistant that has a bunch of social issues that's not likely, they don't have a living donor alternative. We will, um, absolutely offer a, a, a, a, a, a primary fistula. But if you have a patient that, you know, we, we do a lot of in utero or renal therapy babies, that, that's, they're, they're out of the, the, the, you know, they're not an fistula is not an option. I think for kids in that, you know, 5 to 12 or 1512 15 years, that's the toughest population because those vessels are proportionally smaller, though, they will, uh, mature and so dialysis can be done, but it's going to be. So at least from a very programmatic stand, you know, standpoint, we oftentimes will wait until those kids are in their pre, um, late, I mean, just preteen, teen years before we offer primary f oil. But this is an ongoing conversation with our dialysis team, um, as we evolve. But it, it is pretty nuanced because it ties to social situations, which oftentimes are very challenging in patients with adrenal disease. Um, as today, Greg, I'm gonna have to cut it short because we're about 15 minutes over, half an hour over, and we're gonna upgrade the chat again. So, um, we were gonna wait for the video, but people are having trouble again. So Andrew, go ahead and just upgrade the chat to a better server. It'll be down for about 1 minute, but we're gonna keep going, Bob, with your next slide. OK, moving along, um, the next patient is an IVD patient, 16 year old female with Crohn's disease presenting with increased pain and nausea. Uh, she has been treated with steroids and infliximab in the past. A CT scan shows, uh, her disease is diffuse, uh, uh, involving her ileum, and her family prefers non-operative management. So, uh, which of the following medications is targeted specifically, uh, at the GI tract? Um, Steroids, azathioprine, methotrexate, infliximab, and um, Entyvio, um. So, uh, the question that we've gotten is, uh, you know, people want to know more about these newer agents used, uh, for inflammatory bowel disease. Um, as we follow the literature, there, there's a huge array of, um, Of um newer agents. And so this is more focused, um, uh, on the one that's probably most commonly seen in our centers. Um, So, I'll move on so the answers in yo, uh, in the interest of time. So again, a lot of these patients present under the, uh, age of 20 years and so they're in our practices. Uh, just, uh, as a review, corticosteroids are used for induction therapy, uh, but they really aren't used to maintain remission, uh, because of their high, uh, uh, number of complications. Um, azathioprine and methotrexate are immunomodulators, uh, both maintain remission, uh, but there's increasing concerns about infection and malignancy. Um, Uh, Remicade and ADA are both anti-TNF antibodies approved, uh, for use in children with, uh, uh, Crohn's. Remicade is really our best agent. And so, uh, there's some increasing, uh, thoughts on how we can Uh, increase our ability to use Remicade, and that's the combined trial, uh, which a lot of centers are accruing patients for right now. And that's a prospective randomized trial that will be coming out designed to compare the outcomes of anti-TNF agents alone and in combination with methotrexate. Uh, the thought would be that, uh, uh, you'd be able to use Remicade for a longer period of time if you add methotrexate. Um, because currently about 10% of patients will no longer respond to Remicade, uh, per year, uh, and so that's what they're hoping with methotrexate. Uh, the newer biologic agent, um, there's a couple out, but Entyvio is a monoclonal antibody targeted at the gut epithelium. Um, adult sur, uh, studies have demonstrated, uh, a great safety profile, and, um, Uh, in 2017, there was a review of 64 kids who had failed anti-TNF therapy, with 25 of them, uh, uh, reaching a steroid-free, uh, uh, remission. And so this is a, a great, uh, new agent in that it seems to be very gut-specific. It really, uh, looks at how lymphocytes, um, uh, cause inflammation within the gut. And so the, the safety profile should be very good. Uh, early studies in adults show that the, uh, complications after surgery are equivalent between Remicade and Entyvio. And, um, uh, and the pediatric, uh, studies are, are just starting to come out. All right. Um, Rod, so I know, so, um, we did, we just upgraded the servers again. We had to quadruple our server space, um, which is a good thing but a bad thing, but it's working now. So if you have trouble, you can go ahead and refresh. This is something I just learned about, about the past few years, Bob. I, um, have had patients that have, have, have needed to go to Entyvio and it's, they've, they've had, um, good results with that, but Um, I, I'm curious. It looks like, um, Rod, yeah, most of the people are kind of leaning towards Entyvio, and then the next popular is infliximab. Um, I mean, I will say I'm the type of resident that just hates the names of monoclonal antibodies. You can only make so many mnemonics, so it gets confusing, but vitalizumab, most of the people are saying that, and then the next comment about third saying infliximab, so. Yeah. It, it, this is such a fast-changing thing which is great. I mean, we used to just be steroids and now we got all these uh things to choose from. So this was a great summary here. Um, this is the thing that we're all afraid of. You're doing a laparoscopic inguinal hernia repair in a six-month female and, uh, you notice abnormal appearing gonads. Um, further evaluation reveal androgen insensitivity with a 46 XY genotype. Um, at what age do we do a gonadectomy in patients with androgen insensitivity, complete androgen, uh, insensitivity? Um, at diagnosis at 5 years of age, before puberty, after puberty, or timing should be individualized. So, um, when should gonadectomy be performed? Uh, who's had this happen? Anyone in the faculty? I hear crickets. I had it happen my very first year of practice. It was an interesting post-op discussion with the family. Yeah. I did too, Todd. OK. And I know that this is a, uh, a changing target, a moving target that, uh, changed since in the last several years I've heard, I, I think it was ABSA when I, this was When we talked about this, um, so, um, go ahead, um, Bob, what are, what are the results? What's the right answer? So the timing really needs to be individualized, and, uh, I think Todd's, um, discussion is, uh, kind of referencing Epps's presentation, presentation as well in Arizona, which was really a great presentation on, um, androgen insensitivity. So I would refer you to that. You can get to it through the nat. And, um, it's about a 10-minute talk on this topic. It's much better than what I can summarize now. Uh, but again, this is an X-link recessive genetic condition caused by androgen receptor gene mutation that results in resistance to androgens. You produce plenty of testosterone, but it, uh, it just doesn't interact with your receptors. Uh, formerly called testicular feminization, uh, presents, uh, uh, with feminized external genitalia. And so, how these are gonna present in our practice is either the uh baby that we're, uh, uh baby girl that we have um gonads, uh, bilaterally, uh, or in the teenager who has amenorrhea. Those are the two ways they generally present, um, or if they have a family history. So those are the three ways. Um, and you can have complete where they look like a typical female, so you're not gonna identify them unless they're, um, Uh, having hernia repairs or they're in adolescence. It can be partial, um, and these are the patients with ambiguous genitalia and so they're being evaluated, uh, early on, uh, in the, in the, uh, neonatal, uh, period or mild, and these probably get identified in adults, males, uh, uh, excuse me, adults, um, uh, males that are, uh, infertile. Uh, gonadectomy should be discussed at length with the family and, and, um, uh, the reason to preserve the ovaries is that the risk of cancer is probably lower than previously thought. The literature is really moving on this. It's probably even lower than the 2 to 5%. Um, and it's probably closer to 1 to 2%. Um, and so there is a, a risk of cancer, but how high that is, is, is debated. Um, uh, the, these patients report that surprisingly, once you remove their testes. Um, they feel abnormal even if you get, when you give them estrogens, uh, because those testes are a source of estrogen, uh, as well as testosterone that is converted, uh, peripherally into estrogens. And so getting that milieu kind of restored is very difficult. And so this is from, um, uh, support groups that they've really said, uh, delay this as much as you can, certainly until after puberty. Um, uh, what we know in, in older women who are on estrogens for prolonged periods of time, they have increased cardiovascular risk after gonadectomy. Um, and some people have wanted to go on to, uh, have kids, and so there are fertility techniques, uh, that have successfully been utilized in these patients. Um, and so in my mind, this is part of that, um, move in absa to really think before you remove these gonads. Um, you know, if you're in a, uh, Uh, the situation when you're doing a hernia repair and you think they're, they're testes, um, I think if you're unsure, you biopsy them. Uh, if you're not sure, you probably want to go ahead and get a karyotype, go ahead and do your hernia repair and do a karyotype, uh, but we really shouldn't be removing these, um, testes, uh, uh, without first having a careful conversation with the family. It's Todd, I have a question real quick, which maybe Dan or Bob could answer. I, when, when this happened to me, I went ahead. I have a large thyroid practice, so I speed dialed my favorite endocrinologist who came to the OR with me, and I took a bunch of pictures, and then I dragged one of my urology friends in. And so that way the three of us went to talk to the family together at that point, Bob and Dan. How would you have approached this differently? I think that's a great approach, uh, as I. Noted, when it happened to me, it was my first year of practice. Uh, so I was, uh, uh, a tad surprised, uh, but, you know, had certainly learned about this, went out to talk to the family and the mom's response was, oh yeah, my sister had that. And that was, it made the conversation much easier. Yeah, but I, I, I do think that getting it, you know, these are obviously require a multi-specialty team with, uh, endocrine and urology and ethics and all the other folks that need to be involved to properly manage these. Dan, I had the exact same patient my first year in practice, and your first year in practice and my first year in practice were the same. Hey, Todd, uh, so I would agree with Kurt. I was gonna make the comment that, uh, when it happened to me, I was relatively young and practice and I got an endocrinologist to come meet with the family and me. So, because they're the questions really center more on what the endocrinologist has to say than what the surgeon has to say. So, I think that's a really good thing to do, to call your endocrinologist and have them meet, meet the family with you. And I will tell you that um I've had this happen a couple of times, but it was a number of years ago and ago and ago but anyway, we're taking the gonads out early, um, and now it's the pendulum is completely swung the other way around, which is interesting and I think the reason we took them out early was the thinking that the, the girl, um. Wouldn't know what the issues were. Uh, and so, and now I guess the pendulum has swung to the, the young lady can, can, you know, understand things, it's better to take it out when they're later because of the estrogen production from the gonads. All right. So let's, let's, this has been a great discussion, but I wanna make sure we move on and try to catch up about uh, now we're almost 30 or 40 minutes behind. So, let's um end this session. This has been a phenomenal session and To the PDC, to, uh, Liz, Eric, and Bob. These, we love these. These are fantastic and we hope to do this again next year. Um, this is incredibly helpful and clearly shows the gaps because we have every one of these with the rainbow-colored poll results. Um, and these are practice-changing things. So thank you to the three of you. We please hope you stay on to be part of the discussion for the rest of the talks.