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 going to open it to um Liz Bierly. We have Liz Bierly, who else we have, Bob Cusick, Eric Skarsgard. And they are representing APSA and they're going to talk to us about what the PDC has noticed have been the biggest um practice gaps among pediatric surgeons that have 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. Okay, so, um, what what the PDC? What we do on the PDC is um, look through uh 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 or the the 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 APSA 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 80s. So what do people think about this? She has obstructive sleep apnea because of her BMI of 45. Okay, 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 do the faculty think? What would you, what would Mac, what are your thoughts on this? Well 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 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 a important education point here. This is I'm telling you, this is why I love PDC because this is where we learn. All right. So, um, Rod, what do we find in 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 work up. 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 DVTP. Not a lot of people thinking uh opioid overdose. Hardly anyone saying the lock zone. 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 I think that would be a a good first step, but um, but uh I I think that I agree with Mac that this child most likely has obstructive sleep apnea. Yeah yeah, Alan, I agree with Mac. Uh, we you know, we see this all the time and that when a patient shows up to our bariatric clinic, we do this big work up and and we think about all these things. We also, you know, heris is on there. We do think about uh VTE prophylaxis and doing something like that. 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 uh a venous thromboembolism pathway or program in place and then what is the compliance with that pathway. Okay. 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 the prevalence of obesity is 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 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 get, who are obese and who are getting therapy for uh DVT 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 is presenting to see you for follow up for esophageal atresia. And he had been on reflex medications until about six 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 atresia. So what is your recommendation for this 13 year old boy? No further follow up, yearly esophagogastroscopy, a barium esophagram, esophagoscopy right now and the next available uh operative time or esophagoscopy in early adulthood. Liz, um if it were me and he was new to me, I would do a barium esophagram as a screening study. 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 to that study? Well, to me he's been treated correctly or incorrectly for reflux. And so I would want to make sure that he doesn't have um, an anastomotic um 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 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 Whit completely, except I would vote for esophagoscopy because if you what you really want to 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 structure, 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. Okay. Well, um, we would actually recommend esophagoscopy based on um, the current available data. And those current available data mostly come out of um recommendations of NASPGHAN 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 third 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 and since clearly most of these children live long, long, long into adulthood now compared to the 1960s and 70s, but the main reason is because there's 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 NASPGHAN and so forth are uh because we want to 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, so I'm glad you brought this uh this question up. And I I think it's going to 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 three week old infant who is admitted earlier in the day. And you bluntly gain transabdominal access, put in your expandable tro car and insufflation is initiated. Shortly after starting um your insufflation, your anesthesiologist is mentioning that the entitle 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 lose entitle 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 entitle CO2 going away because of monitor error? Has the child become extabated? Is there something called a gas embolus or could there be a pneumo pericardium from extraperitoneal insufflation? So those of us who have been here last year and 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 is a repeated topic, but as Todd mentioned, um, studies would show that as adult learners, we need to hear this maybe three 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? Is is is it another rainbow? It's a rainbow rod. It's it's worse than. 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. The answer is D. Dr. Holcom, 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 Billmeyer and and her colleague sent out a a poll to um the pediatric surgeons in um the United States and and this 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 that the baby has a patent ductus and a patent umbilical vein and this allows um uh this allows a gas embo to occur. So entitled 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 embo 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 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 um dioxide is. So it's almost like the baby gets the bends when you insufflate all that air. So 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 Trendelenburg, um, put the the baby right side up, give volume, giveotropes, chest compression, um, ECMO if needed. There are some reports of actually removing the air from the rightatrium 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's 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, you know, way to enter the umbilicus. Other people say that you should actually once you put your car in, actually look in the abdomen at the scope. It's not insulflated. So before you insuflate, put put put your scope in and look to make sure that you're actually in the 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 I do you have more I want to come and want to say. So first of all, I know Max is going to 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 insuflete. I make sure I feel the air first before it's out and then connect it. I look with the scope before I insuflete. I do all 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 some of the comments here um that uh we have uh let's see, uh Chuck Brow and Mike Chen are talking about and I know Liz, uh Mike mentioned that you do a transumbilical open pylomyotomy and I I want to 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 canulate 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 comment and a question uh for for people. Um, you know, what I've changed also is this is part of my timeout. 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, kind of agree with Whit's comment from last year that probably still inadvertent 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? Wow. Um, we had no change in our entitle. 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. I would have continued on as well. I mean you already had done the, you've already had gone in. So, um, this is the part I don't understand. I mean, why is there no bleeding? 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. It's a new problem. Let me let me ask you a quick question though. This is a relatively recent observational phenomenon. That is in the last two or three 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 are they 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 six or eight 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 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. You know, I also think this is a culture change. In the past, we didn't talk about our cult complications as openly. Exactly. 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. Okay, the last uh the the last one I have here is you have a 13-year-old who has a transmediastinal 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 R time. What do you do for this patient who has a prolonged R time on tag? What is the most appropriate factor replacement is it platelets, FFP, does the child need tranexamic acid or does the child need factor seven? So while we're waiting for those poll results to come in, um, I'm curious what um any of the faculty here, anyone, uh, do you use tag? Yes. I see Dan, I see Liz. I can't see all the faculty, so speak up. Especially in transplant, Todd, we use it all the time. Yeah, we've been using it for the last. Okay. 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? Well, I know about Cincinnati, but what about other hospitals? So we've actually started using it in um, you know, you have these former premies who've had drains in their abdomen and they they have a bad liver and they need an X lap and oftentimes that's just a big bloody alley. So we've actually sent a tag preop 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 do we find him? 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 tranexamic acid. And then the uh the other two factor seven and platelets, those are less than uh 9%. Um, I will say some people in the comments, uh Baga Maputy. Dr. Maputy 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 and 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? Okay, well this child needs FFP.