QUAD #7 Anesthesia for Thoracoscopic Techniques with Dr. Nathaniel Tighe

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