I'm going to go into part two of this discussion of some of the anesthesia specific aspects of colorectal care. Um, First of all, um, many of you know, surgeons attitudes often, uh, fall, uh, well, are represented by this, um, cartoon. So sort of funny but sort of sad as well. OK. I mentioned this, but associated malformations that you need to think through. We're very blessed by having a very strong PC program here. Um, I'm amazed by the detail that's put into getting these patients ready. It is a very rare day that a patient is not properly preoperatively organized. It has to be canceled at the last minute. That used to be very common. It never happens here, in large part because of the system that's put in place to read these detailed charts. Many of them are very complicated. Records are not always complete. from other countries, not an easy job. Thank you to all those who help with that part of the anesthetic care. But just to be aware that many of these patients have obviously they have a colorectal problem, but their airway and their cardiac system are very relevant to the anesthesia choices that you make. Um, neuromuscular blockade. So this comes up a lot of whether we can give neuromuscular blockade. So, um, to have some knowledge behind it, of course, always ask. We talk about it in advance, but basically if we are creating an anus today, we need to know where to put the anus. How do we know? We stimulate with the electrical stimulator and we see contractions and we determine the ideal syncteric ellipse where that anus ought to go. If neuromuscular blockade is on board, that stimulator doesn't work. We can't see any jumping of muscles and we might misplace the location of the anus. So in general, we like to avoid neuromuscular blockade at the beginning of the case. Get the patient safely under anesthesia. We then mark the sphincter because it's obviously very stimulating and certainly painful to stimulate them if they were awake. So we have to, we need them asleep. And then once we have marked the sphincter, then you can give neuromuscular blockade. Now there are circumstances where a baby needs neuromuscular blockade just to get them intubated, and we recognize that. And let's have that conversation because, Basically we can stimulate later also or we can let it wear off or we can reverse the patient once they're safely gotten their airway. So that does happen rarely. Most of the time you can get a patient safely under anesthesia without giving neuromuscular blockade, but sometimes it's required. Let's have that conversation. But that's the reason why we are in need of the capacity to stimulate. Many of our patients have an anus. Hirschrug's patients have an anus. Fecal incontinence patients that are getting them alone have an anus. We aren't doing any anal reconstruction today. Neuromuscular blockade, no problem. Patient positioning, this is one area of annoyance to the anesthesia team is the prone position and particularly the prone supine, prone to flips, which I know drive you crazy because of the airway. Concerns and the padding. It is not easy, and I know we're asking a lot, but we have better access to the pelvis through a prone position. This was the major advance of Alberto Pena in 1980 was approaching the rectum posterior sagitally. No one had done that before, and it was a crazy idea in those days to go in that way. And now you know that we can accomplish a lot of things. Entering that way. Of course, that requires the patient in a prone position, proper positioning of the head, the neck, the airway, etc. And then we want to operate on the abdomen on the same patient with the same prep. So we have to flip them within the drape, which I know is a big challenge. You need two people. We are never in a rush. Whatever it takes, however amount of personnel you need there, just do it safely. And, um, I recognize this is a pain in the neck. And neck, literally the neck. Um, and, uh, but it has to be done because it, it really gives us better access. I will also tell you from a surgical training point of view, operating on a patient in prone position is good for 3 surgeons. Three surgeons can see the field really, really well. Think about a laparotomy. If you try to operate on the perineum in supine position, you can only really have one person who can see well. The other two people are behind their shoulder. Torture. They don't see anything. They can't get anything out of the case, whereas in prone positions you can have 3 surgeons and many of those cases need enough retraction, etc. So it's really advantageous to the patient. Um. IVs in the lower extremities. Sometimes it's not so easy to get an upper extremity IV and then we prep over a foot and you might want to avoid it. No problem. Foot is fine. We do sterile tubing across the drape. So don't resist. Of course, you can get it in the upper extremity. That makes it easier on everybody, but if you can't, no problem. Put it in the lower extremity, we'll do sterile tubing. So that works quite well. Um, the hematocrit, I, um, this is relevant for a couple of reasons. Some of these cases are relatively long. We want to know what is the starting hematocrit in case we rarely lose blood. I can't remember the last time we transfused. It doesn't happen more than maybe once or twice a year that we actually have to give a transfusion. But sometimes it's nice when you're starting a long case to know what is the starting hematocrit. The other thing is you don't want to be hyper viscous. Some of these patients have. Medical we move things. We move the rectum down. It's based on a single blood vessel. We do a vaginal replacement based on a single blood vessel. We augment the bladder with a piece of colon based on a single blood vessel. So we don't want that blood vessel to clot. So we don't want them hyper viscous for one, and I'll talk a little bit about vasoconstricting agents. It's sort of like a free flap case, some of those cases. Many of you know like what to do in a free flap case. Certain cases of ours are basically free flap, and they're not free, meaning one tissue is moved to another part of the body and re-sutured. The vessels remain intact, but they're moved to a location where they weren't intended to move, and they're based on a single vessel. So that's why the importance of the hematocrit. Um, bowel prep patients have often received a bowel prep. You'll know if they did from the chart that obviously makes them a little bit dehydrated and maybe some catch up to do. Many of our cases, the bladder is open. You have no idea what the urine output is for 6 hours. I know how difficult that is from a fluid management point of view. We will be able to tell you when that will happen, um, what time from when to when the bladder will be open, but it makes it much more difficult. Laparotomy and the calculation of insensible losses. The length of the case, we're usually pretty good at predicting. Today's a very good example. It says Cloaca. I'm not sure who's doing that case today. But, are you? Excellent. So that could be 3 hours or 8 hours. I'll just tell you today. You, you, you, you lucked out. 3 hours is the plan. We talked about that yesterday. Relatively easy, easy cloaca compared to many. That changes the game. We'll be prone only. We won't be in the abdomen. Many implications of that decision making. Obviously we need to talk about that before. And Sophie and some of her other colleagues often join us on a Tuesday morning as we do our huddle for the following week. So we hope you're getting information on what these cases are all about. And then please ask us if you're at all unsure. Length of the case sometimes influences your decision about recovery room or directly to the ICU. I will tell you we have done so well with regional pain management here that we almost never use the ICU. This is a big change from where I worked before. There were many acts, uh, rapid responses. Patients were in pain, not breathing well at night, where I worked before. That almost never happens. I think because they have better pain management, good pain management planning, successful epidurals, all the things that you do so well to make the patients ready for surgery, and therefore we rarely need the ICU. I will say that there are patients that have big operations. That pain management is going to be a big challenge. So there is some advantage sometimes to leaving them intubated overnight. Of course, the annoyance then is they might not get extubated the next day like we all want them to. Because the ICU doesn't do that as quickly necessarily as we would want them. But there is some value to not having that patient in pain at midnight on the floor, now moving to the ICU. So that all has to be planned. We talked about this, but this is a pedicleis graft being moved actually in this case for vaginal replacement, that is a segment of colon, blood viscosity, vasoactive meds. So if you have a soft blood pressure, obviously there are fluid choices, there's colloid choices, there's dopamine versus norepinephrine. It's not as vasoconstricted. We have lost some of these pedicles in cases where the patient received a vasoconstrictive medication. This is in previous, uh, work that I've done in other places. But so just be cognizant of the fact that a, a small dose of the vasoconstrictive medication, maybe someone needs to go on. So that's probably what sounded. If someone out there could go on mute, we're hearing your crackling. Um, can, it can, it can constrict a, a small vessel. OK, um, we talked a little bit about this, but regional anesthesia, really key part of our care, your care to our patients, um, you know, whether it's a QL catheter or, uh, some sort of regional block or an epidural or a caudal, um, one shot, another shot at the end. This is your world. You do what you think is right. You think what's best. We will be able to tell you where the incision is. Sometimes our incisions are higher than the umbilicus. You have to plan accordingly. Sometimes many of our incisions are transverse, which is more painful than vertical. You have to plan accordingly. We talked, um, Sophie and I discussed earlier a little bit about Eros. We're very into that. We try to get these patients moving along. A lot of that has to do with their perioperative care. And then you mentioned the ICU versus the floor. Um, just a point about, um, post-op, um, um, narcotics where, um, I have found that it's best practice to wait until a patient is on a regular diet before advancing them to an oral, uh, narcotic because they get nauseous. And then we don't know, are they nauseous because something's wrong with their GI surgery or are they nauseous because they took some codeine. So, If they have an epidural, let's leave it in until they're on a regular diet, that kind of thing. So we don't want to advance them to oral narcotics too early because they may throw up and then we don't know what we're, what we're dealing with. And I think there's a, did I mention ketorolac somewhere? Yeah. Let's mention that for a second, um, because this is a really good drug. Um, obviously it avoids narcotics, but some of our patients have renal insufficiency. They usually have a, a creatinine and other data relative to their, uh, kidney, and many of them have normal renal function, even though they may have a single kidney. So we can have those conversations, but I think in general, uh, NSAIDs are fine and they work extremely well and they do avoid narcotics. All right. So I'm happy to open up to questions. I just wanna say again, we are incredibly thankful for your collaboration. We can't do it without you. We know we're asking a lot. There are a lot of nuances to colorectal care. You may not see it in another hospital. You may not have to deal with at another hospital. We have a high volume, uh, of these kinds of patients and we're very appreciative of your, uh, collaboration and I'm thankful for the invitation to be with you all today. So thank you. We do have some time for questions and I do wanna make sure there are no questions on the chat. Somehow. I, I monitor. Oh, you're able to see that in there. Awesome, thank you. All right, any questions, please? It was Um No questions? Impossible. Someone come up with one OK, um, great presentation. Thank you. I have a question regarding vasopressors. Uh, you mentioned dopamine as like the best option. Uh, are there any other good options like besides dopamine, like if we have problems with blood pressure that we cannot like treat with fluids or blood. Or I think, I think you'd be better able to answer that question than I would. OK. Um, I just happen to know that norepinephrine and epinephrine have been associated with vasoconstriction of small vessels in a pedicolli situation. Dopamine is not as vasoconstrictive. It is very rare that we even need to even think about such a drug because the blood pressure is usually fine and it's well managed with fluids or colloids. But if you do have that situation, just Sway away from a vasoconstricting agent or at least have the conversation. Um, the blood pressure's soft. I've given lots of fluid. What's happening with your, how are your pedicles? What are you doing? It might be a case where we didn't actually do much in the way of pedicles and he's perfectly fine. That's all. By the way, you remind me of another collaborative idea that I have that I would love to bring the piano into the operating room. Right? Don't you think we could have some music on, like live music? Would you, would you be able to provide that? Could you do, could you do that and provide the anesthesia at the same time? I think you're capable. OK. You have to wear your hat though. All right. Any other questions, please? Any questions in the chat? I just want to take a moment to welcome some of our special guests here. We have, um, surgeons visiting us from Canada, Greece, and Israel in the room. All of them going back to their home countries at some point to develop colorectal care, uh, in those countries. So, uh, George, Hussein, and Nimbal, thank you guys for, uh, for being here. So, um, in your experience at the previous institution, you were saying the majority of the patients that needed ICU care were, were secondary to pain, um, and here it hasn't been much of an issue. Are there any other issues that we should be concerned about in. Pre-planning to make sure that, you know, a certain patient population that would require ICU care postoperatively. Yeah, so I can tell you where I worked before, if the patient's case was longer than 6 hours, they went to the ICU. That was a rule When I came here, we had conversations, Sophie and others about, you know, uh, regional management, all those kind of things. And I said, great, let's do it. And then what, what did we notice? Particularly during COVID when there were no ICU beds available. We're like, we're not stressing the ICU because we never needed the ICU. I can tell you in the last 6 months, I can think of maybe 1, maybe 2 patients that needed the ICU. I think it's proactive thinking through what will be the regional plan and actually successful regional management, right? If you put an epidural and it doesn't work, then that's not a pain managed patient. It doesn't happen here. The patients get really good care and we haven't needed the ICU. So I think the long case, the really long case, we had a 16 hour case about 6 weeks ago. Clearly they need to go to the ICU in large part, not just for pain management, but also fluid management. It made a lot of sense to put that patient in the ICU. We expected that patient would go to the ICU. Some of the joint cases with urology that we know are going to take 8 or 10 hours, some of the robotic cases are particularly long. I think we can, we book those cases and we usually say we don't need the ICU. And then of course it's up to you whether you want to use the ICU or use the PACU overnight. I know that has some challenges to it. That is an option. We haven't really stressed the intensive care part of the hospital very much with our patients, and I believe the major change is better regional care. In fact, I think it would be a great article, right, because we definitely didn't use resources. Interestingly, at the time where we did not have ICU beds. We discussed it and said good news, we don't need ICU beds because I think it's mainly because of that. Fluid shifts I think are a big part of the ICU management. Blood pressure is usually not a problem. Pain management is the, I think is the main, is the main issue, because if they aren't properly pain managed and it's 10:00 at night and they're on the regular floor, then you end up calling an act and it's a bit of a mess. Where if you tuck that patient away in the ICU, everyone sleeps that night. I'll, I'll repeat your question, but just if it's not in the microphone, then the people out. No worries in the hinterlands can't hear it. Um, I guess one of my questions was about, um, kind of planning for these procedures, like how long does it take theoretically when you have a patient that presents with the colico or the physiology that you, um. Mentioned and then I guess my other question to that is how do you manage that patient in the interim when you're waiting for them to have this surgical procedure done. Yeah, that's a really good thoughtful question. So the first part is we, the patients contact our center. We have Have a collaborative meeting with all the teams every Tuesday morning after anesthesia has head off to their life. We keep going with the upcoming patients, not the ones next week, but what do we do with so and so from such and such place who needs, needs the surgery. It usually takes about 3 or 4 months to actually get them here, paperwork, insurance, all of those things, planning, making sure we review their medical records. Um. But they're safe because they have a colostomy or they're draining their urine through a vesicostomy. One of the reasons why we can be a regional center is because these are not urgent. These are all patients that are safe. They're living their life, not a great situation with a colostomy or a bag or a vesicostomy, but they are safe and then they come for the reconstruction. So there's no urgency. I mean, if we had a, if you've tried to have a center that only deals with urgency, like, Uh, ruptured aortic aneurysm. You can't have a center for that, right, because it just happens. You have to deal with it wherever you are. But in colorectal surgery, as long as they get a colostomy and the urine is draining successfully, the operation could take place anytime within the first year of life. So, uh, it allows us to really take our time and plan, uh, properly. Have I answered your question? Yes. Thank you. Um, is there an ideal time frame that you want to perform these reconstructions? Yeah, so the question was, is there an ideal time frame to do the reconstructions? I like to tell the families they'd like to get everything done by 1 year. So usually they get a newborn colostomy, then the reconstruction can take place somewhere between 2 and 6 months, and then the colostomy can be closed sometime thereafter, and by about 1 year they're done with their surgery, which sets them up to then have about 2 years of. Getting to know their anatomy and seeing if they can successfully potty train and in anticipation of that if they're not successful and they're approaching nursery school and they're still not potty training, then we have our bowel management program with our nur nursing team to get them mechanically clean and getting them into normal and ready for school. So that's usually the timeline. Of course that timeline is often messed up with the patients that have had surgery done elsewhere. They come to us at the age of 6 or 12 or 17. So, but the ideal, a newborn managed correctly in the newborn period has the reconstruction and there's soma closure and everything's done by about 1 year of life. So the vast majority of our patients are within the first year of life. Then there's a group of the re-operative patients or the ones that need them Malones that are in sort of the 3 to 10 years of life. And then of course we see teenagers that have never had their problems solved and find us at a late age. Well, thank you all very much for your attention. Do you have something more to say. I, uh, really appreciate the invitation. And hope to see some of you later today in the OR. Thank you Mark. This is very informative. I do have just um mostly a comment um to kind of piggyback on the the collaboration you mentioned the Tuesday morning meeting where we discussed the upcoming patients for for the the upcoming week and. I think it's I want to just stress the importance of that collaboration and the conversations that happened at that meeting, but that can also happen in the operating room so I really encourage whether it's during time out to continue that discussion. But also during these very long cases which could be 3 to 4 or 5 hours, to at some point pause and just check in with one another. They are, it's a little bit more, it's a little, I would say more hazy. When is a critical time to do this. This is not a scoliosis repair where there are critical portions of the surgery, such as, for example, for scoliosis. As many of you know, there's the, the, the period where the distraction happens and the de-rotation, and those are there's a very defined point where we, where we're, uh, everybody's present and, and checks in, um, here these, these procedures because also there's multiple providers that are involved can last a long time but it's also sometimes unclear to us on the other side what what is what is the critical. Part of the operation so I would just encourage you know residents, our AAs, our faculty to just do that check in from time to time and it's, you know, welcome on your end as well just because again it's it's unknown when when you know just where we should just have a discussion about fluids and hemoglobin and whatnot. Yeah, I think that's a very excellent suggestion. I agree. And as you mentioned, the bladder is sometimes open on the field. We do lose a very important monitor there, which is our urine output, and it's just very difficult for us to know in a way what are the, you know, fluid status at that point in terms of I have to say that part I've been fairly amazed with. We used to have a lot of trouble with dilated bowel, overhydration. I haven't seen that once, honestly in. Um, in all the time here. The, the guessing, the estimated, educated guessing of the urine output, or the fluid needs I should say, has been quite accurate. So however you guys are calculating it's working because one of the biggest problems if you over hydrate that patient, then the bowel gets very swollen and it's very hard to close. We haven't really had that issue, and we will know from this point until this point, you will not have urine output. And we'll be able to tell you that, but I agree we should have sort of stages of our conversation. Many of the many of the, a lot of the cases not critical. They're sort of we're moving along slowly. You may see like a change in the team, the urology comes and does their thing. That might be a good time to take a pause and say, hey, where are we? How much longer are we gonna be? That kind of thing. So I think it's an excellent suggestion. OK, thank you all. Thank you.
