A multicenter audit of the use of bronchoscopy during open and thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.

BACKGROUND: Esophageal atresia (EA) with tracheoesophageal fistula is usually repaired in the neonatal period. Preferential ventilation through the fistula can lead to gastric distension. Bronchoscopy has a role in defining the site and size of the fistula, and may be carried out by the surgeon or the anesthetist. The use of bronchoscopy varies across different institutions. METHODS: This is a multicenter case note review of infants with EA with tracheoesophageal fistula who underwent surgery between January 2010 and December 2015. This retrospective audit aims primarily to document the use of bronchoscopy during open and thoracoscopic repair at a selection of United Kingdom centers. Respiratory complications, that is relating to airway management, the respiratory system, and difficulty with ventilation, at induction and during surgery, are recorded. The range of techniques for anesthesia and analgesia in these centers is noted. RESULTS: Bronchoscopy was carried out in 52% of cases. The incidence of respiratory complications was 7% at induction and 21% during surgery. Thoracoscopic repair usually took longer. One center used high-frequency oscillatory ventilation, on an elective basis during thoracoscopic repair, to facilitate surgical access and address concerns about hypoxemia and hypercarbia. CONCLUSION: The use of bronchoscopy varies considerably between institutions. Infants undergoing tracheoesophageal fistula repair are at risk of perioperative respiratory morbidity. The advent of thoracoscopic repair has introduced further variation.

Metabolic changes during major craniofacial surgery.

OBJECTIVES: The purpose of this study was to document the degree and duration of perioperative metabolic disturbance during major craniofacial surgery in children. AIM: The aim was to quantify the degree and duration of perioperative metabolic disturbance and to determine the relationship between the metabolic changes and the duration of surgery and total volume of blood and colloid given during surgery. BACKGROUND: These patients have the potential for massive blood loss and significant metabolic acidosis. Routine perioperative monitoring includes the serial measurement of base deficit (BD) as a marker of metabolic disturbance. METHODS/MATERIALS: All patients undergoing elective major craniofacial surgery were prospectively studied over a 10-month period. BD from arterial blood gas analysis was measured at standardized intervals during the perioperative period. The duration of surgery and total volume of blood and colloid given intraoperatively were used as covariates in a multiple regression analysis. RESULTS: Maximum recorded BD ranged from -3 to -20 (median -9). Median time taken to return to normal was 9.25 h (range 0-18 h). Median duration of significant BD was 3.8 h (range 0-20 h). CONCLUSIONS: Children undergoing major craniofacial surgery develop a varying degree of perioperative metabolic acidosis persisting for several hours. The maximum BD appears to be related to the amount of intraoperative blood loss and replacement rather than duration of surgery. As it is difficult to predict the extent and duration of metabolic acidosis for an individual patient, this study confirmed our current practice that all patients should be admitted to a neurosurgical high-dependency unit postoperatively for overnight monitoring.

Repair of sinus venosus defect in a patient with untreated vein of Galen aneurysmal malformation.

The vein of Galen aneurysmal malformation (VGAM) is a rare cerebral arteriovenous shunt, which may be associated with a congenital cardiac defect. Embolisation of the VGAM may be undertaken in the neonatal period if necessary, but is safer in infancy. Recent advances in neuroradiology have changed the prognosis for this group with many patients achieving survival with normal development. This case report describes a patient with a sinus venosus defect (SVD) and a VGAM and considers both the optimal timing of treatment of the two malformations and the conduct of anaesthesia for open repair of the SVD in the presence of an untreated VGAM.