2019 FSA Posters

P071: JOINED TOGETHER OR IS SEPARATE BETTER? AN ANALYSIS OF AN UNCOMMON APPROACH TO THE ANESTHETIC MANAGEMENT OF CONJOINED TWIN SEPARATION
Rhae Battles, MD, Maria Irwin, MD; University of Florida

Introduction/Background: Conjoined twins are rare and have multiple anatomical variants which makes every case unique. Separation always demands meticulous planning, detailed organization, multiple procedures, and long recovery. Can there be a standard of care for such a rare surgery? Does it require two separate anesthesia teams? Yes and no.

Case Presentation: We present a case of omphalopagus twin separation that we adapted to our unique patients and institutional resources. The babies were nine weeks old with a combined weight of 4.3 kg and had a shared diaphragm, liver, and portion of the colon. Subcutaneous expanders were placed a month prior. Expected operating room (OR) challenges included limited workspace with multiple surgical and anesthesia teams, extra equipment and support staff, traffic control, and significant blood loss. To prepare for these events, the surgical team elected to use one operating table as the patients were planned to be kept side-by-side after separation and through closure. We chose to have one attending and two anesthesia residents to manage the case instead of two complete separate teams based on the babies’ similar anatomy and physiology,  We had a unique plan for fluid resuscitation by using one fluid management system (Belmont) Y-split into each baby since they shared circulation (confirmed preoperatively).

Prior to the procedure, separate anesthesia machines, computers for electronic record keeping, airway trays and medications for each baby were prepared, labeled, and color coded. On arrival to the OR, airways were managed, arterial lines were placed and reliable venous access was obtained in SVC basins.  Medications were dosed carefully due to the risk of an unintended effect in the opposite twin.

Discussion/Conclusion: The separation proceeded successfully. Challenges included difficult airway and line placement because the babies were facing each other in close proximity, twin to twin transfusion before separation, and the expected massive blood loss during the liver portion of the procedure. Using a single fluid management system significantly conserved blood products utilized and provided adequate resuscitation. Considerations for the future will still include meticulous planning with clear understanding of the anatomy, physiology, surgical plan in order to prevent possible complications perioperatively. Our model may not apply to patients with abnormal circulation (congenital heart defects) or if there is a need to move one of the twins to a separate table or OR. We found it resourceful and efficient to not just keep the babies separate, but to find ways to treat them as one unit.

References:

Chalam KS. Anaesthetic management of conjoined twins’ separation surgery. Indian J Anaesth. 2009;53:294–301.

Mian A, Gabra NI, Sharma T, et al. Conjoined twins: From conception to separation, a review. Clinical Anatomy. 2017;30(3):385-396.

Thomas JM, Lopez JT. Conjoined twins - the anesthetic management of 15 sets from 1991-2002. Paediatr Anaesth. 2004;14:117–29.