Separation of omphalopagus conjoined twins using combined caudal epidural — general anesthesia

Abstract

Purpose: To describe the anesthetic management of newborn omphalopagus conjoined twins undergoing a series of diagnostic and surgical procedures which culminated in successful separation at one month of age.Clinical features: Evaluations of the extent of shared organ systems were carried out without the need for anesthesia. The twins were anesthetized twice, once for insertion of skin expanders, and later for surgical separation. Various airway management techniques were utilized. To facilitate surgical separation, caudal epidural catheters were inserted in an effort to provide both operative and post-operative analgesia. In addition, prior to the induction danesthesia, the extent of cross-circulation between twins was assessed, Conclusion: Caudal epidural catheters can be used to provide both operative and post-operative analgesia. Early extubation, another benefit of regional analgesia, was not achieved because both twins developed respiratory failure in the immediate postoperative period. Testing for the extent of cross-circulation between twins proved valuable, allowing for detailed scripting of the complex induction sequence and airway management. A LTHOUGH conjoined twins are a rare occurrence, several successful operative separations have been reported.l,3,4, (>9 To our knowledge, none of these reported operations have included regional anesthesia as part of the intraoperative anesthetic management or for postoperative analgesia. In addition, there are no reports of testing the extent of cross-circulation between conjoined twins to evaluate what might occur during the induction of anesthesia. We report the successful separation of omphalopagus conjoined twins using caudal epidural anesthesia with continuous infusion of local anesthetic for postoperative analgesia. We also tested for the extent of cross circulation between twins with both inhaled and iv drugs, and suggest how that information can be used to plan the induction of anesthesia and management of the airway. ObjectifCase report Male omphalopagus twins were delivered by Cesarean section at 36 weeks gestation. They needed no resuscitation at birth. The combined birth weight was 5600 g and they shared a single umbilical cord. TheyFrom the

Pediatric tracheostomy in conjoined twins: Multidisciplinary approach

“…To prevent potential drug crossover, small doses should be titrated to desired effect. It was known that the twins shared portions of their livers, intestines, and diaphragms and there was a real possibility of significant anesthetic transfer [14]. After desflurane inhalation anesthetic induction of Twin A, no desflurane was detected in the end tidal expired gases of Twin B after 5 min indicating anesthetically insignificant cross-circulation between the twins in the early phase of anesthetic administration.…”

Anaesthetic challenges in conjoined twins′ separation surgery

“…The presence of cross-circulation can be tested by administering atropine to one baby and assessing the changes in heart rate in the other baby. [7] In the presence of cross-circulation, there is possibility of passage of drugs given to one twin to the other which may cause sedation and airway obstruction in the other and the anaesthesiologist must be aware of this possibility. [8] Regardless of the presence and degree of cross-circulation, drugs should be administered as they would be given for two separate infants.…”

General anesthesia for repair of omphalocele in a pair of conjoined twins in Enugu, Nigeria

“…[4–6] There are numerous reports in the literature documenting anesthetic management strategies for the separation of conjoined twins. [7–13] There are also reports in the literature detailing anesthetic approaches for surgical procedures not involving separation, surgical separation where one or both twins had congenital heart disease, and surgical procedures on the heart before separation. [14–17] This is the first report of the anesthetic management of a set of omphalagous presenting for palliative repair of omphalocele in Nigeria.…”