Thursday, June 07, 2007

Conjoined twins

The Dogaru twins have been in the news a lot lately. The most recent news was that yesterday's surgery was stopped due to swelling in Anastasia's brain. They had planned a staged procedure and this means they'll have to reassess and make new plans. I'm fascinated by the whole process. Conjoined twins aren't something you typically see in a community hospital NICU.

We did get one set. It was back in my early days as a NICU nurse. Before prenatal ultrasounds were so common. Before the equipment gave the sort of clear images widely available now.

Preterm twins. I don't remember how premature, but something between 30 and 35 weeks. It was a maternal transport from a small hospital in a distant part of the state. The only thing we knew initially was that they were twins and preterm. When the mom was re-scanned, the verdict was "hugging twins" and almost certainly conjoined. The state of the art in prenatal ultrasound was nowhere near what it is now.

Ideally, the way to move these babies would be in utero, but by the time she reached us, the mom was very actively laboring and moving her again wasn't an option. The regional neonatal transport team was notified to be on standby and we got ready to admit the babies to our NICU for stabilization.

Unlike the Dogaru twins who are joined at the head (cephalopagus), these twins were joined from the top of the sternum to just above the umbilicus (thoracopagus). This is the most common form of conjoined twins, and the heart is always involved. It was obvious that this was the case for these twins once they were admitted - they always had the same heart rate.

There were a number of interesting challenges.

First, positioning the babies to intubate them so they could be placed on ventilators was a challenge. It had to be done very quickly so that they could both be ventilated. One baby had to be held up out of the way so that the other could be intubated, then the babies had to be flipped without dislodging the tube so that the second twin could be intubated.

Once that was accomplished, placing lines for access to do blood gases and provide fluids was the next challenge. At least the babies could be kept in a side-lying position so no acrobatics were required, just the usual challenges of placing umbilical lines. We had to settle for lateral (side) views on the xrays since positioning the babies for any other view would have been more of a challenge than we wanted.

Each baby had his own nurse and they had to coordinate their care so as not to be in each others way. Medication dosages had to be calculated, and since the circulation was connected, what one got, the other did as well.

We were glad to see the transport team when they arrived. It was a fascinating experience, but the babies could only receive definitive treatment at a center with more advanced capabilities.

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