Anesthetic management of Tracheo Esophageal fistula and Eosphageal Atresia


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Presented at Pediatric Anesthesia Conference held at cairo, Egypt.

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Anesthetic management of Tracheo Esophageal fistula and Eosphageal Atresia

  2. 2. Type A : Esophageal atresia + no fistula Type B : Esophageal atresia + fistula between the upper segment and the trachea. Type C : Esophageal atresia + fistula between the lower segment and the trachea (The commenest 87%) Incidence : 1 : 3500 live births Types : Gross and vogt classification
  3. 3. Type D : Esophageal atresia + 2 fistulas between the upper and the lower segment and the trachea. Type E : No atresia but a fistula between the oesophagus and the trachea. Type H or N : are subtypes of E, where tracheal opening is more cephalad than esophageal opening
  4. 4. • Failure of passage of a catheter down to the stomach is diagnostic (except in type E). • On feeding, chocking, cyanosis and coughing occur → aspiration pneumonia. • Prenatally, polyhydramnios is present. Clinical Picture : 1- It is diagnosed as follows : 2- Dehydration.
  5. 5.  Respiratory acidosis due to : 3- Acid-base disorders :  Metabolic acidosis : due to severe dehydration and shock • Pneumonia • Shunting • Hypoxia • Hypercarbia • Atelectasis • Gastric distention with elevation of diaphragm → impaired diaphragmatic excursion, so the infant may need one lung ventilation until gastric decompression occur.
  6. 6. • if the newborn is mechanically ventilated by mask, gastric distention may occur, which may impair ventilation and venous return resulting in hypoxemia and cardiopulmonary arrest. This needs gastrostomy under L.A and one lung ventilation until gastrostomy is done. 4- During neonatal resuscitation :
  7. 7. • VATER : 5- Associated congenital anomalies : V : Vascular or vertebral anomalies A : Anal or GIT atresia T.E : Tracheo-Esophageal fistula R : Renal or radial anomalies • VACTER : As VATER in addition to cardiac anomaly and limb anomaly • C.V congenital anomalies : VSD, ASD or fallot tetralogy they need Echo 6- Investigations such as plain x-ray, CT scan
  8. 8. The infant’s general condition and the anatomy of the defect govern the choice of surgical management : ANESTHETIC MANAGEMENT Preoperative Management :  Primary complete repair (ligation of fistula and esophageal anastomosis) which is preferred.  Staged repair (gastrostomy followed by division of the fistula, followed later by repair of the esophagus). Often the operation is preceded by bronchoscopy to define the site of the fistula and exclude other tracheal defects.
  9. 9. 1- Preoperative assessment and management of TEF and complications :  Pulmonary infection with antibiotics.  Dehydration and acid base balance disturbances should be managed  Frequent suction of the upper esophageal pouch in the semi-sitting position is required
  10. 10. (A) Risk classification according to Waterston and colleagues. ManagementCriteriaGroup Total repair immediatelyBody weight > 2500 g and well A Staged repair (gastrostomy 1st) Body weight 1800-2500 g and well B1 Body weight > 2500 g with moderate pneumonia and cong heart diseases B2 Surgeries should be post poned Body weight <1800 gC1 Body weight 1800-2500 g with severe pneumonia and CHD C2 2- Preoperative assessment of prognosis :
  11. 11.  Group I : Birth weight >1500 g without cardiac diseases survival rate is 97%.  Group II : Birth weight <1500 g or major cardia diseases survival rate 59%  Group III : Birth weight <1500 g and major cardiac disease the survival 22% (B) The spitz classification :  High risk : Life threatening anomalies or a major anomaly and ventilator dependence  Low risk : all other patients : It is recently used because advances in neonatal intensive care have improved the outcome so that birth weight is no longer an independent risk factor for mortality. (C) The montreal classification system : It divides patients into two groups :
  12. 12. 3- Gastrostomy : may be done in the pre-repair period value :  Prevent gastric distention and rupture so improve ventilation and venous return.  Prevents reflux of gastric content into lungs.  Allows proper nutrition of the baby in pre- and post-repair periods.  It prevents elevation of the diaphragm so avoiding respiratory distress.
  13. 13. 4- Patient’s position : The neonate is placed in a head-up position to decrease regurgitation of gastric secretion through the fistula. Premedications :  Sedatives avoided.  Atropine used to avoid bradycardia which may be caused by : • Traction on the hilum or mobilization of the esophagus, which stimulates the vagal nerve. • Halothane.
  14. 14. Induction and intubation : Before intubation suction the upper pouch is done by a catheter, apply lidocaine 4% to the gums and palate using a gauze sponge this lessens the response to intubation. INTRAOPERATIVE MANAGEMENT Induction : Inhalational induction with spontaneous ventilation, without muscle relaxant is better. It is performed by an extrapleural approach for ligation of the defect and primary anastomosis of the esophagus.
  15. 15. ETT :  Size : large enough without a Murphy eye to allow easy suction and allow blocking of the fistula.  Position : above the carina and below the opening of the fistula. It is passed 1st into the Rt main bronchus then withdrawn gradually until breath sounds are heard bilaterally equal this position is confirmed by : 1. Auscultation of both lungs and stomach. 2. Fiberoptic bronchoscopy. 3. By placing the gastrostomy tube into a baker of water and applying positive airway pressure, absence of bubbling confirms good positioning while presence of bubbling indicates bad positioning requiring more advancement.
  16. 16. Other options that prevent gas from entering the stomach include :  A snug abdominal binder that can compress the stomach and prevent over-distention.  A Fogarty catheter that is placed across the fistula to occlude it. This can be done via the trachea with the aid of fiberoptic bronchoscope. The disadvantage of this technique is that if the catheter is disloged into the trachea. It can occlude the airway.
  17. 17.  If the fistula is connected to the carina or the main stem bronchus, in this case it is impossible to place the tube end distal to the opening of the fistula, so, intermittent venting of a gastrostomy tube that has been placed preoperatively may allow P.P.V without excessive gastric distention or alternatively by using ECMO (Extracorporeal membrane oxygenator).  Endobronchial intubation can occur it should be observed and managed.
  18. 18. Patient position : The patient should be in : • Semi-setting during gastrostomy • Left lateral position during repair Maintenance :  O2 : air (+ N2O), sevoflurane or halothane and spontaneous ventilation are used.  O2 : air (+ N2O) : maintain PaO2 50-70 mmHg or SaO2 87-92% to avoid retinopathy of prematurity if gastrostomy was done O2 can be diluted by N2O according to patient status.
  19. 19.  Spontaneous ventilation with sevoflurane or halothane is used before doing the repair then controlled ventilation with sevoflurane or halothane and a muscle relaxant is used after doing the repair because : Mediastinal stability is essential for proper repair. No fear of gastric distension.  I.O fluid therapy.  I.O body temperature
  20. 20. Monitoring :  Beside the standard monitors : - Precordial stethoscope : placed in the dependent axilla to monitor respiratory obstruction because traction on the upper lung causes a kink of the main bronchus of the dependent lung or obstruction of the ETT by blood or mucus, which must be sucked. - Arterial blood gases. - Invasive arterial blood pressure and CVP  Extubation and recovery : - Before extubation adequate suctioning from ETT with 100% O2 and tracheo bronchial toilet are done. - The criteria of extubation should be fulfilled such as : Level of consciousness Muscle power
  21. 21. POSTOPERATIVE MANAGEMENT 1. The child with a clear chest who is awake and moving vigorously should be extubated in the OR. Some surgeons may prefer to keep the trachea intubated and a gastroesophageal tube in place for several days to avoid reintubation and damage to the tracheal repair. 2. If there are pulmonary complications or inadequacy of ventilation, continue controlled ventilation. 3. The pharynx is suctioned with a soft catheter that has a suitable maximum length of insertion, it must not reach the anastomotic site.
  22. 22. 4. Prolonged intensive respiratory care. 5. Prognosis after the repair depends on the maturity of infant, whether other congenital anomalies are present, and whether pulmonary complication develop. In absence of these conditions, the prognosis is excellent. 6. Postoperative analgesia may be provided by a caudal epidural catheter inserted intraoperatively and threaded to the thoracic level, careful management of local anesthetic doses is required.
  23. 23. If staged repair is planned, a preliminary gastrostomy is performed under local or general anesthesia. Management of the second stage should follow the sequence outlined for primary repair. Further surgery to repair the atresia may be done when the child’s condition is optimal. ANESTHESIA MANAGEMENT- STAGED REPAIR
  24. 24. Late complications :  Diverticulum of the trachea, at the site of the old fistula is common in children who had tracheoesophageal fistula repaired during infancy.  The tracheal cartilage structure is abnormal and tracheomalacia may cause symptoms during infancy after repair of a TEF. Episodes of stridor, dysnea, and cyanois (dying spells) characteristically occur during feeding. This is caused by compression of the soft trachea between the dilated esophagus and arch of the aorta. Severe symptoms require surgical treatment by aortopexy or tracheoplasty with an external splint. These children often have a deep barking cough much like children with croup.
  25. 25.  Stricture may develop at the site of the esophageal anastomosis with episodes of esophageal obstruction with food (the hotdog of the esophagus) it may require repeated dilatations and later, possibly resection with replacement using the colon or a gastric tube.