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Anesthesia for tracheoesophageal fistula

Anesthestic management for tracheoesophageal fistula neonate

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Anesthesia for tracheoesophageal fistula

  1. 1. Anesthesia forAnesthesia for Tracheo-esophagealTracheo-esophageal Fistula RepairFistula Repair ByBy Dr. Hazem Sharaf (M.D.)Dr. Hazem Sharaf (M.D.) Anesthesia ConsultantAnesthesia Consultant
  2. 2. This is part II after PediatricsThis is part II after Pediatrics
  3. 3. What’s aWhat’s a Grand round  Grand round is an important teaching tool and usual of  medical education and inpatient care, consisting of presenting the medical problems and treatment of a particular patient to an audience consisting of doctors, residents, medical students and nurses.
  4. 4. What’s aWhat’s a Grand round  The patient was traditionally present for the round and would answer questions; grand rounds have evolved with most sessions now rarely having a patient present and being more like lectures.
  5. 5. Interdisciplinary CareInterdisciplinary Care  interdisciplinary teaminterdisciplinary team a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient.
  6. 6. Today’s PatientToday’s Patient  Our Pediatric surgeon informed me aboutOur Pediatric surgeon informed me about a baby-girl in NICU at 1.00 pm fora baby-girl in NICU at 1.00 pm for emergency thoracotomy for TEF repairemergency thoracotomy for TEF repair  The pt was a full term girl 15 hrs oldThe pt was a full term girl 15 hrs old diagnosed as esophageal atresia withdiagnosed as esophageal atresia with tracheo-esophageal fistula for emergencytracheo-esophageal fistula for emergency surgical intervention as soon as possiblesurgical intervention as soon as possible
  7. 7. On checking: the baby was well medicallyOn checking: the baby was well medically stabilized in NICU with secured:stabilized in NICU with secured: Intra-venous lineIntra-venous line Endotracheal tubeEndotracheal tube Oro-Gastric tube to drain the pouchOro-Gastric tube to drain the pouch Urinary CatheterUrinary Catheter
  8. 8. Types of TEFTypes of TEF
  9. 9. • Maternal and perinatal history • Birth history • Minimum labs: glucose and CBC • Look for associated anomalies • Cardiac and respiratory status • Metabolic and electrolyte imbalance • Hydration status & IV access • Coagulation profile Preoperative EvaluationPreoperative Evaluation
  10. 10. O.R. readinessO.R. readiness Every thing is ready for O.R. for example:Every thing is ready for O.R. for example: Complete preoperative assessmentComplete preoperative assessment StabilizationStabilization Ruling out other associated anomaliesRuling out other associated anomalies Counseling the familyCounseling the family Cross-matched bloodCross-matched blood Prepared Theater for neonatal emergencyPrepared Theater for neonatal emergency high risk surgeryhigh risk surgery Prepared anesthesia machine & drugsPrepared anesthesia machine & drugs
  11. 11. O.R. readinessO.R. readiness Multi-disciplinary approach byMulti-disciplinary approach by methodical detailedmethodical detailed discussion with pediatriciansdiscussion with pediatricians and pediatric surgeonsand pediatric surgeons
  12. 12. ““Safe and effective anesthesia forSafe and effective anesthesia for neonates undergoing surgery is one ofneonates undergoing surgery is one of the most challenging tasks presented tothe most challenging tasks presented to anesthesiologist.”anesthesiologist.” KnowledgeKnowledge Manual skills of the whole teamManual skills of the whole team Continuous practiceContinuous practice ++ Adequate monitoring & OptimumAdequate monitoring & Optimum Postoperative Intensive CarePostoperative Intensive Care ↓↓ Satisfactory OutcomeSatisfactory Outcome
  13. 13. Esophageal Atresia/TEF 1:4000 M:F 25:3 First fed chocking, cyanosis
  14. 14. Anesthetic ManagementAnesthetic Management  Operating room set upOperating room set up::  ““keep warmkeep warm””:: warm room, warmingwarm room, warming blanket, overhead warmerblanket, overhead warmer  Low body temp:Low body temp:  Release Nor-Epinephrine: vasoconstriction,Release Nor-Epinephrine: vasoconstriction, increases metabolism, change degree ofincreases metabolism, change degree of shuntingshunting  Affect anesthetic agents: likely over-Affect anesthetic agents: likely over- dosage, postop hypo-ventilation, apneadosage, postop hypo-ventilation, apnea  Coagulopathy, metabolic acidosisCoagulopathy, metabolic acidosis
  15. 15. Anesthetic ManagementAnesthetic Management  Standard monitoringStandard monitoring:: EKG,EKG, (pericordial stethoscope) pulse(pericordial stethoscope) pulse oximetry, end tidal CO2, BP monitoringoximetry, end tidal CO2, BP monitoring (Arterial line in high risk infants), Urinary(Arterial line in high risk infants), Urinary OutputOutput
  16. 16. Patient PositionPatient Position Lateral decubitus position Posterolateral thoracotomy
  17. 17. OGT / NGT is a very crucial issue to be determined before draping I never anesthetized a big baby from NICU
  18. 18. Anesthetic ManagementAnesthetic Management  Induction:Induction: ““establish airway without pulmonary aspiration or gastricestablish airway without pulmonary aspiration or gastric distensiondistension”” In preparation for intubation:In preparation for intubation:  Suction, pre-oxygenationSuction, pre-oxygenation  MaintainMaintain spontaneous ventilationspontaneous ventilation::  Avoid positive pressure ventilationAvoid positive pressure ventilation::  Insufflation of the stomach via the fistulaInsufflation of the stomach via the fistula or loss of ventilation through theor loss of ventilation through the gastrostomygastrostomy  Gastric distention: compromise ventilation,Gastric distention: compromise ventilation, aspirationaspiration
  19. 19. Intubation/AirwayIntubation/Airway  Awake intubationAwake intubation  SafeSafe  Appropriate positioning of ETTAppropriate positioning of ETT  Positive pressure ventilationPositive pressure ventilation  BUTBUT Difficult and traumatic in vigorous infantsDifficult and traumatic in vigorous infants  Inhalation/IV anesthetic +/- muscleInhalation/IV anesthetic +/- muscle  relaxant: Maintain spontaneous ventilation:relaxant: Maintain spontaneous ventilation:  With assistance ventilation until fistula is ligatedWith assistance ventilation until fistula is ligated  Keep airway pressure low (10-15 cmHKeep airway pressure low (10-15 cmH22 0)0)
  20. 20. Intubation/AirwayIntubation/Airway  ETT positionETT position  Below the fistula and above the carinaBelow the fistula and above the carina  Right main-stem intubationRight main-stem intubation, then withdraw, then withdraw  Proximal to carina, (no Murphy's Eye)Proximal to carina, (no Murphy's Eye) bevelbevel facing anteriorlyfacing anteriorly so that posterior wall canso that posterior wall can occlude the fistulaocclude the fistula  ConfirmationConfirmation  Fiberoptic bronchoscopy (!! Catheter inFiberoptic bronchoscopy (!! Catheter in Fistula!)Fistula!)  Gastrostomy to water sealGastrostomy to water seal
  21. 21. Induction drugs:Induction drugs: Non-analgesic technique practice is no longer acceptable. Narcotics Based induction & maintenance Is the method Of Choice: Fentanyl:*  10 mcg/kg IV during induction provides stable cardiovascular response  2-4 mcg/kg/hr adjuvant to anesthesia  Stable cardiovascular response * Newborn Services Drug Protocol recommended higher dose (50 mcg/kg)
  22. 22. Anesthetic ManagementAnesthetic Management  Intra-op problems:Intra-op problems:  One lung ventilationOne lung ventilation: hypoxia, as well as: hypoxia, as well as CO2 retentionCO2 retention  ETT obstructionETT obstruction: blood clot, secretion: blood clot, secretion  kinking of tracheakinking of trachea  Vagal response:Vagal response: tracheal manipulation,tracheal manipulation, lead to bradycardia, cardiac arrest!!lead to bradycardia, cardiac arrest!!
  23. 23. Intraop problems:Intraop problems:  Frequent interruption to the surgery byFrequent interruption to the surgery by the anesthesia team:the anesthesia team: To minimize lung compression (no OLV)To minimize lung compression (no OLV) To readjust monitorsTo readjust monitors To reposition OGT/NGTTo reposition OGT/NGT To check the IV accessTo check the IV access Stabilize unstable babyStabilize unstable baby To fight for the time!!!To fight for the time!!!
  24. 24. • Obstruction of ETT • V/Q mismatch  lateral decubitus position  Interrupt lung retraction • Vagal response to tracheal manipulation Intraop problems:
  25. 25. Maintenance of Anesthesia  Narcotic based technique  Minimal Inhalational + Ms relaxant  No place for nitrous oxide
  26. 26. Intraoperative Volume ReplacementIntraoperative Volume Replacement Hypovolemia with blood loss accounts forHypovolemia with blood loss accounts for 12% of causes of pediatric cardiac arrest in12% of causes of pediatric cardiac arrest in OR with almost half of it due to underOR with almost half of it due to under estimation of blood loss.*estimation of blood loss.* **Anesthesia-Related Cardiac Arrest in Children: Update from the PediatricAnesthesia-Related Cardiac Arrest in Children: Update from the Pediatric Perioperative Cardiac Arrest RegistryPerioperative Cardiac Arrest Registry Bananker et al, Anesthesia & Analgesia, August 2007Bananker et al, Anesthesia & Analgesia, August 2007
  27. 27. Anesthetic Management:Anesthetic Management: Postoperative problemsPostoperative problems  Post op ventilationPost op ventilation (Our pt ventilated for(Our pt ventilated for 10 days post-op)10 days post-op)  Conditions:Conditions:  Defective tracheal wall at the site of fistulaDefective tracheal wall at the site of fistula  Contaminated lungContaminated lung  Problems associated with prematurity orProblems associated with prematurity or associated anomalies & the general condition.associated anomalies & the general condition.  ETTETT positionedpositioned >1cm>1cm away from site of fistulaaway from site of fistula repairrepair  Avoid suction too deepAvoid suction too deep
  28. 28. I’ll Love You Too Much If You Do It Easier:I’ll Love You Too Much If You Do It Easier:
  29. 29. Thoraco-scopic Repair EA/TEFThoraco-scopic Repair EA/TEF Fistula LigationFistula Ligation • SutureSuture • ClipClip
  30. 30. Thoraco-scopic Repair EA/TEFThoraco-scopic Repair EA/TEF  Anastomosis – SutureAnastomosis – Suture • VicrylVicryl • PDSPDS • SilkSilk  Anastomosis –Anastomosis – TechniqueTechnique • ExtracorporealExtracorporeal • IntracorporealIntracorporeal
  31. 31. Thoraco-scopic RepairThoraco-scopic Repair EA/TEFEA/TEF  Thoraco-scopic repair of EA/TEFThoraco-scopic repair of EA/TEF can be performed safely andcan be performed safely and effectivelyeffectively && may be advantageousmay be advantageous by reducing the musculoskeletalby reducing the musculoskeletal sequelae seen followingsequelae seen following thoracotomythoracotomy
  32. 32. Pediatric Anesthesia PearlsPediatric Anesthesia Pearls
  33. 33. Pediatric Anesth PearlsPediatric Anesth Pearls • Almost all neonatal surgical “emergencies”Almost all neonatal surgical “emergencies” are really “challenges”are really “challenges” • Immaturity of organ system in neonatesImmaturity of organ system in neonates alters pharmacology and physiologyalters pharmacology and physiology • Thorough preop assessment is required in allThorough preop assessment is required in all neonatesneonates • One anomaly mandates a search for othersOne anomaly mandates a search for others • Murmurs necessitate a cardiology consultMurmurs necessitate a cardiology consult
  34. 34. • Successful perioperativeSuccessful perioperative outcome depends on openoutcome depends on open communication and teamworkcommunication and teamwork betweenbetween neonatologist,neonatologist, anesthesiologistanesthesiologist andand surgeonsurgeon
  35. 35. • Initial resuscitation of neonatal surgicalInitial resuscitation of neonatal surgical candidates includes:candidates includes:  airway protectionairway protection  adequate IV accessadequate IV access  fluid resuscitationfluid resuscitation  temperature stabilizationtemperature stabilization  gastric decompressiongastric decompression  administration of antibioticsadministration of antibiotics  identify associated anomaliesidentify associated anomalies
  36. 36. -Infant's fragile cerebral blood vessels is an important-Infant's fragile cerebral blood vessels is an important factor in the development of intra-ventricularfactor in the development of intra-ventricular hemorrhage.hemorrhage. -The spinal cord extends to a lower segment of the-The spinal cord extends to a lower segment of the spine than in older children .spine than in older children . -The volume of CSF and the spinal surface area are-The volume of CSF and the spinal surface area are proportionally larger in neonatesproportionally larger in neonates ►► increased amount ofincreased amount of local anesthetics (mg/kg) required for a successfullocal anesthetics (mg/kg) required for a successful neuroaxial anesthesia in infants.neuroaxial anesthesia in infants.
  37. 37. ReferencesReferences  SmithSmith’’s Anesthesia for Infants and Childrens Anesthesia for Infants and Children, 8th, 8th edition, 2011 Mosbyedition, 2011 Mosby  Clinical Cases in AnesthesiaClinical Cases in Anesthesia, 3rd edition, 2012, 3rd edition, 2012 ElsevierElsevier  Pediatric Anesthsia:The Requisites inPediatric Anesthsia:The Requisites in AnesthesiologyAnesthesiology, 2004 Mosby Elsevier, 2004 Mosby Elsevier  Yao & ArtusioYao & Artusio’’s Anesthesiology; Problems Anesthesiology; Problem Oriented Patient Management, 2011 LippincottOriented Patient Management, 2011 Lippincott