ANAESTHETIC CONSIDERATION ON TRACHEOESOHAGEAL FISTULA .pptx

1. ANAESTHETIC CONSIDERATIONS
IN TRACHEOESOHAGEAL
FISTULA
DR zikrullah

2. INCIDENCE OF TEF??

3. • Approximately 1:3000 live birth.
• More commonly in male(60%) as compared
to female(40%).

4. DIAGNOSIS??

5. • Prenatal presence of polyhydromnios.
• Absent or a very small gastric fluid bubble.
• Excessive drooling or coughing with or
without cyanosis while feeding.
• On X-ray, a radio-opaque nasogastric tube
will be seen curled in the upper pouch.

6. THREE CLINICAL C's FOR IDENTIFYING
TEF??

7. • Choking.
• Coughing.
• Cyanosis.

8. WHAT ARE THE ASSOCIATED ANOMALIES??

9. • 50% of children with TEF will have
additional anomalies.
• Most often as VACTERAL, occur in 13% of
these patients.
• CHARGE syndrome, assoc. in 16% patients
of TOF.

10. • VACTERL-Vertebral defects(10%)
Anorectal malformations(14%)
Cardiac anomalies(29%)
Tracheoesophageal fistula
Esophageal atresia
Renal and/or radial anomalies
Limb defect

11. • VATER
• MUSCULOSKELETAL-Hemivertebrae
• Syndactyly
• Radial aplasia
• Rib anomalies
• Scoliosis
• CARDIAC- VSD
• TOF
• COA

12. • GIT-Imperforate anus
• Meckel's diverticulum
• Duodenal atresia
• Annular pancreas
• Malrotation
• GENITOURINARY-
• Renal agenesis
• Hypospaidasis
• Horseshoe kidney
• Polycyclic kidney disease

13. • CHARGE -
• C-coloboma.
• H-heart disease.
• A-choanal atresia.
• R-growth retardation.
• G-genital hypoplasia.
• E –ear abnormality/deafness

14. CLASSIFICATION??

15. GROSS CLASSIFICATION
 Type A:EA with no fistula-prevalence rate 7%.
 Type B:EA,upper segment communicating
with the trachea-prevalence rate 1%.
 Type C:EA with blind upper pouch and lower
segment communicating the trachea-
prevalence rate 85%.

16.  Type D:EA with both upper and lower segment
communicating with the trachea 3%.
 Type E:No atresia persent, but a
communication exist between the trachea and
esophagus (H type) 4%.

18. VOGT classification
• Type 1-esophageal agenesis, very rare
• Type 2- pure esophageal atresia
• Type 3A-EA with proximal TEF
• TYPE3B-EA with distal TEF
• TYPE3C-dual TEF with both segments
communicating with trachea

19. MONTREAL CLASSIFICATION SYSTEM
Based on the level of risk and classified as
follows.
• High risk : Life threatening anomalies or a
major anomaly and ventilator dependence.
• Low risk : All other patients.

20. SPITZ’s CLASSIFICATION OF TOF
• Based on the patient weight and presence or
absence of cardiac lesion.
Group 1 : Body weight>1500g without
cardiac disease( survival 97%).
Group 2 :Body weight<1500g or major
cardiac disease( survival 59%).
Group 3 : Body weight<1500g and major
cardiac anomaly( survival 22%).

21. PREOPERATIVE ASSESSMENT??

22. • Baby’s post-conceptual age.
• Detailed perinatal history:
 presence of foetal distress
 birth hypoxia
 respiratory distress syndrome
 APGAR score.

23. • Baby’s weight helps in predicting baby outcome.
• Assess the presence and severity of pulmonary
disease

24. • Plain chest x-ray: pulmonary infiltrates and
presence of congestive heart failure,
• A radio-opaque OGT will be coiled in the
proximal oesophageal pouch.
• An abdominal x-ray may show air in the
bowel entering through fistula.

25. • Because of risk of aspiration, contrast dye is
introduce only when diagnosis is uncertain.
• An echocardiogram is mandatory, as major
cardiac defects strongly influence survival.

26. •Spinal plain film-to exclude vertebral anomalies.
•Renal ultrasound-to rule out hydronephrosis.

27. Investigations??

28. • Complete blood count
• RFT-Blood Urea, S.electrolytes
• Blood glucose level
• x-ray chest
• blood for cross matching
• ECG
• ECHO
• Renal USG

29. HOW WILL YOU PREVENT THE ASPIRATION
DURING TRANSPORTATION??

30. • The upper blind pouch is placed on a cont. low
pressure suction.
• Baby is maintained and transported in semi-
sitting position.

31. Anaesthetic considerations??

32. • Pediatric patient
• Difficult iv access
• shared airways
• Difficult airway
• preoperative dehydration
• hypothermia
• Associated anomalies

33. NPO PROTOCOL & MAINTANANCE
FLUID

34. • NPO status should be commenced from the
moment TOF is diagnosed.
Holiday and segar:Daily fluid requirements
depends on metabolic demand.
4:2:1 rule
• Nature of fluid: 5-10% glucose with or without
quarter strength normal saline.

35. TYPE OF MASK USED AND BREATHING
CIRCUIT??

36. • Rendell Baker mask fits well to the facial
anatomy, has minimal dead space.
• Jackson Rees modification of Ayres T-piece,
recommended for children <20 kg.

37. PREMEDICATION??

38. • Sedative premedication is not required.
• Vitamin k should be administered.
• Stores of vit k are low at birth and bleeding
can occur because of low factors II, VII, IX
and X
• Antibiotics must be started preoperatively
to prevent infection.

39. • Atropine (0.01-0.02 mg/kg) premedication is
desirable to offset the vagal stimulation
at the time of induction
or traction on the hilum
or during mobilization of esophagus
and to reduce the secretion.

40. INDUCTION??

41. • Inhalational agent with or without muscle relaxant.
• Gastric distension may occur during assisted or
controlled ventilation
leads to diaphragmatic splinting, bradycardia, cardiac
depression, impaired pulmonary ventilation , ↓venous
return and pulmonary aspiration.
 Therefore keep the baby on spontaneous respiration
until the fistula is ligated.

42. INTUBATION??

43. • An awake intubation is advisable in a sick
baby.
• However, if the baby is struggling, gastric
regurgitation occur into the trachea.
• Therefore, perform an inhalational
induction with or without a muscle relaxant.

44. • ETT is large enough to permit suctioning
but still, has small leak around it.
• Used a straight blade laryngoscope to lift
the large floppy epiglottis.
• ETT without murphy's eye is preffered

45. • 2 techniques of intubation:
• Routine intubation with tip of ETT above
carina
• intentional intubation of right bronchus then
withdraw the tube gently so that tip of tube
lies just above carina and fix it.

46. • During intubation, position the tip of ETT in the
lower half of the trachea as the fistulous
communication usually lies in the mid trachea.
• To confirm that the stomach is not ventilated,
auscultate over the epigastrium or immerse the
gastrostomy tube in a bowl of water to see any
bubbling.

49. MONITORING??

50. • ECG for rate and rhythm.
• BP-invasive for complicated cardiac lesion,
otherwise a non-invasive technique.
• intra arterial cannula ti on for ABG
• A precordial stethoscope to monitor both
resp & cardiac activity.

51. • Temperature monitoring.
• Blood loos by weighing sponges and measuring
suction bottles.
• Do not put an esophageal stethoscope for fear
of perforating the blind pouch.

52. AIRWAY PROBLEMS??

53. • In some patients, leakage of the ventilated gas
into the stomach becomes a big problem.
• Remedial methods include an urgent
gastrostomy to prevent gastric distention,
however do not prevent gas leak or improve
ventilation.

54. IATROGENIC
It is common for surgeons to exert traction on the upper
lung
Leads to kinking of main bronchus of dependent lung.
A stethoscope place over the dependent axilla help in
identifying airway obstruction.
In case obstruction is due to traction, the surgeon can be
requested to release the pressure.

55. USE OF NITROUS OXIDE??

56. • Used with caution in these patient especially
if prior gastrostomy has not be done.
• If nitrous oxide is avoided, ensure that the
inspired oxygen has been diluted with air to
prevent- hyperoxia
-retinopathy of prematurity.

57. EXTUBATION??

58. • Most babies can be safely extubated at the
end of the procedure.
• The ETT must be suctioned and the lungs
inflated with oxygen prior to extubation.

59. • Be gentle in all your procedures so as not
disrupt suture line.
• If the baby had pulmonary complications,
consider mechanical ventilatory support.

60. POSTOPERATIVE VENTILATION??

61. • Considered in patients if
- Premature infant
- Chest infection present
- Associated anomalies present
- Respiratory distress syndrome

62. CAUSE OF SUDDEN AIRWAY OBSTRUCTION
IMMEDIATELY AFTER EXTUBATION??

63. • A consistent finding in patient of TOF is the
reduced amount of tracheal cartilage.
• This reduced support by the deficient
tracheal rings can cause tracheal collapse.
• And it requires immediate re-intubation.

64. POST-OPERATIVE PAIN RELIEF??

65. • Acetaminophen may be administered as
suppository 35-40mg/kg.
• Infiltration of surgical incision with 0.25%
bupivacaine.
• Morphine 0.1mg/kg/hr in full term baby
and 0.05mg/kg/hr in premature baby.

66. THANK YOU
THANK YOU