This case presentation discusses a 3 day old male infant diagnosed with tracheoesophageal fistula (TEF). The infant presented with nasal flaring, difficulty breathing, choking and cyanosis since birth. Examination and investigations confirmed TEF, which was repaired surgically. Nursing management involved strict vital monitoring, ensuring nutrition via NG tube, preventing infection, and educating the family on post-operative care.

1. CASE PRESENTATION
ON
TEF(Tracheoesophageal fistula)
SANDEEP KAUR
M.Sc. 1st year
PAEDIATRIC NURSING

2. BIODATA OF THE PATIENT
Name: Kaka Kirpal singh
Age/sex: 3 days/male
Father’s name: Kirpal singh
Mother’s name: Gurwinder kaur
Occupation of parents: Shopkeeper
M.R.D no.:1933536
D.O.B: 31 march 2018
Doctor incharge: Dr. Karuna thapar & Gurpreet singh
Diagnosis: Tracheo oesophageal fistula
Informant: Father and written records
Birth Weight: 2.7 kg

3. CHIEF COMPLAINTS:
• Nasal flaring, difficulty in breathing since
birth
• Choking and cyanosis

4. HISTORY OF PRESENT ILLNESS
• Baby is born through LSCS delivery.
• Mother observes when baby take feed
turns blue and difficulty in breathing.
• After that they came into this hospital
and diagnosed with TEF

5. HISTORY OF PAST ILLNESS
• No H/O pulmonary HTN, TB, DM

6. PAST SURGICAL HISTORY.
• No past surgical history in patient

7. PRESENT SURGICAL HISTORY
• TEF is repaired on 2/4/18 by Dr. Pardeep
Bhatia.
• Premedication glycol 0.02
• Tramadol 6mg is given
• Induction: Propofol 3mg + atracurium 1.5mg,
ET tube fixed at 8.5cm, oxygen and nitrogen
oxide is given.
• Pulse rate at duration was up to 154-170
• SpO2 was 100%
• I/V fluids 10% dextrose+ inj. Paracip 30mg
was given

8. FAMILY HISTORY
• Type of family: Joint
• No. Of family members: 5
• Any illness in the family: H/O
Hypothyroidism in mother and she is
taking tab. Thyronorm 2.5mg. No H/O
HTN, DM, TB, Epilepsy in family

9. HEALTH FACILITY NEAR HOME
• TYPE: PHC
• DISTANCE:7km
• TRANSPORTATION: own

10. HOUSING
• Type of house: Pucca
• No. Of rooms: 6
• Toilet facility: Present
• Electricity: good
• Drinking water: RO

11. BIRTH HISTORY
• Gestational history: or antenatal history
• T1: -Spontaneous conception
Urine pregnancy test is positive
No H/O fever in mother
• T2: - Two doses of tetanus are given to mother
Folic acid is taken by mother
H/O Hypothyroidism is present.
• T3 : - Uneventful

12. CONT...
• Intranatal history: - baby is term and
delivered by LSCS in breech
presentation.
-Cries immediately after birth
-Cord is cut and clamped
-Vit. K was given
-Oronasal suction is done

13. CONT...
• Postnatal history:Apgar score was @
1min: 7/10 @ 5min : 9/10
• Birth order: 4
• Mode of delivery: LSCS
• Place of delivery: Local private hospital
• Gestational age: 37 completed weeks
• Birth weight: 2.7 kg
• Condition at birth: normal

14. DEVELOPMENTAL
MILESTONES
• Baby has good sucking and routing reflex.
• Good grasp reflex.

15. DIETARY HISTORY
• Breastfeeding: expressed breast milk is
giving by NG
• Weaning: no
• Present diet: NG tube feeding

16. IMMUNIZATION HISTORY
• Vit. K is given at birth
• BCG is given
• Polio drops are given

17. PHYSICAL EXAMINATION
• SKIN COLOUR: pinkish body and extremities
• POSTURE: normal
• GAIT: normal
• BLEEDING/DISCHARGE: no
• HAIR: Black and shiny
• EYE/ENT: -normal symmetry in eyes
-No any discharge from eyes and ears and nose
Pupil B/L reactive to light.
• Body build: thin
• Emotional state: normal
• Foul body odor: absent
• Foul breath: absent

18. CONT..
• TEETH AND GUMS: teeth are not present and gums are pink and
normal
• ORAL MUCOSA: good condition
• GLANDS: no any lymph nodes are present
• CHEST: -B/L air entry equal
-B/L symmetrical chest size.
-No retractions
• ABDOMEN: -soft
Non distended
No organomegaly
• TOES AND NAILS: Nails are grown up to finger tips
• DEPENDENCY LEVEL: baby is on ventilator on SIMV mode

19. Vital signs Normal
values
31-3-2018 1-4-2018 2-4-2018
Temperature 98.6°F 98.7º 100ºF 98.6ºF
Respiration
rate
30-60bpm 64bpm 74bpm 74bpm
Heart rate 120-160bpm 156bpm 150bpm 140bpm
VITAL SIGNS

20. Lab Investigation
TEST 31/3/18 1/4/18 2/4/18 NORMAL
RANGE
REMAR
KS
-Hb
-RBC
-PCV
-MCV
-MCH
-MCHC
-Platelet count
-Serum Ca
- CRP
- Random
plasma Sugar
- TLC
- DLC
Neutrophills
lymphocytes
Monocytes
eosinophills
15.7gm%
4.98
48.4
97.2fl
31.5pg
32.4/dl
2.67
9.0
1.33
205
22,300
75
18
02
05
15.3
-
44.3
-
-
-
-
-
-
-
-
-
-
-
-
15.0gm%
-
48.2
97.4
31.5pg
32.4/dl
2.8
7.6
0.2mg/dl
-
14,700
85
10
02
03
12-16gm%
5.1-5.3million
42-64%
95-125fl
27-33picogram
33-36gm/dl
2%
7.5-8.5mg/dl
1.8-.4mg/dl
74-140mg/dl
4000-11000/cum
50-70%
20-40%
2-10%
1-6%
decreased
decreased
normal
normal
normal
increased
increased
normal
normal
increased
Increased
increased

21. -Serum
creatinine
- serum
sodium
-Total bilirubin
-Direct
bilirubin
-Serum
potassium
-PTI
-CONTROL
-TEST
-INDEX
-INR
-Blood urea
nitrogen
-CRP
Quantitative
0.58
-
-
-
3.9
-
-
-
-
-
-
-
134mmol/l
6.3
0.19
4.4
14sec
16sec
87.5%
1.1
-
-
0.35mg/dl
132mmol/l
7.9
-
-
-
-
-
-
6
0.2mg/dl
0.6-
136-145
0.2-1.0mg/dl
0.0-
0.20mg/dl
3.5-
5.1mmol/l
15-17sec
93.3-82.3%
7-18mg/dl
1.8-2.4mg/dl
Normal
Normal
Increased
Normal
Normal
Decrease
d
Decrease
d
decreased

22. MEDICATION
DRUG DOSE ROUTE TIME ACTION
-inj. Amikacin
-Inj.
Pipzo(piperacill
in and
tazobactum
-IVF+Ca
gluconate
-Syrup
Ostocalcium
40mg
200mg
75ml+2.5cc
5ml
I/V
I/V
I/V
NG
OD for 8 days
8Hrly
8Hrly
TDS
Antibiotic
Antibiotic
Mineral
supplement
Mineral

23. DISEASE
DISCRIPTION

24. TEF

25. INTRODUCTION
Congenital atresia of the oesophagus and
tracheoesophageal fistula are rare malformation
that results from failed separation of the
oesophagus and trachea by the fourth week of
gestation. These defects are occur as separate
entities or in combination. They have a fatal
outcome without early diagnosis and treatment.
TEF and oesophageal atresia are malformation of
digestive system, in which oesophagus doesn’t
develop properly. The oesophagus is a tube that
normally caries a food from mouth to stomach.
These disorders are commonly found among
premature or LBW infants and mothers having
polyhydroamnios. Its incidence is 1 in 3500 live
birth.

26. DEFINITION
• A Tracheoesophageal fistula (TEF) is an
abnormal connection (fistula) between
the Oesophagus and the trachea. TEF is a
common congenital abnormality.
• Oesophageal atresia is failure of
oesophagus to form a continuous passage
from the pharynx to the stomach and
• TEF is an abnormal connection between
the trachea and the oesophagus

27. CAUSES
IN BOOK IN PATIENT
-History of maternal
polyhydroamnios
-TEF present with VACTERL
syndromes
Acronym vertebral, anorectal,
cardiovascular, tracheoesophageal,
renal and limb abnormality.
-With cardiac and renal anomalies.
-Teratogenic stimuli
-Genetic factors
Absent
Absent
Absent
Present
absent

28. CLASSIFICATION
TYPE 1: EA without fistula (8%) It is second
most common type. There is no connection of
oesophagus to trachea. The upper segment and
lower segment of oesophagus are blind

29. Cont..
• TYPE 2: EA with TEF. It is rare and found in
less than 1% of all cases. Upper segment of
oesophagus is open into trachea by a fistula.
The distal or lower segment is blind.

30. Cont..
• TYPE 3: EA with TEF(80-90%). It is most
common type. In this condition, upper segment
of the oesophagus has blind end. The distal or
lower segment of oesophagus connects into
trachea by fistula.

31. Cont..
• TYPE 4: EA with TEF both upper and lower
segment. it is also rare(less than 1%). There is
EA with fistula between both upper and lower
ends of the trachea and oesophagus.

32. Cont..
• TYPE 5: H-Type TEF. It is found in about 4%
of all cases and not usually diagnosed at birth.
Both upper and lower segment of the
oesophagus open into the trachea by a fistula.
No EA is present.

33. PATHOPHYSIOLOGY
• In intrauterine life, during the 4th and 5th week of gestation
period the foregut normally lengthens and separate
longitudinally and each longitudinal portion fuses to form
two parallel tubes, the trachea and the oesophagus, which
are joined at the larynx. The abnormality of the trachea-
esophagus occurs due to defective separation , incomplete
fusion of the tracheal folds or abnormal cellular growth
during the development of child.

34. CLINICAL MANIFESTATION
IN BOOK IN PATIENT
•Excessive salvation
•Constant drooling
•Large amount of secretions from
mouth
•Coughing
•Gagging
•Choking
•Cyanosis
•After first feed during first and
second swallow the infant coughs ,
chokes or fluid returns through nose
and mouth
•Abdominal distension
•Apnoea
Present
Present
Present
Present
Present
Present
Present
Present
Absent
Absent

35. DIAGNOSTIC EVALUATION
IN BOOK IN PATIENT
-USG
-Chest X-ray
-Passing radio opaque
catheter through
oesophagus and
conforming the anomaly
by X-Ray
-Bronchoscopy
-ECG
NOT DONE
DONE
DONE
NOT DONE
NOT DONE

36. CHEST X-RAY

37. MANAGEMENT(IMMEDIATE)
IN BOOK IN PATIENT
Nothing per mouth
30° position to prevent reflux of
gastric secretions
NG Tube aspiration
NG tube to be kept in situ
Oxygen therapy
I/V Fluid therapy
Blind pouch to be washed with
NS
Gastrostomy
Prevention of infection
Antibiotic therapy
Respiratory support
Continuous monitoring of patient
Chest physiotherapy
Postural drainage

38. SURGICAL MANAGEMENT

39. SURGICAL MANAGEMENT
IN BOOK IN PATIENT
•Postereolateral
thoracotomy followed
by intercostal chest
drainage
•Gastrostomy is done in
initial stage followed
by oesophageal
anastomosis
DONE
DONE

40. NURSING MANAGEMENT
• Assess the vital signs of the patient continuously including pulse
oximetery.
• Assess the colour of the child.
• Assess the family coping strategy and after explanation at the
time.
• Written consent was taken by the family member.
• Ensure adequate nutrition.
• Monitor fluid intake and output chart.
• Strict vital monitoring.
• Provide information to family before discharge about;
• how to manage the temperature of the child.
• Encourage the mother to give breast feeding to the child.
• Follow up.

41. NURSING DIAGNOSIS
• Ineffective airway clearance related to disease
process as evidence by surgery.
• Risk of infection related to surgical incision and
long stay in the hospital as evidenced by fever.
• Impaired nutrition related to surgery as evidenced
by patient is on ventilator.
• Fluid volume deficit as evidence by the nil oral
intake and less and less output.
• Knowledge deficit related to disease condition as
evidence by doubtful questioning by family
members