Tef.class ppt. shahin taj mam class

PES Institute of Medical Sciences & Research
LIVE ONLINE TEACHING
Subject: anaesthesia
Topic : tracheo oesophageal fistula
Year :2019 -2020
MODERATER ; dr .Shaheen taj
PRESENTATOR : Sai gupta

EMBRYOLOGY
 Division of foregut happens at 4th & 5th week of intrauterine life
 imperfect division results in a communication FISTULA
 Embryologically the defect is probably due to imperfect division of foregut during 4TH–5TH
WEEK OF INTRAUTERINE LIFE.
 During embryologic development, the trachea and esophagus begin as a ventral
diverticulum of the foregut.
 Around the third week of intrauterine life, a proliferation of endodermal cells appears on
the lateral aspect of the growing diverticulum.
 The cell masses then divide the foregut into tracheal and esophageaL tubes.
 Tracheoesophageal abnormalities occur as a result of interruption of this normal event.

Associated With Other Congenital Anomalies-
• Vertebral Anomalies-hemi-vertebra, Hypoplastic Vertebra
• Anal Defects
• Cardiac Defects-atrial Septal Defect, Ventricular Septal Defect,
Tetralogy Of Fallot (>15%)
• Tracheo-esophageal, Esophageal Atresia
• Renal Defects
• Limb Defects-hypoplastic Thumb, Polydactyl, Syndactyl, Radial
Aplasia

Esophageal atresia is closely related to tracheo-esophageal
fistula and can be divided into1:
type A: isolated esophageal atresia (8%)
type B: proximal fistula with distal atresia (1%)
type C: proximal atresia with distal fistula (85%)
type D: double fistula with intervening atresia (1%)
type E: isolated fistula (H-type) (4%

CLINICAL PRESENTATION
• Early indicators
POLYHYDRAMNIOS
Coiling of the nasogastric tube high up in the esophagus
Choking, Cyanosis and Coughing on oral feeding.
(3 Cs)
Breathing leading to abdominal distension
• Clinical presentation depends on
1.Dehydration-proximal esophagus does not communicate with
stomach
2.Aspiration pneumonia-reflux of stomach contents through the distal
esophagus into the trachea

DIAGNOSIS
Inability to pass a suction catheter into the stomach
CXR: coiled oro gastric tube in the cervical pouch; air in the stomach
and intestine

24-03-2021
PRE OPERATIVE ASSESMENT
age of presentation;- neonates with first few days of life ,premature
and low birth weight ,neonate often present for TEF repair
CLINICAL EXAMINATION;-
signs of cyanosis be looked for . Baseline saturation to be noted
auscultation of chest for bilateral birth sounds
Auscultation of heart sounds and any associated murmur
prresence of a sacral dimple can indicate associated vertebral defects
weight of the patient should be asseded

LABORATORY INVESTIGATIONS
Baseline Investigations Including
CBC, SERUM ELECTROLYTES
RENAL FUNCTIONAL TESTS
ARTERIAL BLOOD GAS ANALYSIS
BLOOD GROUPING
Chest X Ray- Signs Of Aspiration Like Pulmonary Infiltrate
Abdominal X-ray
Echocardiogram Is Mandatory Due To High Risk Of Cardiac
Anomaly
Side Of AORTIC ARCH Needs To Be Determined As Presence Of
Right Sided Aortic Arch Warrant's A Left Thoracotomy Seen In 5%
Patients

P R E O P E R AT I V E R I S K A S S E S M E N T:_
Prognosis Can Be Explained On The Basis Of Spitz Classification
,Previously Watersons Classification Was Followed

The montreal classification system
• In the Montreal experience, only two characteristics
independently affected survival: preoperative ventilator
dependence and associated major anomalies.
• It divides the patients in two groups.:-
• High risk: life threatening anomalies or a major anomaly and
ventilator dependence.
• Low risk:all other patients
It is recently used because advance in neonatal intensive care have
improved the outcomes that birth weight is no longer an
independent risk factor for mortality.

ANAESTHETIC CONSIDERATION
1.Dehydration-hydrate adequately, correct electrolyte imbalance
2.Aspiration pneumonia-
If degree of reflux is high, then a gastrostomy is planned to
protect the pulmonary system
3.Fistula repair is taken up if neonate is in good health. It
consists of ligation of fistula and approximation of two ends of
esophagus at 24-48 hours.
4. for complex presentation a cervical eosophagostomy and
gastrostomy tube placement is done for drainage of upper pouch
and entera feeding
5. Intubation to be avoided prior to repair of fistula as initiation of
positive pressure ventillation can worsen the neonatal
physiological status.

The protocol in the pre-operative
management should be :
1. Take help of a neonatologist
2. Look for associated congenital anomalies
3. Pass a nasogastric tube – It helps to know, whether
it is TOF or TOF with OA. It also helps in evacuating proximal
oesophageal pouch. It also helps to exclude ‘web’ if present.
4. Neonate should be nursed in propped up position
5. Evaluation of lung condition and proper treatment of aspiration
pneumonia
6. Correction of fluid and electrolytes
7.Control of hypothermia.

OT PREPARATION
• At least one unit of packed red blood cells should be typed and cross
matched
• resuscitation equipment should be checked and kept ready
• OT temparature should be kept at 27* c for neonates
• Emergency drugs
• endotracheal tubes of appropirate sizes
• anaesthesia workstation checked with sevoflorane vapourizer installed

Gastrostomy
May be done in the pre-repair period :
• 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.
• Also helps in removal of anaesthetic gases that
traverse through TOF during IPPV.

INTRAOPERATIVE MANAGEMENT
Main Concern:-
oxygenation and ventilation
securing the airway
COCERNS
Interferrance With Ventillation Due To Lung Retraction ,Produce Atelectasis And
Frequent Desaturation, Retracted Lung May Need To Be Intermittently Re
Expanded To Avoid Severe Hypoxia
Difficulty in maintaining normocarbia with increase in paco2
ETT displacement due to surgical handling of pliable trachea
- proximaldisplacement – above the fistula causing ventillation through the
fistula
distal displacement – into the right bronchus causing single lung ventillation

Anesthetic Technique:
• “Classic approach”
GA without muscle paralysis
• Combined light GA + epidural (Bosenberg)
• GA with muscle paralysis
ETT blocking need frequent suction to:
blood
secreations
Compression of mediastinal structures due to surgical manipulation can result
in adverent haemodynamic collapse
severe gastric distension can occur before the fistula is ligated if the ETT is
ventillating fistula as well which will need an immediate decompression

Tracheal Intubation Can Be Done In Three Ways
Using An Inhalation Induction With Topical Spray Of Lidocaine.
Intubating While The Infant Is Breathing Spontaneously.
Intravenous Or Inhalational Induction Agents Are Employed And
Muscle Paralysis Is Additionally Achieved Using Relaxants Before
Intubation Is Attempted.—Associated Complication Might Be In The
Form Of A Fistula Distending Secondary To Excessive PPV. The Same
Sort Of Dilatation Is Seen In The Stomach. All Attempts Therefore Must
Aim At Minimising Distension Of Stomach And Potential For Reflux
During Controlled Ventilation.
Awake Intubation With Mild Sedation. Advantage Being Airway Is
Protected From Aspiration.

Surgical Options
1.Surgical Approach By An Open Thoracotomy
2.Thoracoscopic Approach
Preliminary Approach Is Being Routinely Employed Intra Operatively Before
Initiation Of Surgical Repair To Define The Site Of Entry Of The Distal TEF And
For Detection Of Any Anomaly In The Larynx And Trachea Like Tracheomalacia
Thoracoscopy
Minimally Invasive
Advantage: Reduction In Musclo Skeletal Sequeale As It Prevents Injury To
Long Thoracic Nerve Supplying The Serrates Anterior
DISADVANTAGES
Compression Of The Ipsi Lateral Lung With Operative Pneumothorax To Achieve
An Adequate Working Space Causes Rapid Desaturation
Reduction In Venous Return Due To Direct Compression Of Ivc And Right Atrium
CO2 Absorption Causing Hyper Carbia And Acidosis Which Is Poorly Tolerated
By An Already Sick Neonate
Requirement Of One Lung Ventilation Which Is Difficult To Achieve In These
Patients

OTHER TECHNIQUES
POSITION ;- Technique Of Choice Where Equipment And Training
For Thoracoscopic Repairis Not Available
Position – Lateral Decubitus With The Arm Across The Front Of The
Chest For Posterolateral Thoracotomy.Usually The Infant Is In Left
Decubitus Positioning For A Right Thoracotomy
Incision – Curved 5-6 Cm Incision 1 Cm Below The Inferior Angle Of
Scpula Thorax Is Opened Through The 4 And 5 Th Intercoastal Space
Extrapleural Approach
Confers Protection Of The Pleural Space In The Event Of An
Anastomotic Leak . The Pleura Is Freed Off The Chest Wall Using
Blunt Dissection Starting Postreiorly .It Is More Time Consuming
Repair Of The Anamoly – First The Upper Oesophagus Is Mobilized
.Subsequently The Distal Oesophagus Is Dissected To The Level Of
The Fistula And Joined.
Tracheal Side Of The Fistula is Closed Using Tight Sutures.
Closure- Done With ICD Placement

Monotoring:-
 ECG
 Non invasive blood pressure
 Pulse oximetry
 ETCO2
 Temperature
 An arterial line may be placed for blood gas analysis and
monitoring of invasive blood pressure.
1. Urine output especially if anticipated prolonged surgery
precordial stethoscope – preferably two should be used .
2. One over the chest to asses for adequate ventilation.
3. Second to be placed over the stomach to know if the fistula is
getting ventilated.

Induction
awake intubation
rapid sequence IV induction
inhalation induction with spontaneous ventilation
without muscle relaxant
Assessment of ETT position
Goal: ETT just above the carina and just below
the fistula
Right mainstem intubation and withdraw ETT until
bilateral
breath sounds.
Careful confirmation of tube position
by moving tube mm by mm
Patients position:
lateral decubitus

Beware of gastric distention
Gentle positive pressure ventilation
Gastrostomy: open if present
Other options that prevent gas from entering the stomach include:-
A snug abdominal binder that can compress the stomach and prevent
over-distention.
Bronchoscopy;-
To determine precise
location and size of
fistula

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.

Maintenance:
O2 : air(±N2O), sevoflurane and spontaneous ventilation are used.
O2:air(±N2O):maintain PaO2 50-70mmHg or SaO2 87-92% to
avoid retinopathy of prematurity
if gastrostomy was done O2 can be diluted by N2O according
to patient status.
Spontaneous ventilation with sevoflurane or halothane is used
before doing the repair then controlled ventilation with sevoflurane
or halothane and 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

Fluid requirements in neonates:
During the 1st week reduced fluid requirements:
Day 1 - 70 ml/kg
Day 3 - 80 ml/kg
Day 5 - 90 ml/kg
Day 7 - 120 ml/kg
Concern is immaturity of the neonatal kidney
The volume of extracellular fluids in neonates is large
Consider use of radiant warmers, and heated humidifiers –
decrease insensible water loss.
Include if present: Fluid deficits
Third spaces losses
Hypo/hyperthermia
Unusual metabolic fluids demands

Surgical repair
• ligation of fistula check air leak in suture line
• esophageal repair
identify the pouch
placement of feeding tube
• chest tube placement and closure of thoracic cavity
Intraoperative problems
Endobronchial intubation
Intubation of fistula
Obstruction of ETT
V/Q mismatch
lateral decubitus position
nondependent lung retraction
Vagal response to tracheal manipulation
Return to transitional circulation and shunting

Extubate or Not?
Must consider pre-op lung disease and other comorbidities
Spontaneous ventilation decreases the stress placed on the
suture line
Risk of injury to the repaired fistula with re-intubation
Before extubation adequate suctioning from ETT with 100%
O2 and tracheobronchial toilet are done.
The criteria of extubation should be fulfilled such as : Level of
consciousness to be achieved

EARLY EXTUBATION
early – minimizes tension on suture line which can occur due to PPV
RISKS INVOLVED-
Deficiency Of Tracheal Cartilage At The Level Of Fistula Can Cause
Tracheomalacia Causing Airway Obstruction And Immediate Re Intubation
Pre Existing Lung Diseases Due To Prematurity Or Aspiration Pneumonia
Use Of Opiods Intraoperatively And Post Operatively Can Make Them
Susceptible To Hypoventillation .Use Of Alternativemethods Pain Reliefs To
Avoid Opiods For Early Extubation
Delayed Extubation
If The Oesophagus Anastomosis Is Achieved Under Tension , Patient Is
Mechanically Ventillated Electively For3-5 Days Postopratively
If Post Operative Elective Ventillation Is Planned , Minimum Inspiratory
Presuure Should Be Used To Protect The suture Line From Getting Disrupted
Managed In PICU,
Broad Spectrum Antibiotics To Be Given
Analgesia And Sedation Should Be Carefully Monitored
efforts for early extubation to be planned
transanastamotic tube feeding is usually started by 48 hours after surgery

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.
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.
Postop Pain Management
1. IV narcotics
2. Epidural infusion: 0.1% bupivacaine +
fentanyl 0.5 mcg/ml at 01.-0.2 ml/kg/hr
3. Rectal acetaminophen + LA infiltration of incision

Post operative pain management;-
Intravenous analgesia;- opoid infusion with fentanyl or morphine especially
for patient planned for post operative mechanical ventillation
intercoastal nerve block:
given at completionof surgery at two segment above and below the
incision
provides good analgesia and helps attain satisfactory respiratory efforts
careful about local anaesthetics systemic toxicity
port site infilteration :
local anaesthetics can be given at the port site in thoracoscopic approach
port site can cause a lot of pain . Hence adequate relief should be
provided
thorasic epidural anaesthesia
0.1% bupivacaine or ropivacaine with fentanyl 2-3 micrograms per ml or
morphine can beused .

Complications following TEF
Repair
Anastomotic leak-
may need surgical intervention if they don’t close spontaneously
Recurrent esophageal fistula
Esophageal strictures, dymotility, -
may recquire multiple ballon dilations
GERD/Esophageal dismotility
Tracheomalacia/ Pulmonary Issues
can cause collapse of the airway resulting in stridor ,apnoea or
recurrent pneumonia . It generally improves after the first 3-5 years of life
but if severe may require surgical intervention
Musculocutaneous disturbances

Advances in TEF repair
NIVATS – nonintubated video assisted thoracoscopic surgery
it is considered beneficial due to faster recovery , reduced morbidity and
shorter length of stay
it is agood alternative in patients with low risk of GA and use of one lung
ventillation
There is a avoidance of haemodynamic changes occuring as a result of
trachealintubation , mechanical ventillation and muscle relaxation
‘ contraindications;-
expected difficult airway
thick and extensive pleural adhesions
haemodynamically unstable patients
asa II
Limitations;-
inadequate analgesia , respiratory fluctuations resulting in hypoxia and
hypercarbia
chances of conversion into general anaesthesia’ aspiration and loss of
airway during deep sedation
refluxed gastric contents or secreations can result - laryngospasm
bronchospasm , and increase in morbidity.

Tef.class ppt. shahin taj mam class

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