Case 61 - tracheoesophageal fistula Flashcards

1
Q

What is a tracheoesophageal fistula (TEF)?

A

TEF

  • congential malfomation involving:
    • esophageal atresia
    • fistual connecting esophagus to trachea
  • Most common is Type C
    • upper esophageal atresia ( blind pouch)
    • fistula of lower esophagus to trachea
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2
Q

What is the typical presentation of a patient with TEF?

A

clinical presentation

  • unable to pass orogastric tube into stomach
  • ** first feeding associated with 3 C’s: coughing, choking, cyanosis**
  • also see excessive salivation and resp distress

CXR

  • confirms diagnosis
  • OG catheter curled in uppper esophagus
  • presence of air in stomach
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3
Q

What is VACTREL?

A
  • TEF is associated with other congenital anomalies termed VACTREL
  • V - vertebral
    • vertebral malformation
  • A - anal
    • imperforate anus
  • C - Cardiac
    • ASD, VSD, TOF, coarct of Aorta
  • T - TEF
  • E - Esophageal atresia
  • R - Renal
    • renal agensis, hydronephrosis
  • L - Limb
    • polydactyly, wrist anomalies
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4
Q

what are pre-op concerns in patients with TEF?

A
  • association with VACTREL, therefore individually assess each component

1) Cardiac anomalies

  • ECHO, EKG
  • VSD, ASD, TOF, coarct of aorta

2) renal anomalies

  • renal ultrasound
  • BUN/Cr

3) Vertebral malformation

  • lumbar ultrasound
  • sacral dimple –> although benign, may could also be due to spina bifida –> can result in neurologic deficits and meningitis if a myelomengiocele

4) Pulmonary complications

  • 1) aspiration of gastric contents into lungs via fistula –> lung damage
  • 2) air from trachea into stomach –> gastric distension –> compress lungs and prevent lung expansion–> decrease pulm compliance and atelectasis (V/Q mismatch and intrapulmonary shunting –> hypoxemia)
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5
Q

is pre op pulmonary function important, what can be done to optimize pulm function pre-operatively?

A

Pulm complications

  • 1) aspiration of gastric contents into lungs via fistula –> lung damage
    2) air from trachea into stomach –> gastric distension –> compress lungs and prevent lung expansion–> decrease pulm compliance and atelectasis (V/Q mismatch and intrapulmonary shunting)

pulm function pre-op mgmt

  • cessation of feeding
  • position infant head up 30 degrees to minimize regurgitation through fistula
  • intermittent suctioning of prox esophageal pouch catheter
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6
Q

How will you prepare the OR and what lines would you place in a TEF patient coming for surgery?

A

1) Opearting room setup

  • Warm room
  • warming blanket
  • fluid warmer

2) monitors and lines

  • ASA standard monitors
  • IV access prior to induction
  • consider arertial line for high-risk infants (cardiac anomaly) and those with thoracoscopic repair (can inadvertenly compress large vessels)
  • precordial stethoscope in left axilla
    • detects intraop airway obstruct (occurs with trachea kinking during surgery)

G-tube

  • ?? gastrostomy tube placed under local by sx pre induction to decompress stomach
  • not usually done anymore
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7
Q

What are induction and intubation considerations for TEF patients?

A

Induction

1) suction esophageal pouch
2) admin atropine to prevent brady
* assoc with suction, laryngoscopy, intubation
3) Maintain spontaneous ventilation = KEY GOAL

  • spontanous till fistula is ligated
  • PPV can result
    • a) insufflation of stomach via fistula –> leads to poor pulm compliance and atelectasis and V/Q mismatch.
    • b) loss of ventilation to fistula therefore not ventilating lungs –> hypercarbia and hypoxia
    • c) aspiration of gastric contents via fistula
  • **can also consider gentle PPV to avoid gastric distension***

Intubation

1) Awake vs asleep

  • awake - is the safeset approach, maintain airway reflexes, spont ventilation throughout
  • asleep - inhalation induction w/o muscle relaxation
    • muscle relaxation –> requires PPV therefore avoid it.
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8
Q

How would you guide the ETT into its correct position? What is the correct position?

A
  • TEF = fistula between trachea and esophagus.
  • fistula usually located proximal to carina

ETT position

  • ETT - should lay proximal to carina and occluding fistula
  • 1) right main stem intubation, and redraw until b/l breath sounds heard
    • does not assure that fistula is occluded
  • 2) FOB guidance
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9
Q

Suppose there is a large fistula that cannot be occluded by ETT, or a fistula that is distal to carina. How can you manage this?

A
  • Recall - goal of ETT is to be proximal to carina, and occlude fistula.
    • occlude fistula to avoid ventilation of stomach (path of least resistance) and aspiration.

Fogarty catheter

  • can be placed within or at the opening of the fistula to occlude it
  • placed via FOB or through gastrostomy
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10
Q

how would you maintain anesthesia?

A
  • Goal: maintain spont ventilation or gentle PPV to avoid
  • inhalation anesthesia + judicious use of opioid
  • avoid muscle relaxants (thereby avoiding need for PPV) until fistula is ligated

Pitfalls of PPV

  • a) insufflation of stomach via fistula –> leads to poor pulm compliance and atelectasis and V/Q mismatch.
    b) loss of ventilation to fistula therefore not ventilating lungs –> hypercarbia and hypoxia
    c) aspiration of gastric contents via fistula
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11
Q

during surgery, you all of a sudden lose breath sounds and EtCO2 tracing. What may be happening?

A

Ddx:

  • secretions or blood in ETT
  • kinking of trachea during surgical manipulation
    • tell surgeon to release surgical traction
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12
Q

Post-op concerns in TEF patients?

A

to extubate or not to extubate?

  • healthy infants, extubation desirable to decrease stress at surgical anastomosis
  • infants with comorbidities (congential heart disease, pulm complicatoins) –> may require post op intubation and ventilatoin

Pain

  • thoracic epidural via caudal approach, verified by xray
  • IV opioid
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