Case 61 - tracheoesophageal fistula Flashcards
What is a tracheoesophageal fistula (TEF)?
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
What is the typical presentation of a patient with TEF?
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
What is VACTREL?
- 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
what are pre-op concerns in patients with TEF?
- 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)
is pre op pulmonary function important, what can be done to optimize pulm function pre-operatively?
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
How will you prepare the OR and what lines would you place in a TEF patient coming for surgery?
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
What are induction and intubation considerations for TEF patients?
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.
How would you guide the ETT into its correct position? What is the correct position?
- 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
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?
- 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
how would you maintain anesthesia?
- 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
during surgery, you all of a sudden lose breath sounds and EtCO2 tracing. What may be happening?
Ddx:
- secretions or blood in ETT
-
kinking of trachea during surgical manipulation
- tell surgeon to release surgical traction
Post-op concerns in TEF patients?
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
