UBP 1.7 (Long Form): Pediatrics – Tracheoesophageal Fistula Flashcards
Secondary Subject -- Complications of the Premature Infant/ VACTERL/Gastrostomy Tube/Cuffed or Uncuffed ETT in the Pediatric Patient/Neonatal Thermal Regulation/Post-intubation Croup/Tracheomalacia
Intra-Operative Management:
Which monitors would you place for this case?
- (**A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
In addition to the standard monitoring of EKG, blood pressure, pulse oximetry, temperature, and end-tidal carbon dioxide,
I would place an arterial line for monitoring of blood gases, hemodynamics, and blood glucose.
A precordial stethoscope placed in the left axilla would help to monitor ventilation and heart rate, while aiding in the detection of surgical obstruction of the mainstem bronchus and intentional or accidental right mainstem intubation.
I would also place a Foley catheter to guide fluid management.
Finally, I would place a second precordial stethoscope over the stomach and/or place the end of the gastrostomy tube under a water seal in order to detect ventilation through the fistula (bubbling would indicate gas movement through the fistula).
Xtra Q – Would you place a precordial stethoscope?
Intra-Operative Management:
Do you need an arterial line?
Where would you place it?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
Yes.
For this large intrathoracic case with the potential for significant bleeding, cardiac depression, hemodynamic instability, and pulmonary complications,
an arterial line is important to allow close hemodynamic monitoring as well as to aid in serial ABG analysis during the perioperative period.
Therefore, if one had not already been placed in the NICU, I would place an arterial catheter in the umbilical artery or one of the femoral arteries.
Intra-Operative Management:
How would you induce and intubate the patient?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
My goals in inducing and securing the airway of this patient include –
- avoiding aspiration, gastric distention, and hypoxia;
- minimizing the sympathetic stimulation that often occurs with laryngoscopy
- (may increase the risk of intraventricular hemorrhage in a premature neonate); and
- positioning the tip of the ETT distal to the fistula and proximal to the carina to allow for adequate positive pressure ventilation
- (this may be impossible if the fistula is too close or distal to the carina), while minimizing gastric distention through the fistula.
Since the presence of the gastrostomy reduces the risk of gastric distention (gas can be released through the gastrostomy if necessary),
I would ensure proper monitoring and intravascular access, place the patient in the head up position, suction the proximal esophageal segment, suction the gastrostomy tube, topically anesthetize the airway, administer Atropine 0.02 mg/kg to ablate the vagal response to laryngoscopy, and perform a rapid sequence induction.
I would then advance the ETT into the right mainstem bronchus and slowly withdraw the ETT until breath sounds are heard through the precordial stethoscope in the left axilla (ensure equal and bilateral breath sounds).
Next, I would verify that I could provide adequate positive pressure ventilation through the ETT without causing excessive bubbling from the open and submerged end of the gastric tube.
If I felt I was unable to provide adequate positive pressure ventilation (excessive flow through the fistula), I would consider repositioning the ETT or passing a Fogarty catheter retrograde through the gastrostomy to occlude the esophagus from below.
Intra-Operative Management:
If this patient did not have a gastrostomy tube, would you change your method of induction and intubation?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
I wouldn’t necessarily need to change my plan, but I would need to be even more careful about excessive positive pressure ventilation leading to gastric distention.
If I wanted to change my method, other options for induction and intubation would include –
- intubating the neonate awake, or
- intubating her following deep inhalational induction.
An awake intubation reduces the risk of aspiration, but may increase the difficulty of intubation (especially with a vigorous neonate) and/or the risk of intraventricular hemorrhage in a premature neonate (secondary to sympathetic stimulation during laryngoscopy).
Performing a deep inhalational induction has the potential advantage of avoiding positive pressure ventilation by maintaining spontaneous ventilation until the fistula is ligated.
However, maintaining adequate spontaneous ventilation may prove difficult, surgical conditions may not be optimal without neuromuscular blockade, and inducing deep anesthesia prior to securing the airway places the neonate at increased risk of aspiration (although this is greatly reduced with careful suctioning of the upper esophageal segment and gastrostomy tube).
Any of these methods are acceptable, but I would consider the advantages and disadvantages of each when planning for induction and intubation.
Xtra Q – Would you consider an awake intubation?
Intra-Operative Management:
Does intubation protect the child from aspiration?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
Not entirely.
Placement of an ETT and inflation of the cuff does provide some protection from the aspiration of oral secretions spilling into the oropharynx from the upper esophageal segment.
Unfortunately, if the cuff of the ETT is not successfully placed distal to the fistula, it will provide no protection from the aspiration of gastric contents flowing from the lower esophageal segment to the trachea through an open TEF (suctioning of the gastrostomy tube prior to induction would decrease the risk of aspiration from this source).
Intra-Operative Management:
Would you use a cuffed endotracheal tube in a pediatric patient?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
It has been common practice to use uncuffed ETTs for children under 8 years of age to minimize the risk of post-extubation croup.
However, clinical data has not demonstrated a difference in post-intubation complications, when comparing children managed with uncuffed ETTs with children managed with cuffed ETTs.
Therefore, for this patient, I would prefer to use a cuffed 3.0 mm ETT –
to minimize the risk of aspiration, recognizing that placement of the ETT cuff distal to the fistula is ideal (continuous suctioning of the upper esophageal segment and gastric decompression via the gastrostomy tube further reduce this risk).
However, as with an uncuffed ETT, I would ensure that there was an air leak around the inflated cuff at 20-25 cm H20 to minimize the risk of post-extubation croup.
Additional potential benefits of using a cuffed ETT include –
decreased need for repeated laryngoscopy to place an appropriately sized ETT, reduced subglottic pressure, more reliable delivery of high airway pressures (avoided in this case unless absolutely necessary, and may require occlusion of the fistula with a Fogarty catheter), and reduced operating room pollution.
On the other hand, a potential disadvantage of using a cuffed ETT is the potential need to place an ETT with a smaller internal diameter (smaller ETTs are often required to compensate for the added external diameter that results from the presence of the cuff), which leads to increased airway resistance.
Discussion of Pros/Cons of Cuffed vs Uncuffed ETT’s above.
Intra-Operative Management:
During the surgery the SpO2 gradually drops to 89% and the airway pressure has increased. What do you think is going on?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
Mild hypoxia and increased airway pressures could be the result of:
- distal displacement of the ETT into the right mainstem bronchus;
- proximal displacement of the ETT caudad to the fistula with resultant gastric distention and impaired ventilation;
- surgical retraction of the trachea, mainstem bronchus, or lung;
- gastric distention from overaggressive positive-pressure ventilation (assuming the fistula has not yet been ligated);
- bronchospasm;
- pneumothorax;
- aspiration; or
- plugging of the ETT by mucous or clot.
per online course, anything that causes V/Q mismatch.
Intra-Operative Management:
During the surgery the SpO2 gradually drops to 89% and the airway pressure has increased.
What are you going to do?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
I would –
- inform the surgeon,
- hand ventilate with 100% oxygen,
- auscultate breath sounds in all lung fields,
- suction the ETT,
- use a pediatric bronchoscope to verify appropriate placement of the ETT (optimally proximal to the carina and distal to the fistula),
- check for gastric distention,
- ensure that the gastrostomy is open,
- ask the surgeon to relieve any surgical traction,
- check an ABG, and
- consider an intra-operative CXR.
Immediate intervention is important since persistent hypoxia may lead to pulmonary hypertension, with subsequent intracardiac and extracardiac shunting.
Intra-Operative Management:
You reposition the ETT and apply suction to the gastrostomy tube. The neonate’s airway pressures and oxygenation return to baseline.
How would you manage intraoperative fluid replacement?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
I would continue the neonate’s preoperative parenteral and maintenance fluids separately to avoid the abrupt discontinuation of glucose containing solutions, which could lead to significant hypoglycemia secondary to increased levels of circulating insulin.
I would then provide additional maintenance fluids using isotonic solutions to achieve a total of 4 ml/kg/h
(the additional maintenance fluids would be calculated by subtracting the hourly volume of the separately administered parenteral and maintenance solutions from the total desired maintenance fluid volume of 4 ml/kg/h).
Insensible losses would be replaced with normal saline or lactated ringers solution at 6 ml/kg/h, and each milliliter blood loss would be replaced with a milliliter of albumin or pRBCs to maintain a Hct >35% (blood loss could be replaced at a ratio of 3 ml crystalloid for every 1 ml blood loss as long as the neonate’s hematocrit was carefully maintained above 35%).
Given the importance of accurate fluid management in a premature neonate (relatively small margin of error), I would carefully monitor urine output, heart rate, blood pressure, and serial ABGs; and adjust fluid replacement as indicated.
Clinical Note:
- Recognizing that surgery often induces a hyperglycemic response some practitioners will reduce glucose containing infusions (i.e. maintenance fluids and/or parenteral nutrition solutions) by one third to one half.
- This approach would require very close monitoring of serum glucose levels to avoid significant hypoglycemia (serum glucose levels < 40 mg/dL in the neonate can lead to jitteriness, seizures, lethargy, temperature instability, and apnea).
—-
Note from online course – Always think of neonatal hypoglycemia especially if mother has GDM or diabetes.
Intra-Operative Management:
After 2 hours of surgery the patient’s temperature is 36.3 °C.
Are you concerned?
Why are neonates prone to hypothermia?
How would you warm this patient?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
I am concerned because, while this temperature does not meet the definition of hypothermia (< 35 °C), it is lower than normal (35.5 - 37.5 °C) in a neonate who has limited ability to maintain normothermia.
Neonates are prone to hypothermia due to their relatively thin skin, large surface area to body mass ratio, low subcutaneous fat, and an inefficient mechanism of heat production (brown fat metabolism).
(Xtra Q – What are potential deleterious effects of hypothermia?)
The potential deleterious effects of hypothermia include – increased oxygen consumption, increased pulmonary vascular resistance, increased cardiac shunting (increased flow across the VSD with increasing PVR), altered drug response, postoperative hypoventilation, apnea, coagulopathy, delayed wakening, cardiac irritability, impaired wound healing, and metabolic acidosis.
–
Therefore, I would ensure that all irrigation and intravenous fluids are being warmed, increase the operating room temperature (26-30 °C), ensure the presence of a heat-moisture exchanger in the circuit, and consider actively warming the patient with radiant warmers or a forced-air blanket.
Post-Operative Management:
Would you extubate this patient in the operating room?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
Early extubation following the procedure is desirable to minimize endotracheal tube pressure on the anastomotic suture line.
However, this premature neonate with a VSD is at high risk of requiring re-intubation secondary to –
significant atelectasis, aspiration pneumonia, respiratory distress syndrome, tracheomalacia, respiratory depression (i.e. narcotics), excessive secretions, and excessive cardiovascular shunting with hypoxia (i.e. VSD, potential for increased PVR and/or a patent ductus arteriosus).
Therefore, my preference would be to delay extubation.
I would only consider early extubation after evaluating the neonate’s cardiopulmonary stability and taking into account the risks of re-intubation, such as –
- airway trauma,
- intraventricular hemorrhage
- (secondary to a sympathetic response with inadequate anesthesia), and
- disruption of the anastomotic suture line
- (neck extension, laryngoscopy, advancing the ETT).
–
Xtra Q: What would be some risks of re-intubation?
–
My extubation requirements for this premature neonate would include –
- an awake patient (due to her prematurity and risk of tracheomalacia),
- complete reversal of neuromuscular blockade,
- intact cough and gag reflexes,
- spontaneous tidal volumes of 5 to 7 cc per kilogram on CPAP,
- peek inspiratory pressures below 30 cm H20, and
- oxygen requirements below 40% with a PEEP of 3-5 cm H2O.
Post-Operative Management:
Assume you decide to keep the patient intubated.
During transport to the NICU, hand ventilation through the ETT becomes difficult, and the patient becomes hypoxic.
What do you think is the cause? What would you do?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
Hypoxia in association with hand ventilation could indicate –
- an obstructed ETT (i.e. secretions, blood, kinking),
- bronchospasm,
- anastomotic leak,
- right mainstem intubation,
- pneumothorax, or
- extubation.
Therefore, I would quickly transport the patient to the NICU or back to the OR, depending on which were closer.
At the same time, I would continue ventilation with 100% oxygen; auscultate the chest over all lung fields; ensure proper ETT positioning, suction the ETT, confirm the presence of end-tidal CO2, and consider a CXR and/or bronchodilator.
Post-Operative Management:
The respiratory therapist in the NICU places the patient on the ventilator with the following settings: PIP 30, PEEP 2, IMV 35, and FiO2 100%.
Do you agree with these settings?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
While I agree with the IMV mode of ventilation and a mandatory rate setting, I would minimize peak inspiratory pressures to decrease stress on the anastomotic suture line and decrease the risk of anastomotic leak.
In order to reduce the risk of retinopathy of prematurity (retrolental fibroplasia), I would also recommend decreasing the Fio2 to the lowest level necessary to maintain a normal PaO2 of 60-80 mmHg.
Risk factors for retinopathy of prematurity include – age younger than 44 weeks post-conception, excessive inspired oxygen concentrations (although this relationship is unclear), multiple blood transfusions, parenteral nutrition, hypoxia, hypercapnia, and hypocapnia.
- Xtra Q: What does IMV = 35 mean?*
- Are you ok with 100% Fio2?*
- What would you be concerned with in hyperoxia in a premature neonate?*
- What are risk factors for retinopathy of prematurity?*
Post-Operative Management:
The postoperative Hct is 30%.
Would you transfuse this patient?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
Since the normal hematocrit of a healthy full-term neonate is around 55%, and considering that the presence of fetal Hgb (75% at birth) results in a leftward shift of the hemoglobin-oxygen dissociation curve,
I would transfuse this neonate with a Hct of 30%.
Maintaining a sufficient Hct level is important to avoid the potential consequences of tissue hypoxia, such as – metabolic acidosis, necrotizing enterocolitis, impaired wound healing, myocardial ischemia, and cerebral ischemia.
Post-Operative Management:
Two hours after extubation the patient develops a barking cough with inspiratory stridor.
What is your differential diagnosis?
How would you treat this patient?
- (A 12-hour-old, 33 weeks gestational age infant, weighing 2,500 grams presents to the operating room for repair of a Type C tracheoesophageal fistula. She has a gastrostomy tube and central line for parenteral nutrition in place, is breathing spontaneously via a non-rebreathing facemask, and an orogastric tube for continuous suctioning of the proximal esophageal pouch.*
- PMHx: A 33 weeks gestational age infant delivered vaginally secondary to preterm labor. Her APGAR scores were 6 at 1 minute and 8 at 5 minutes*
- Meds: Supplemental oxygen*
- Allergies: NKDA*
- PE:*
- Vital Signs: HR = 172, BP = 68/40 mmHg, SaO2 = 94% on 2L oxygen, RR = 49, Hgb = 15 gm/dL*
- CV: holosystolic murmur over the left sternal border*
- Pulmonary: Lungs clear to auscultation*
- Abdominal: Gastrostomy tube noted*
- GU: imperforate anus*
- Labs: Hgb 15 gm/dL, ABG: pH 7.32, PaCO2 42, PaO2 92, HCO3 23, BE -2, Electrolytes WNL*
- CXR: no acute disease*
- Echo: Small VSD, normal systolic function)*
While inspiratory stridor may occur with any extrathoracic upper airway obstruction such as epiglottitis, laryngotracheobronchitis, or laryngeal foreign body, a barking cough, inspiratory stridor, and recent intubation are most consistent with post-intubation croup, a condition that develops secondary to glottic or tracheal edema formation.
The risk factors for developing post-intubation croup include –
- traumatic intubation,
- excessively tight-fitting endotracheal tubes,
- prolonged intubation,
- surgery of the head and neck,
- intra-operative changes in the child’s position,
- a small larynx,
- a history of croup, and
- coughing with the ETT in place.
Assuming this patient’s stridor was a symptom of post-intubation croup, I would treat with nebulized racemic epinephrine and intravenous dexamethasone (0.25 - 0.5 mg/kg).
