Anesthestic management for tracheoesophageal fistula neonate

1. Anesthesia forAnesthesia for
Tracheo-esophagealTracheo-esophageal
Fistula RepairFistula Repair
ByBy
Dr. Hazem Sharaf (M.D.)Dr. Hazem Sharaf (M.D.)
Anesthesia ConsultantAnesthesia Consultant

2. This is part II after PediatricsThis is part II after Pediatrics

3. What’s aWhat’s a Grand round
 Grand round is an important
teaching tool and usual of
medical education and inpatient care,
consisting of presenting the medical
problems and treatment of a
particular patient to an audience
consisting of doctors, residents,
medical students and nurses.

4. What’s aWhat’s a Grand round
 The patient was traditionally present
for the round and would answer
questions; grand rounds have
evolved with most sessions now
rarely having a patient present and
being more like lectures.

5. Interdisciplinary CareInterdisciplinary Care
 interdisciplinary teaminterdisciplinary team a group of
health care professionals from diverse
fields who work in a coordinated fashion
toward a common goal for the patient.

10. Today’s PatientToday’s Patient
 Our Pediatric surgeon informed me aboutOur Pediatric surgeon informed me about
a baby-girl in NICU at 1.00 pm fora baby-girl in NICU at 1.00 pm for
emergency thoracotomy for TEF repairemergency thoracotomy for TEF repair
 The pt was a full term girl 15 hrs oldThe pt was a full term girl 15 hrs old
diagnosed as esophageal atresia withdiagnosed as esophageal atresia with
tracheo-esophageal fistula for emergencytracheo-esophageal fistula for emergency
surgical intervention as soon as possiblesurgical intervention as soon as possible

12. On checking: the baby was well medicallyOn checking: the baby was well medically
stabilized in NICU with secured:stabilized in NICU with secured:
Intra-venous lineIntra-venous line
Endotracheal tubeEndotracheal tube
Oro-Gastric tube to drain the pouchOro-Gastric tube to drain the pouch
Urinary CatheterUrinary Catheter

13. Types of TEFTypes of TEF

14. • Maternal and perinatal history
• Birth history
• Minimum labs: glucose and CBC
• Look for associated anomalies
• Cardiac and respiratory status
• Metabolic and electrolyte imbalance
• Hydration status & IV access
• Coagulation profile
Preoperative EvaluationPreoperative Evaluation

15. O.R. readinessO.R. readiness
Every thing is ready for O.R. for example:Every thing is ready for O.R. for example:
Complete preoperative assessmentComplete preoperative assessment
StabilizationStabilization
Ruling out other associated anomaliesRuling out other associated anomalies
Counseling the familyCounseling the family
Cross-matched bloodCross-matched blood
Prepared Theater for neonatal emergencyPrepared Theater for neonatal emergency
high risk surgeryhigh risk surgery
Prepared anesthesia machine & drugsPrepared anesthesia machine & drugs

16. O.R. readinessO.R. readiness
Multi-disciplinary approach byMulti-disciplinary approach by
methodical detailedmethodical detailed
discussion with pediatriciansdiscussion with pediatricians
and pediatric surgeonsand pediatric surgeons

17. ““Safe and effective anesthesia forSafe and effective anesthesia for
neonates undergoing surgery is one ofneonates undergoing surgery is one of
the most challenging tasks presented tothe most challenging tasks presented to
anesthesiologist.”anesthesiologist.”
KnowledgeKnowledge
Manual skills of the whole teamManual skills of the whole team
Continuous practiceContinuous practice
++
Adequate monitoring & OptimumAdequate monitoring & Optimum
Postoperative Intensive CarePostoperative Intensive Care
↓↓
Satisfactory OutcomeSatisfactory Outcome

19. Esophageal Atresia/TEF
1:4000
M:F 25:3
First fed
chocking,
cyanosis

20. Anesthetic ManagementAnesthetic Management
 Operating room set upOperating room set up::
 ““keep warmkeep warm””:: warm room, warmingwarm room, warming
blanket, overhead warmerblanket, overhead warmer
 Low body temp:Low body temp:
 Release Nor-Epinephrine: vasoconstriction,Release Nor-Epinephrine: vasoconstriction,
increases metabolism, change degree ofincreases metabolism, change degree of
shuntingshunting
 Affect anesthetic agents: likely over-Affect anesthetic agents: likely over-
dosage, postop hypo-ventilation, apneadosage, postop hypo-ventilation, apnea
 Coagulopathy, metabolic acidosisCoagulopathy, metabolic acidosis

22. Anesthetic ManagementAnesthetic Management
 Standard monitoringStandard monitoring:: EKG,EKG,
(pericordial stethoscope) pulse(pericordial stethoscope) pulse
oximetry, end tidal CO2, BP monitoringoximetry, end tidal CO2, BP monitoring
(Arterial line in high risk infants), Urinary(Arterial line in high risk infants), Urinary
OutputOutput

23. Patient PositionPatient Position
Lateral decubitus position
Posterolateral thoracotomy

25. OGT / NGT is a very crucial
issue to be determined
before draping
I never anesthetized a big
baby from NICU

26. Anesthetic ManagementAnesthetic Management
 Induction:Induction: ““establish airway without pulmonary aspiration or gastricestablish airway without pulmonary aspiration or gastric
distensiondistension”” In preparation for intubation:In preparation for intubation:
 Suction, pre-oxygenationSuction, pre-oxygenation
 MaintainMaintain spontaneous ventilationspontaneous ventilation::
 Avoid positive pressure ventilationAvoid positive pressure ventilation::
 Insufflation of the stomach via the fistulaInsufflation of the stomach via the fistula
or loss of ventilation through theor loss of ventilation through the
gastrostomygastrostomy
 Gastric distention: compromise ventilation,Gastric distention: compromise ventilation,
aspirationaspiration

27. Intubation/AirwayIntubation/Airway
 Awake intubationAwake intubation
 SafeSafe
 Appropriate positioning of ETTAppropriate positioning of ETT
 Positive pressure ventilationPositive pressure ventilation
 BUTBUT Difficult and traumatic in vigorous infantsDifficult and traumatic in vigorous infants
 Inhalation/IV anesthetic +/- muscleInhalation/IV anesthetic +/- muscle
 relaxant: Maintain spontaneous ventilation:relaxant: Maintain spontaneous ventilation:
 With assistance ventilation until fistula is ligatedWith assistance ventilation until fistula is ligated
 Keep airway pressure low (10-15 cmHKeep airway pressure low (10-15 cmH22 0)0)

28. Intubation/AirwayIntubation/Airway
 ETT positionETT position
 Below the fistula and above the carinaBelow the fistula and above the carina
 Right main-stem intubationRight main-stem intubation, then withdraw, then withdraw
 Proximal to carina, (no Murphy's Eye)Proximal to carina, (no Murphy's Eye) bevelbevel
facing anteriorlyfacing anteriorly so that posterior wall canso that posterior wall can
occlude the fistulaocclude the fistula
 ConfirmationConfirmation
 Fiberoptic bronchoscopy (!! Catheter inFiberoptic bronchoscopy (!! Catheter in
Fistula!)Fistula!)
 Gastrostomy to water sealGastrostomy to water seal

29. Induction drugs:Induction drugs:
Non-analgesic technique practice is no
longer acceptable.
Narcotics Based induction & maintenance Is the
method Of Choice:
Fentanyl:*
 10 mcg/kg IV during induction provides stable
cardiovascular response
 2-4 mcg/kg/hr adjuvant to anesthesia
 Stable cardiovascular response
* Newborn Services Drug Protocol recommended higher dose
(50 mcg/kg)
http://www.adhb.govt.nz/newborn/drugprotocols/FentanylPharmacology.htm

31. Anesthetic ManagementAnesthetic Management
 Intra-op problems:Intra-op problems:
 One lung ventilationOne lung ventilation: hypoxia, as well as: hypoxia, as well as
CO2 retentionCO2 retention
 ETT obstructionETT obstruction: blood clot, secretion: blood clot, secretion
 kinking of tracheakinking of trachea
 Vagal response:Vagal response: tracheal manipulation,tracheal manipulation,
lead to bradycardia, cardiac arrest!!lead to bradycardia, cardiac arrest!!

32. Intraop problems:Intraop problems:
 Frequent interruption to the surgery byFrequent interruption to the surgery by
the anesthesia team:the anesthesia team:
To minimize lung compression (no OLV)To minimize lung compression (no OLV)
To readjust monitorsTo readjust monitors
To reposition OGT/NGTTo reposition OGT/NGT
To check the IV accessTo check the IV access
Stabilize unstable babyStabilize unstable baby
To fight for the time!!!To fight for the time!!!

33. • Obstruction of ETT
• V/Q mismatch
 lateral decubitus position
 Interrupt lung retraction
• Vagal response to
tracheal manipulation
Intraop problems:

34. Maintenance of Anesthesia
 Narcotic based technique
 Minimal Inhalational + Ms relaxant
 No place for nitrous oxide

35. Intraoperative Volume ReplacementIntraoperative Volume Replacement
Hypovolemia with blood loss accounts forHypovolemia with blood loss accounts for
12% of causes of pediatric cardiac arrest in12% of causes of pediatric cardiac arrest in
OR with almost half of it due to underOR with almost half of it due to under
estimation of blood loss.*estimation of blood loss.*
**Anesthesia-Related Cardiac Arrest in Children: Update from the PediatricAnesthesia-Related Cardiac Arrest in Children: Update from the Pediatric
Perioperative Cardiac Arrest RegistryPerioperative Cardiac Arrest Registry
Bananker et al, Anesthesia & Analgesia, August 2007Bananker et al, Anesthesia & Analgesia, August 2007

36. Anesthetic Management:Anesthetic Management:
Postoperative problemsPostoperative problems
 Post op ventilationPost op ventilation (Our pt ventilated for(Our pt ventilated for
10 days post-op)10 days post-op)
 Conditions:Conditions:
 Defective tracheal wall at the site of fistulaDefective tracheal wall at the site of fistula
 Contaminated lungContaminated lung
 Problems associated with prematurity orProblems associated with prematurity or
associated anomalies & the general condition.associated anomalies & the general condition.
 ETTETT positionedpositioned >1cm>1cm away from site of fistulaaway from site of fistula
repairrepair
 Avoid suction too deepAvoid suction too deep

37. I’ll Love You Too Much If You Do It Easier:I’ll Love You Too Much If You Do It Easier:

38. Thoraco-scopic Repair EA/TEFThoraco-scopic Repair EA/TEF
Fistula LigationFistula Ligation
• SutureSuture
• ClipClip

39. Thoraco-scopic Repair EA/TEFThoraco-scopic Repair EA/TEF
 Anastomosis – SutureAnastomosis – Suture
• VicrylVicryl
• PDSPDS
• SilkSilk
 Anastomosis –Anastomosis –
TechniqueTechnique
• ExtracorporealExtracorporeal
• IntracorporealIntracorporeal

40. Thoraco-scopic RepairThoraco-scopic Repair
EA/TEFEA/TEF
 Thoraco-scopic repair of EA/TEFThoraco-scopic repair of EA/TEF
can be performed safely andcan be performed safely and
effectivelyeffectively && may be advantageousmay be advantageous
by reducing the musculoskeletalby reducing the musculoskeletal
sequelae seen followingsequelae seen following
thoracotomythoracotomy

41. Pediatric Anesthesia PearlsPediatric Anesthesia Pearls

42. Pediatric Anesth PearlsPediatric Anesth Pearls
• Almost all neonatal surgical “emergencies”Almost all neonatal surgical “emergencies”
are really “challenges”are really “challenges”
• Immaturity of organ system in neonatesImmaturity of organ system in neonates
alters pharmacology and physiologyalters pharmacology and physiology
• Thorough preop assessment is required in allThorough preop assessment is required in all
neonatesneonates
• One anomaly mandates a search for othersOne anomaly mandates a search for others
• Murmurs necessitate a cardiology consultMurmurs necessitate a cardiology consult

43. • Successful perioperativeSuccessful perioperative
outcome depends on openoutcome depends on open
communication and teamworkcommunication and teamwork
betweenbetween neonatologist,neonatologist,
anesthesiologistanesthesiologist andand surgeonsurgeon

44. • Initial resuscitation of neonatal surgicalInitial resuscitation of neonatal surgical
candidates includes:candidates includes:
 airway protectionairway protection
 adequate IV accessadequate IV access
 fluid resuscitationfluid resuscitation
 temperature stabilizationtemperature stabilization
 gastric decompressiongastric decompression
 administration of antibioticsadministration of antibiotics
 identify associated anomaliesidentify associated anomalies

45. -Infant's fragile cerebral blood vessels is an important-Infant's fragile cerebral blood vessels is an important
factor in the development of intra-ventricularfactor in the development of intra-ventricular
hemorrhage.hemorrhage.
-The spinal cord extends to a lower segment of the-The spinal cord extends to a lower segment of the
spine than in older children .spine than in older children .
-The volume of CSF and the spinal surface area are-The volume of CSF and the spinal surface area are
proportionally larger in neonatesproportionally larger in neonates ►► increased amount ofincreased amount of
local anesthetics (mg/kg) required for a successfullocal anesthetics (mg/kg) required for a successful
neuroaxial anesthesia in infants.neuroaxial anesthesia in infants.

46. ReferencesReferences
 SmithSmith’’s Anesthesia for Infants and Childrens Anesthesia for Infants and Children, 8th, 8th
edition, 2011 Mosbyedition, 2011 Mosby
 Clinical Cases in AnesthesiaClinical Cases in Anesthesia, 3rd edition, 2012, 3rd edition, 2012
ElsevierElsevier
 Pediatric Anesthsia:The Requisites inPediatric Anesthsia:The Requisites in
AnesthesiologyAnesthesiology, 2004 Mosby Elsevier, 2004 Mosby Elsevier
 Yao & ArtusioYao & Artusio’’s Anesthesiology; Problems Anesthesiology; Problem
Oriented Patient Management, 2011 LippincottOriented Patient Management, 2011 Lippincott