Anesthesia forAnesthesia forTracheo-Tracheo-

esophageal Fistula esophageal Fistula RepairRepair

ByBy

Dr. Hazem Sharaf Dr. Hazem Sharaf (M.D.)(M.D.)

Anesthesia ConsultantAnesthesia Consultant

This is part II after PediatricsThis is part II after Pediatrics

What’s a What’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.

What’s a What’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.

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.

Today’s PatientToday’s Patient

Our Pediatric surgeon informed me Our Pediatric surgeon informed me about a baby-girl in NICU at 1.00 pm about a baby-girl in NICU at 1.00 pm for emergency thoracotomy for TEF for emergency thoracotomy for TEF repairrepair

The pt was a full term girl 15 hrs old The pt was a full term girl 15 hrs old diagnosed as esophageal atresia with diagnosed as esophageal atresia with tracheo-esophageal fistula for tracheo-esophageal fistula for emergency surgical intervention as emergency surgical intervention as soon as possiblesoon as possible

On checking: the baby was well On checking: the baby was well medically stabilized in NICU with medically stabilized in NICU with secured: secured: Intra-venous lineIntra-venous lineEndotracheal tubeEndotracheal tubeOro-Gastric tube to drain the pouchOro-Gastric tube to drain the pouchUrinary CatheterUrinary Catheter

Types of TEFTypes of TEF

• 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

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 assessmentStabilization Stabilization Ruling out other associated anomalies Ruling out other associated anomalies Counseling the familyCounseling the familyCross-matched bloodCross-matched bloodPrepared Theater for neonatal emergency high Prepared Theater for neonatal emergency high risk surgeryrisk surgeryPrepared anesthesia machine & drugsPrepared anesthesia machine & drugs

O.R. readinessO.R. readiness

Multi-disciplinary Multi-disciplinary approach by methodical approach by methodical detailed discussion with detailed discussion with pediatricians and pediatricians and pediatric surgeons pediatric surgeons

““Safe and effective anesthesia for Safe and effective anesthesia for neonates undergoing surgery is one neonates undergoing surgery is one

of the most challenging tasks of the most challenging tasks presented to anesthesiologist.”presented to anesthesiologist.”

KnowledgeKnowledge

Manual skills of the whole teamManual skills of the whole team

Continuous practiceContinuous practice

++

Adequate monitoring & Optimum Adequate monitoring & Optimum Postoperative Intensive CarePostoperative Intensive Care

↓↓

Satisfactory OutcomeSatisfactory Outcome

Esophageal Atresia/TEF

1:4000M:F 25:3

First fed chocking, cyanosis

Anesthetic ManagementAnesthetic Management Operating room set upOperating room set up: :

““keep warmkeep warm””:: warm room, warm room, warming blanket, overhead warmer warming blanket, overhead warmer

Low body temp:Low body temp: Release Nor-Epinephrine: Release Nor-Epinephrine:

vasoconstriction, increases vasoconstriction, increases metabolism, change degree of shuntingmetabolism, change degree of shunting

Affect anesthetic agents: likely over-Affect anesthetic agents: likely over-dosage, postop hypo-ventilation, apneadosage, postop hypo-ventilation, apnea

Coagulopathy, metabolic acidosisCoagulopathy, metabolic acidosis

Anesthetic ManagementAnesthetic Management

Standard monitoringStandard monitoring: : EKG, EKG, (pericordial stethoscope) pulse (pericordial stethoscope) pulse oximetry, end tidal CO2, BP oximetry, end tidal CO2, BP monitoring (Arterial line in high risk monitoring (Arterial line in high risk infants), Urinary Output infants), Urinary Output

Patient PositionPatient Position

Lateral decubitus

position

Posterolateral

thoracotomy

OGT / NGT is a very crucial issue to be determined before

draping

I never anesthetized a big baby from NICU

Anesthetic ManagementAnesthetic Management Induction: Induction: ““establish airway without pulmonary aspiration or gastric establish airway without pulmonary aspiration or gastric

distensiondistension” ” In preparation for intubation:In preparation for intubation:

Suction, pre-oxygenationSuction, pre-oxygenation Maintain Maintain spontaneous ventilationspontaneous ventilation: : Avoid positive pressure ventilationAvoid positive pressure ventilation: :

Insufflation of the stomach via the fistula or Insufflation of the stomach via the fistula or loss of ventilation through the gastrostomyloss of ventilation through the gastrostomy

Gastric distention: compromise ventilation, Gastric distention: compromise ventilation, aspirationaspiration

Intubation/AirwayIntubation/Airway Awake intubationAwake intubation

SafeSafe Appropriate positioning of ETT Appropriate positioning of ETT Positive pressure ventilationPositive pressure ventilation BUT BUT Difficult and traumatic in vigorous Difficult and traumatic in vigorous

infantsinfants Inhalation/IV anesthetic +/- muscle Inhalation/IV anesthetic +/- muscle

relaxant: Maintain spontaneous relaxant: Maintain spontaneous ventilation:ventilation: With assistance ventilation until fistula is With assistance ventilation until fistula is

ligatedligated Keep airway pressure low (10-15 cmHKeep airway pressure low (10-15 cmH220)0)

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) bevel bevel

facing anteriorlyfacing anteriorly so that posterior wall can so that posterior wall can occlude the fistulaocclude the fistula

ConfirmationConfirmation Fiberoptic bronchoscopy (!! Catheter in Fiberoptic bronchoscopy (!! Catheter in

Fistula!)Fistula!) Gastrostomy to water sealGastrostomy to water seal

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

Anesthetic ManagementAnesthetic Management

Intra-op problems:Intra-op problems: One lung ventilationOne lung ventilation: hypoxia, as well : hypoxia, as well

as CO2 retentionas CO2 retention ETT obstructionETT obstruction: blood clot, secretion: blood clot, secretion kinking of tracheakinking of trachea Vagal response: Vagal response: tracheal tracheal

manipulation, lead to bradycardia, manipulation, lead to bradycardia, cardiac arrest!! cardiac arrest!!

Intraop problems:Intraop problems: Frequent interruption to the Frequent interruption to the

surgery by the anesthesia team:surgery by the anesthesia team:

To minimize lung compression (no To minimize lung compression (no OLV)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!!!

• Obstruction of ETT

• V/Q mismatch lateral decubitus position

Interrupt lung retraction

• Vagal response to

tracheal manipulation

Intraop problems:

Maintenance of Anesthesia

Narcotic based technique

Minimal Inhalational + Ms relaxant

No place for nitrous oxide

Intraoperative Volume Intraoperative Volume ReplacementReplacement

Hypovolemia with blood loss accounts Hypovolemia with blood loss accounts

for 12% of causes of pediatric cardiac for 12% of causes of pediatric cardiac

arrest in OR with almost half of it due arrest in OR with almost half of it due

to under estimation of blood loss.* to under estimation of blood loss.* **Anesthesia-Related Cardiac Arrest in Children: Update from the Anesthesia-Related Cardiac Arrest in Children: Update from the

Pediatric Perioperative Cardiac Arrest RegistryPediatric Perioperative Cardiac Arrest RegistryBananker et al, Anesthesia & Analgesia, August 2007Bananker et al, Anesthesia & Analgesia, August 2007

Anesthetic Management:Anesthetic Management:Postoperative problemsPostoperative problems

Post op ventilation Post op ventilation (Our pt ventilated (Our pt ventilated for 10 days post-op)for 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 or Problems associated with prematurity or

associated anomalies & the general condition.associated anomalies & the general condition. ETTETT positioned positioned >1cm>1cm away from site of away from site of

fistula repairfistula repair Avoid suction too deepAvoid suction too deep

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

Thoraco-scopic Repair EA/TEFThoraco-scopic Repair EA/TEF

Fistula Fistula

LigationLigation

• SutureSuture

• Clip Clip

Thoraco-scopic Repair EA/TEFThoraco-scopic Repair EA/TEF

Anastomosis – SutureAnastomosis – Suture• VicrylVicryl• PDSPDS• SilkSilk

Anastomosis – TechniqueAnastomosis – Technique• ExtracorporealExtracorporeal• IntracorporealIntracorporeal

Thoraco-scopic Repair Thoraco-scopic Repair

EA/TEFEA/TEF Thoraco-scopic repair of Thoraco-scopic repair of

EA/TEF can be performed EA/TEF can be performed safely and effectivelysafely and effectively & & may may be advantageous by reducing be advantageous by reducing the musculoskeletal sequelae the musculoskeletal sequelae seen following thoracotomyseen following thoracotomy

Pediatric Anesthesia Pearls Pediatric Anesthesia Pearls

Pediatric Anesth Pearls Pediatric Anesth Pearls • Almost all neonatal surgical Almost all neonatal surgical

“emergencies” are really “challenges”“emergencies” are really “challenges”

• Immaturity of organ system in neonates Immaturity of organ system in neonates

alters pharmacology and physiologyalters pharmacology and physiology

• Thorough preop assessment is required in Thorough preop assessment is required in

all neonatesall neonates

• One anomaly mandates a search for One anomaly mandates a search for

othersothers

• Murmurs necessitate a cardiology consultMurmurs necessitate a cardiology consult

• Successful perioperative Successful perioperative outcome depends on open outcome depends on open

communication and communication and teamwork between teamwork between

neonatologist, neonatologist, anesthesiologistanesthesiologist and and

surgeonsurgeon

• Initial resuscitation of neonatal surgical Initial 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 Safe effective anesthetic managementSafe effective anesthetic management

-Infant's fragile cerebral blood vessels is an -Infant's fragile cerebral blood vessels is an important factor in the development of intra-important factor in the development of intra-ventricular hemorrhage.ventricular hemorrhage.

-The spinal cord extends to a lower segment of -The spinal cord extends to a lower segment of the spine than in older children .the spine than in older children .

-The volume of CSF and the spinal surface area -The volume of CSF and the spinal surface area are proportionally larger in neonates are proportionally larger in neonates ►► increased amount of local anesthetics (mg/kg) increased amount of local anesthetics (mg/kg) required for a successful neuroaxial anesthesia required for a successful neuroaxial anesthesia in infants.in infants.

ReferencesReferences

SmithSmith’’s Anesthesia for Infants and s Anesthesia for Infants and ChildrenChildren, 8th edition, 2011 Mosby , 8th edition, 2011 Mosby

Clinical Cases in AnesthesiaClinical Cases in Anesthesia, 3rd edition, , 3rd edition, 2012 Elsevier2012 Elsevier

Pediatric Anesthsia:The Requisites in Pediatric Anesthsia:The Requisites in AnesthesiologyAnesthesiology, 2004 Mosby Elsevier, 2004 Mosby Elsevier

Yao & ArtusioYao & Artusio’’s Anesthesiology; Problem s Anesthesiology; Problem Oriented Patient Management, 2011 Oriented Patient Management, 2011 LippincottLippincott