Anesthetic management of congenital tracheoesophageal fistula

Neonatal peri-procedural extracorporeal membrane oxygenation in the management of tracheo-esophageal fistula/esophageal atresia and left pulmonary agenesis

Congenital tracheo-esophageal fistula/esophageal atresia (TEF/EA) with concomitant pulmonary agenesis is exceedingly rare and has a high mortality rate. While there are several reported cases of successful repair, all but one patient had right-sided pulmonary agenesis. In the case of left-sided pulmonary agenesis, the patient had incomplete agenesis and underwent repair through a left thoracotomy. We present the first successful repair of TEF/EA with complete left-sided pulmonary agenesis. This patient also underwent elective pre-operative veno-venous extracorporeal membrane oxygenation (ECMO) and subsequent repair of the TEF/EA. We discuss the management, anesthesia risks, and role of periprocedural ECMO in pediatric patients who are high anesthetic risk.

A Case of Asymptomatic Tracheoesophageal Fistula

The tracheoesophageal fistula (TEF) is an abnormal flow between the esophagus and the trachea. Most patients with TEF experience severe symptoms. Asymptomatic TEF is rare. In this case report, a 47-year-old woman planned to undergo orthopedic surgery under general anesthesia. She had no symptoms related to TEF, and the preoperative chest computed tomography was also normal. However, there was significant airway resistance after induction. Using a fiber bronchoscope, a TEF was discovered. The TEF found after anesthesia due to high airway pressure is unusual, and the outcome and treatment of these patients need to be further discussed.

Supraglottic jet oxygenation and ventilation via nasopharyngeal airway for a patient with iatrogenic tracheoesophageal fistula: A case report

Background

Iatrogenic tracheoesophageal fistula (TEF) is a rare but life-threatening condition. No consensus has been reached regarding TEF treatment, though, stenting has been gaining popularity for less invasiveness than thoracic surgery. The airway management during stent placement for TEF could be challenging.

Case presentations

We report a patient who suffered from TEF after cardiac surgery with symptoms of persistent coughing and aspiration. He who was admitted for stent placement but ended up in failure and referred to our institution for further treatment. We successfully took advantage of the supraglottic jet oxygenation and ventilation (SJOV) during stent placement.

Conclusion

This is the first case so far describing SJOV in complicated stenting treatment. This demonstrates that SJOV can be applied for stent placement in TEF patients with restricted airways.

Accidental esophageal intubation via a large type C congenital tracheoesophageal fistula: A case report

BACKGROUND

Tracheoesophageal fistula (TEF) is a congenital anomaly characterized by interruptions in esophageal continuity with or without fistulous communication to the trachea. Anesthetic management during TEF repair is challenging because of the difficulty of perioperative airway management. It is important to determine the appropriate position of the endotracheal tube (ETT) for proper ventilation and to prevent excessive gastric dilatation. Therefore, the tip of the ETT should be placed immediately below the fistula and above the carina.

CASE SUMMARY

A full-term, one-day-old, 2.4 kg, 50 cm male neonate was diagnosed with TEF type C. During induction, an ETT was inserted using video laryngoscope and advanced deeply to ensure that the tip passed over the fistula, according to known strategies. The passage of the ETT through the vocal cords was confirmed via video laryngoscope. However, after inflating the ETT cuff, breath sounds were not heard on bilateral lung auscultation. Instead, gastric sounds were heard. Considering that a large fistula (approximately 6.60 mm × 4.54 mm) located 10.2 mm above the carina was confirmed on preoperative tracheal computed tomography, the possibility of unintentional esophageal intubation was highly suspected. Therefore, we decided to uncuff and withdraw the ETT carefully for repositioning, while monitoring auscultation and end-tidal CO₂ simultaneously. At a certain point (9.5 cm from the lip), clear breath sounds and proper end-tidal CO₂ readings were suddenly achieved, and adequate ventilation was possible.

CONCLUSION

Preanesthetic anatomical evaluation with imaging studies in TEF is necessary to minimize complications related to airway management.

The Phenotypical Profile and Outcomes of Neonates with Congenital Tracheoesophageal Fistula Associated with Congenital Cardiac Anomalies Presenting for Surgery

(1) Background: Neonates born with oesophageal atresia and/or tracheooesophageal fistula (OA/TOF) are usually born with a multitude of other congenital anomalies, which may affect their anaesthetic care and survival to hospital discharge. We reviewed the profile and outcome of neonates with OA/TOF and associated congenital cardiac anomalies presenting for surgery at an academic hospital in South Africa. (2) Methods: A retrospective, cross-sectional analysis of all medical records of neonates who had undergone surgical repair of OA/TOF was conducted at an academic hospital between January 2015 and December 2019. Descriptive statistics were used to report the data. Comparisons in perioperative events and outcomes between those with cardiac lesions and those without were done. (3) Results: Neonates presenting for OA/TOF repair with congenital cardiac defects had an incidence of 62 [95% CI 38.5–99.8] per 1000 days since birth. In total, 45.9% had associated cardiac anomalies, with PDA and ASD as the most prevalent lesions. There were statistically significant differences in intraoperative adverse events seen in neonates with congenital cardiac lesions as compared to those without. (4) Conclusion: Despite advances in neonatal critical care and anaesthetic and surgical techniques, OA/TOF associated with congenital cardiac anomalies is still associated with high mortality rates in developing countries.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Anesthesia management in neonatal congenital bronchobiliary fistula: case report and literature review

Background

There is very little published literature and none that discussed care in a neonate regarding anesthetic risk and management of neonate with congenital bronchobiliary fistula during thoracoscopy and thoracotomy. This article analyzes related risk factors and literature review from perioperative ventilation, circulation and other aspects of management.

Case presentation

A neonate diagnosed as congenital bronchobiliary fistula combined with severe chemical pneumonia, consolidation of the lungs, and infection was facing the risk of anaesthesia under thoracoscopy exploration surgery, who experiened more than 20 days diagnostic period before operation. Many risk factors have led to conversion from minimally invasive surgery to thoracotomy, including persistent hypoxemia, hypercapnia, difficult surgical exposure and extremly difficulty of intraoperative ventilation management. Anesthesia maintenance after conversion to open access remained problematic. Fortunately the patient showed no sign of any adverse CNS effects after 4 months of follow-up.

Conclusions

The most prominent anesthesia challenges are hypoxemia, increased airway resistance, impaired ventilation, and the risk of metabolic acidosis. Close cooperation among the entire neonatal medical team is the key factors in successful management of this rare case.

Tracheoesophageal fistula in the developing world: are we ready for thoracoscopic repair?

PURPOSE

Tracheoesophageal fistula (TEF) is a bellwether for a country's ability to care for sick newborns. We aim to review the existing literature from low- and middle-income countries in regard to management of those newborns and the possible approaches to improve their outcomes.

METHODS

A review of the existing English literature was conducted with the aim of assessing challenges faced by providers in LMIC in terms of diagnostic, preoperative, operative and post-operative care for TEF patients. We also review the limited literature for performing thoracoscopic repair in the developing world context and suggest methods for introduction of advanced thoracoscopic procedures including techniques for providing anesthesia to these challenging babies.

RESULTS

While outcomes related to technique from LMIC are comparable to the developed world, rates of secondary complications like sepsis and pneumonia are higher. In many areas, repairs are conducted in a staged fashion with minimal utilization of thoracoscopic approach. The paucity of resources creates strain on intraoperative and post-operative management.

CONCLUSION

Clearly, not all developing world contexts are ready to attempt thoracoscopic repair but we outline suggestions for assessing the existing capabilities and a stepwise gradual implementation of advanced thoracoscopy when appropriate.

Iatrogenic Complete Ventilatory Failure in Two Neonates Undergoing Tracheoesophageal Fistula Repair

Tracheoesophageal fistula (TEF) is one of the most common congenital anomalies presenting for emergency surgical correction in a neonate. The surgical approach is through the right thoracotomy in the lateral decubitus position. The pathology and surgical approach complicate the ventilatory management for this subset of neonates. Several possible causes of ventilatory insufficiency have been reported during the surgical repair in these cases. We report unusual causes of complete ventilatory failure in two patients undergoing TEF repair.

Outcome of Patients With Esophageal Atresia and Very Low Birth Weight (≤ 1,500 g)

Introduction: Primary repair of esophageal atresia (EA) in infants with very low birth weight (VLBW) and extremely low birth weight (ELBW) has been widely performed in pediatric surgery. However, several studies have shown that complication rates in infants with VLBW are high. We hypothesize preterm children benefit from a shorter, less-traumatizing operation in the first days of life, as staged repair implies. Methods: Patients with EA and VLBW were retrieved from the database of a large national patient organization KEKS e.V. Structured questionnaires were sent to all the patients' families; the responses were pseudonymized and sent to our institution. Results: Forty-eight questionnaires from patients were analyzed. The mean birth weight was 1,223 g (720-1,500 g). Primary repair was performed in 25 patients (52%). Anastomotic insufficiency (AI) was reported in 9 patients (19%), recurrent fistula (RF) in 8 (17%), and anastomotic stenosis in 24 patients (50%). Although AI was almost twice as common after primary repair than after staged repair (24 vs. 13%; p = 0.5), the difference was not statistically significant. RF was more frequent after primary repair (28 vs. 4%; p = 0.04), gastroesophageal reflux was more frequent in the group after staged repair (78 vs. 52%; p = 0.04), and both correlations were statistically significant. Intracranial hemorrhage (ICH) was reported in 11 patients (23%) and was observed in 7 of them (64%, p = 0.4) after primary repair. ICH was reported in 60% of patients with ELBW and 75% of patients when ELBW was paired with primary repair. Conclusion: This study demonstrates the complication rate in patients with VLBW is higher than the average of that in patients with EA. The study indicates that a staged approach may be an option in this specific patient group, as less RF and AI are seen after staged repair. ICH rate in patients with ELBW seemed to be especially lower after staged repair. Interestingly, gastroesophageal reflux was statistically significantly higher in the group after staged repair, and postoperative ventilation time was longer. It is therefore necessary to individually consider which surgical approach is appropriate for this special patient group.

Anesthesia Practice: Review of Perioperative Management of H-Type Tracheoesophageal Fistula

Tracheoesophageal fistula (TEF) is a rare congenital developmental anomaly, affecting 1 in 2500-3000 live births. The H-type TEF, consisting of a fistula between the trachea and a patent esophagus, is one of the rare anatomic subtypes, accounting for 4% of all TEFs. The presentation and perioperative management of neonates with H-type TEFs and all other TEFs are very similar to each other. Patients present with congenital heart disease and other defects and are prone to recurrent aspirations. A barium esophagogram or computed tomography of the chest is a common means to the diagnosis, and surgical repair is carried out through either a cervical approach or a right thoracotomy. During operation, anesthetic management is focused on preventing positive pressure ventilation through the fistula in an attempt to minimize gastric distension. For patients with H-type TEFs, because of the patent esophagus, symptoms are often less severe and nonspecific, resulting in subtle yet important differences in their diagnostic workup and management. This review will cover the finer details in the diagnosis and perioperative anesthetic management of TEF patients and clarify how H-type TEF distinguishes itself from the other anatomic subtypes.

Closer location of the tracheoesophageal fistula to the carina in newborns with esophageal atresia and VACTERL association

BACKGROUND

VACTERL is a complicated syndrome with an unknown etiology where many studies have failed to identify the cause. In esophageal atresia (EA) roughly 10%-23% also have concurrent anomalies that align with VACTERL disorder. The aim of this study is to investigate if there is a difference regarding localization of the tracheoesophageal fistula between patients with VACTERL and non-VACTERL patients.

METHODS

Retrospective chart review of newborn operated for esophageal atresia between 2006 and 2016 at our Institution was performed. Children with a C-type fistula according to Gross and reliable preoperative tracheoesophageal fistula to carina distance measurement at rigid tracheoscopy were included in the study.

RESULTS

A total of 90 patients were included in the study. Fifteen of those were diagnosed with VACTERL. Before and after adjusting for weight and gestational week patients with VACTERL had significantly shorter carina to fistula distance at perioperative rigid tracheoscopy (p = <0.001 nonadjusted, p = 0.016 adjusted).

CONCLUSION

Patients with VACTERL born with EA type C had shorter carina to fistula distance as shown at perioperative rigid tracheoscopy. The significantly shorter distance may not only present surgical difficulties but may also suggest a structural or molecular difference in the development of the esophageal atresia between the two groups.

LEVEL OF EVIDENCE

III.

A multicenter audit of the use of bronchoscopy during open and thoracoscopic repair of esophageal atresia with tracheoesophageal fistula

BACKGROUND

Esophageal atresia (EA) with tracheoesophageal fistula is usually repaired in the neonatal period. Preferential ventilation through the fistula can lead to gastric distension. Bronchoscopy has a role in defining the site and size of the fistula, and may be carried out by the surgeon or the anesthetist. The use of bronchoscopy varies across different institutions.

METHODS

This is a multicenter case note review of infants with EA with tracheoesophageal fistula who underwent surgery between January 2010 and December 2015. This retrospective audit aims primarily to document the use of bronchoscopy during open and thoracoscopic repair at a selection of United Kingdom centers. Respiratory complications, that is relating to airway management, the respiratory system, and difficulty with ventilation, at induction and during surgery, are recorded. The range of techniques for anesthesia and analgesia in these centers is noted.

RESULTS

Bronchoscopy was carried out in 52% of cases. The incidence of respiratory complications was 7% at induction and 21% during surgery. Thoracoscopic repair usually took longer. One center used high-frequency oscillatory ventilation, on an elective basis during thoracoscopic repair, to facilitate surgical access and address concerns about hypoxemia and hypercarbia.

CONCLUSION

The use of bronchoscopy varies considerably between institutions. Infants undergoing tracheoesophageal fistula repair are at risk of perioperative respiratory morbidity. The advent of thoracoscopic repair has introduced further variation.

Preoperative cardiopulmonary evaluation in specific neonatal surgery

Preoperative assessment of surgical neonates often relates to issues of prematurity, low birth weight, or associated malformations. This review explores the preoperative cardiopulmonary evaluation in specific newborn surgical populations, the role of echocardiography in congenital diaphragmatic hernia perioperative management, the impact of bronchopulmonary dysplasia in the ex-preterm surgical neonate and a brief discussion on the risk of general anesthesia and specific anesthetic considerations for any surgical neonate. Newborns with congenital anomalies requiring early general surgical intervention should have an assessment for congenital heart disease. In the asymptomatic neonate, a thorough physical exam may be sufficient preoperatively. Neonates born with esophageal atresia or anorectal malformations should have a full evaluation for VACTERL associations. Initial echocardiography in congenital diaphragmatic hernia is used to evaluate anatomy, but there is emerging evidence to suggest the use of echocardiography in the ongoing surveillance of CDH to influence the timing of surgical intervention. Bronchopulmonary dysplasia is present in up to 40% of ex-premature neonates and increases the risk of postoperative apneas and need for ventilatory support. However, all surgical neonates have an increased risk of post-operative apneas, and the need for surgical intervention should be balanced with the risk of general anesthesia.

Effect of cardia banding and improved anaesthetic care on outcome of oesophageal atresia in a developing country

We comparatively analysed cases of oesophageal atresia (OA) managed in Enugu, south-eastern Nigeria from October 2010 to September 2015 to evaluate our short-term outcome with management following incorporation of temporary cardia banding to gastrostomy for late presenting cases and improved anaesthesia in 2013. Overall, 19 cases were analysed. The clinical parameters did not differ in the cases managed before (Group A) and after (Group B) these introductions. Four (21.1%) cases had primary repair (2 per group), six (31.6%) had delayed primary repair after treatment of pneumonitis (Group A 5; Group B 1) and nine (47.3%) had delayed primary repair after gastrostomy (Group A 4; Group B 5). Anaesthesia-related mortality dropped from 53.8 to 7.7% and survival improved from 9.1 to 62.5% following the introductions. Despite persisting barriers to care, outcome of OA in our setting may improve with better anaesthesia and incorporation of temporary cardia banding to gastrostomy.

Anesthesia of thoracic surgery in children

Providing anesthesia in children with thoracic disease is a challenging task. The effects of the underlying disease, the surgical interventions, and preexisting condition of the patient need to be considered when planning perioperative care. The perioperative care for children undergoing thoracic surgery requires specific techniques adapted to the pediatric physiology and anatomy. This review is focused on anesthetic strategies for thoracic surgery with an emphasis on perioperative analgesia including neuraxial techniques.

Preoperative laryngotracheobronchoscopy in infants with esophageal atresia: why is it not routine?

The value of laryngotracheobronchoscopy (LTB) immediately prior to repair of esophageal atresia with or without tracheo-esophageal fistula is contentious. Currently, there is a wide range of opinion on the utility of this investigation which is reflected by huge variation in clinical practice. This review is a critical analysis of the arguments for and against performing routine LTB prior to esophageal atresia repair. Reserving LTB for selected cases only is potentially disadvantageous since it limits the surgeon's and anesthetist's familiarity with the procedure, equipment, and range of potential findings. There is sufficient evidence to suggest that routine preoperative LTB becomes the standard of care.

Let us save the brain with cerebral oximeter: Two case reports

In the neonates, tracheal atresia and tracheoesophageal fistula (TEF) surgery may result in hemodynamic instabilization, leading to cerebral perfusion insufficiency due to the retraction of the pulmonary vessels and truncus brachiocephalicus. We represented one male and one female neonates which were performed thoracoscopic primary repair of TEF through right thoracotomy at the 3^th and 4^th postpartum day. Anesthesia was induced using sodium thiopental (5 mg/kg), fentanyl 4 mcg, and rocuronium (0.5 mg/kg) given through intravenous route. Sevoflurane 2% and 50% O₂in air were used for the maintenance therapy. During the right lung compression to expose posterior esophagus, no value was observed on the pulse oximeter (PO) probe placed on the right hand, and radial artery was not palpated. At the same time, oxygen saturation was observed as 96%-97% on the left foot probe. As the right cerebral oximeter values (rSO₂) were rapidly decreased to 31%, the lung compression was ceased. Right pulse oximeter and right rSO₂measurements return to the baseline levels. For the second case - different from the first case -both left and right rSO₂was rapidly decreased to 40% levels and return to the baseline levels after was removed the retractors. Right PO and right and left cerebral rSO₂values returned to baseline immediately when the retractor compression was ended During the operations involving the great vessels in neonates, cerebral perfusion could be preserved using cerebral oximeter. Cerebral oximeter is more efficient than pulse oximeter for detecting cerebral tissue oxygenation and could be helpful to minimize neuronal damage in the neonates.

Esophageal Atresia/Tracheoesophageal Fistula Repair Complicated by Tracheomalacia: A Case Report of Successful Management of Respiratory Distress Using Caudal Morphine

We report a case of severe respiratory distress in a neonate who was not endotracheally intubated soon after esophageal atresia/tracheoesophageal fistula (EA/TEF) repair. In this serious situation, any form of emergency respiratory support or definitive airway management may compromise the esophageal anastomosis and fistula repair. The cause of respiratory distress in the early postoperative period after EA/TEF is multifactorial, and in this case, included symptomatic tracheomalacia, which is commonly associated with EA/TEF.

Peri-operative management of neonates with oesophageal atresia and tracheo-oesophageal fistula

Oesphageal atresia is a relatively common congenital anomaly that requires urgent diagnosis, transfer to a neonatal surgical centre and management by a multidisciplinary team. Peri-operative management requires vigilant monitoring for the many possible associated morbidities. There are unique anaesthetic, airway and ventilatory considerations for this group of patients. Beyond the perinatal period, systematic neurodevelopmental follow-up is recommended to better understand the longer term outcomes for these children.

Fluoroscopically guided tunneled trans-caudal epidural catheter technique for opioid-free neonatal epidural analgesia

Epidural analgesia confers significant perioperative advantages to neonates undergoing surgical procedures but may be very technically challenging to place using a standard interlaminar loss-of-resistance to saline technique given the shallow depth of the epidural space. Thoracic epidural catheters placed via the caudal route may reduce the risk of direct neural injury from needle placement, but often pose higher risks of infection and/or improper positioning if placed without radiographic guidance. We present a detailed method of placing a fluoroscopically guided, tunneled transcaudal epidural catheter, which may reduce both of these risks. The accuracy and precision of this technique often provides adequate analgesia to allow for opioid-free epidural infusions as well as significant reductions in systemic opioids through the perioperative period. Opioid-free analgesia using a regional anesthetic technique allows for earlier extubation and reduced perioperative sedation, which may have a less deleterious neurocognitive effect on the developing brain of the neonate.

Anesthetic management for surgery of esophagus atresia in a newborn with Goldenhar's syndrome

BACKGROUND AND OBJECTIVES

Goldenhar's syndrome is a polymalformative condition consisting of a craniofacial dysostosis that determines difficult airway in up to 40% of cases. We described a case of a newborn with Goldenhar's syndrome with esophageal atresia and tracheoesophageal fistula who underwent repair surgery.

CASE REPORT

We report the case of a 24-h-old newborn with Goldenhar's syndrome. He had esophageal atresia with distal tracheoesophageal fistula. It was decided that an emergency surgery would be performed for repairing it. It was carried out under sedation, intubation with fibrobronchoscope distal to the fistula, to limit the air flow into the esophagus, and possible abdominal distension. Following complete repair of the esophageal atresia and fistula ligation, the patient was transferred to the intensive care unit and intubated under sedation and analgesia.

CONCLUSIONS

The finding of a patient with Goldenhar's syndrome and esophageal atresia assumes an exceptional situation and a challenge for anesthesiologists, since the anesthetic management depends on the patient comorbidity, the type of tracheoesophageal fistula, the usual hospital practice and the skills of the anesthesiologist in charge, with the main peculiarity being maintenance of adequate pulmonary ventilation in the presence of a communication between the airway and the esophagus. Intubation with fibrobronchoscope distal to the fistula deals with the management of a probably difficult airway and limits the passage of air to the esophagus through the fistula.

[Anesthetic management for surgery of esophagus atresia in a newborn with Goldenhar's syndrome]

BACKGROUND AND OBJECTIVES

Goldenhar's syndrome is a polymalformative condition consisting of a craniofacial dysostosis that determines difficult airway in up to 40% of cases. We described a case of a newborn with Goldenhar's syndrome with esophageal atresia and tracheoesophageal fistula who underwent repair surgery.

CASE REPORT

We report the case of a 24-hour-old newborn with Goldenhar's syndrome. He had esophageal atresia with distal tracheoesophageal fistula. It was decided that an emergency surgery would be performed for repairing it. It was carried out under sedation, intubation with fibrobronchoscope distal to the fistula, to limit the air flow into the esophagus, and possible abdominal distension. Following complete repair of the esophageal atresia and fistula ligation, the patient was transferred to the intensive care unit and intubated under sedation and analgesia.

CONCLUSIONS

The finding of a patient with Goldenhar's syndrome and esophageal atresia assumes an exceptional situation and a challenge for anesthesiologists, since the anesthetic management depends on the patient comorbidity, the type of tracheoesophageal fistula, the usual hospital practice and the skills of the anesthesiologist in charge, with the main peculiarity being maintenance of adequate pulmonary ventilation in the presence of a communication between the airway and the esophagus. Intubation with fibrobronchoscope distal to the fistula deals with the management of a probably difficult airway and limits the passage of air to the esophagus through the fistula.

[Anesthetic management of a neonate with esophageal atresia, tracheoesophageal fistula and imperforate anus]

Esophageal atresia is a rare condition (1:2,500-4,500), incompatible with life, and a surgical emergency in the neonatal period. It is associated with prematurity in 30% of cases, and to congenital abnormalities in 50% of cases, especially cardiac anomalies. Major congenital heart diseases and low weight are independent predictors of mortality and critical perioperative events. The aim of this article is to describe the most significant anaesthetic challenges presented in a case of a term neonate undergoing emergency surgery after being diagnosed with esophageal atresia, tracheoesophageal fistula type iiib/C, and imperforate anus. The major priorities during the anaesthetic management consist of establishing a safe airway and effective pulmonary ventilation that minimises air leakage to the upper digestive tract.

An audit of anesthetic management and complications of tracheo-esophageal fistula and esophageal atresia repair

BACKGROUND

Many different anesthetic techniques have been suggested for the management of tracheo-oesophageal fistula/oesophageal atresia (TOF/OA) although the incidence of ventilation difficulty is not well known and it is unclear which technique is best in managing this. The aim of our audit was to determine the incidence of ventilation difficulty during repair of TOF/OA. We also recorded the current practice for anesthesia and analgesia in these children as well as the incidence of comorbidities and surgical complications.

METHODS

We retrospectively audited cases of TOF/OA repair over a 3-year period in four hospitals, recording demographics, comorbidities, surgical data, postoperative complications, and anesthetic technique, including ventilation difficulty and management strategy.

RESULTS

A total of 111 patients were identified with TOF/OA, and 106 patient notes and 101 anesthetic records were found. 42% of patients were premature, and 57.5% had significant comorbidities. Death was most likely in infants with low birth weight and low gestational age at birth and in those with major cardiac comorbidity. A range of techniques were used for induction, maintenance, extubation, and pain control. There were ventilation difficulties recorded at induction in seven patients, and significant desaturations were recorded in 15 patients intraoperatively.

CONCLUSIONS

This audit adds to the data already published about incidences of complications and comorbidities associated with TOF/OA repair. Defining anesthetic practice with regard to ventilation and analgesic strategies is important in comparing the adequacy and risk of techniques used. Our audit shows that a range of differing anesthetic techniques are still employed by different anesthetists and institutions and details some of the techniques being used for managing difficult ventilation.