NM-269
Abrupt Changes In Ventilation During Tracheoesophageal Fistula Repair: The Presence of a Second Fistula
1Reynolds M, 2Pellegrino K, 2Hoy D
1University of Nebraska Medical Center, Omaha, Nebraska, USA; 2Children's Hospital & Medical Center, Omaha, Nebraska, USA
Esophageal atresia (EA) with Tracheoesophageal fistula (TEF) is an condition with a reported incidence of 1 in 3500 births. Challenges with tracheal intubation, oxygenation, and ventilation during repair are well described secondary to patient age, size, comorbidities, and the presence of the TEF itself. Anesthesia for TEF repair often includes maintaining spontaneous ventilation during intubation and until the fistula is controlled to avoid gastric insufflation. However, once the fistula is identified and controlled, positive pressure ventilation and the use of paralytics can be initiated allowing for improvement of ventilatory mechanics.
We present a case of a 2 day old term male who came to the OR for EA with TEF repair. The patient had no known prenatal anomalies. Shortly after birth, he demonstrated clinical features common to EA with distal TEF including the inability to pass nasogastric tube and bowel gas present on x-ray. In the OR, the patient was spontaneously ventilated first with a mask during induction with inhaled sevoflurane, then through an ETT for the procedure until the fistula was ligated. After fistula ligation, paralytic was administered and positive pressure ventilation commenced. Shortly after, tidal volume (TV) and end tidal carbon dioxide (ETCO2) abruptly dropped with ETCO2 dropping from 35mmHg to 20mmHg in less than 1 minute and TV no longer registering on the anesthesia machine. Differential diagnosis for this rapid decrease in ETCO2 and/or TV can include: ETT migration into the right main stem bronchus or fistula pouch, a leak in the ventilator system, pulmonary embolus, a mucus plug, blood clot, kinked ETT, or inadvertent extubation. Additionally, the anesthesiologist should be aware of the potential for a second TEF. After communicating the change in ventilation, the surgeon was able to identify the presence of a second TEF while we ruled out other etiologies.
Double fistulas in EA with distal TEF have been identified in case reports but are a rare anomaly. While it is still possible to miss a second fistula, bronchoscopy can be helpful to identify the fistula’s location as well as other airway abnormalities - including second fistula. If pre-operative bronchoscopy is not utilized, the anesthesiologist can perform flexible bronchoscopy during or after intubation. This may provide helpful information for anesthetic management and could have potentially made us aware of a second fistula in advance. Mindfulness of the possibility of a second TEF as well as rapid communication with the surgical team led to our patient maintaining appropriate oxygenation while the second fistula was repaired.
1.Yuvesh Passi, M.D., Venkata Sampathi, M.D., Joelle Pierre, M.D., Michael Caty, M.D., Jerrold Lerman, M.D., F.R.C.P.C., F.A.N.Z.C.A.; Esophageal Atresia with Double Tracheoesophageal Fistula. Anesthes 2013;118(5):1207.
2.Nitin Sharma, M. Srinivas, Laryngotracheobronchoscopy prior to esophageal atresia and tracheoesophageal fistula repair—its use and importance, In Journal of Pediatric Surgery, Volume 49, Issue 2, 2014, Pages 367-369, ISSN 0022-3468
3.Coté, Charles J., et al. Coté and Lerman's a Practice of Anesthesia for Infants and Children. 5th ed., Elsevier, Saunders, 2013
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