NM-259
Unintentional Esophageal Intubation in a Newborn with a Tracheoesophageal Fistula with Unknown Tracheal Atresia
Sualy K, Mangahas E
Rush University Medical Center, Chicago, Illinois, United states
Tracheoesophageal fistulas (TEF) in newborns require careful planning and management by anesthesiologists. Often times, these patients are evaluated with rigid bronchoscopy to determine the presence of multiple fistulas, prior to surgical repair (Broemling & Campbell, 2011). Additionally, concomitant airway abnormalities may be present, including tracheomalacia, tracheal stenosis/agenesis, and/or the presence of a tracheal pouch.
Our patient is a 2-day old, 1.64kg, female born at 33 weeks gestation (twin A, twin-to-transfusion syndrome), who was transferred to Rush University Medical Center (RUMC) with respiratory distress with presumed tracheoesophageal fistula and esophageal atresia after difficulty placing NG tube. The patient was intubated at the outside hospital.
Upon arrival to RUMC, the patient was stable, with endotracheal tube in place. The patient was taken to the OR for TEF repair. The patient was placed on pressure support, with appropriate monitoring in place. End-tidal CO2 monitoring was inconsistent from the start, thought to be secondary to an audible air leak (3.0mm uncuffed ETT). Despite inconsistent EtCO2, other vital signs were stable, so decision was made to keep the ETT in place. The surgical team prepped and draped the patient, and ligation of the distal esophagus from the trachea was performed. Per surgeon request, a bougie was placed to identify the proximal esophageal pouch. Upon insertion, EtCO2 was lost, and the patient began to desaturate. We were unable to manually ventilate the patient via the ETT. The decision was made to remove the ETT. Bag-mask was performed without significant difficulty, with improvement of SpO2.
Endotracheal intubation was attempted in the lateral position, as the chest was open, however unsuccessful via direct laryngoscopy and fiberoptic scope. We were able to bag-mask effectively in between. The chest wall was closed, and the patient was placed in the supine position. An additional pediatric anesthesiologist was called into the OR for assistance. Numerous attempts at endotracheal intubation were made via direct laryngoscopy and fiberoptic scope, however we were unable to obtain EtCO2 and the patient began to desaturate, despite Grade I view of the vocal cords.
The decision was made to contact the Otolaryngology (ENT) service. Rigid bronchoscopy was performed, and it was quickly apparent that the proximal and distal trachea were in discontinuity at the subglottic level, with the proximal trachea opening directly into the mediastinum.
After a group discussion, the chest was reopened, and the trachea was accessed distally, just above the carina. A 2.0mm cuffless ETT was passed without difficulty, and connected to the anesthesia circuit with positive EtCO2. ENT then passed a 2.0mm cuffless ETT through the oral cavity, into the esophageal remnant. The ETT was located by the pediatric surgeons in the chest, and directed into the airway through an additional TEF. The chest was then closed, and the patient was taken to the NICU.
Broemling, N. & Campbell, F. (2011). Anesthetic management of congenital tracheoesophageal fistula. Pediatric Anesthesia (21), p. 1092-1099.
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