Anaesthetic Management of Tracheoesophageal Fistula (TEF) in a Neonate (Day 1 of Life)

Types of TEF - Type IIIB (proximal atresia + distal fistula) accounts for ~90% of cases. - Morgan & Mikhail's Clinical Anesthesiology, 7e

1. Understanding the Lesion

2. Preoperative Assessment and Preparation

Associated Anomalies (MANDATORY workup)

• Screen for VACTERL association: Vertebral, Anal atresia, Cardiac defects, TracheoEsophageal fistula, Renal anomalies, Limb defects
• Echocardiogram: Rule out congenital heart disease and right-sided aortic arch (alters surgical approach) - ~15-25% have cardiovascular anomalies
• Abdominal ultrasound: Rule out major renal abnormalities
• ~50% of affected infants have associated congenital anomalies

Respiratory Status

• Assess for aspiration pneumonia - common from reflux of gastric juice into the proximal pouch and from the fistula itself
• Chest X-ray to evaluate pulmonary status
• Severe pneumonia may necessitate a staging procedure (gastrostomy under local anaesthesia first) and delay primary repair until lungs improve

Stabilisation Before Surgery

• Nil by mouth - stop all feeds
• Place a Replogle tube (double-lumen sump catheter) in the proximal esophageal pouch and apply continuous suction to prevent aspiration
• Head-up, prone position to reduce reflux into the airway
• IV access and fluid resuscitation: neonates are often dehydrated and malnourished
• Correct electrolyte imbalances
• IV antibiotics if aspiration pneumonia is present

Physiological Considerations Specific to Day-1 Neonate

• Transitional circulation may still be present (patent ductus arteriosus, patent foramen ovale)
• Immature thermoregulation - maintain strict normothermia (warm theatre, warm IV fluids, overhead heater, warm blankets)
• Immature hepatic and renal drug metabolism - reduce drug doses accordingly
• High closing capacity relative to FRC - prone to atelectasis

3. Intraoperative Anaesthetic Management

Monitoring

• Arterial line (pre-ductal - right radial preferred): mandatory for beat-to-beat BP monitoring; surgical retraction compresses great vessels and causes sudden desaturation/hypotension
• Pre-ductal AND post-ductal pulse oximetry (right hand + any foot): detects intracardiac shunting
• Precordial stethoscope: placed in the dependent (left) axilla to immediately detect main-stem bronchus obstruction from surgical retraction - a drop in breath sounds is an early warning
• ECG, temperature probe (rectal/oesophageal - not oesophageal in this case!), capnography
• Blood group and crossmatch - blood must be immediately available

Positioning

• Left lateral decubitus for right extrapleural thoracotomy (conventional open approach)
• VATS (video-assisted thoracoscopic surgery) is increasingly preferred and requires similar positioning

Induction - Three Accepted Strategies

Endotracheal Tube Placement - The Critical Step

1. Advance the ETT until it enters a mainstem bronchus (unilateral chest rise, unilateral breath sounds)
2. Slowly withdraw until bilateral equal breath sounds are confirmed
3. The tip now lies just distal to the fistula (which opens just above the carina posteriorly)

• Confirm fistula size and location
• A Fogarty balloon catheter may be placed directly into the fistula lumen to occlude it, enabling safer PPV

• The ETT may inadvertently enter the fistula - suspect if sudden gastric distention, increased difficulty ventilating, and desaturation occur. Surgeon can palpate the tip. Withdraw immediately.
• The fistula may connect to the carina or a mainstem bronchus - in this case correct positioning is impossible; intermittent venting of a gastrostomy tube is the workaround

Maintenance of Anaesthesia

• Inhalational agents (sevoflurane or isoflurane) in air/oxygen mixture
• Maintain spontaneous ventilation if possible until the fistula is ligated - this is the safest strategy to avoid fistula distention
• Once fistula is ligated, controlled ventilation is acceptable
• Use lowest PIP necessary with permissive hypercapnia to avoid barotrauma
• Opioids judiciously (morphine or fentanyl) - be mindful of respiratory depression in day-1 neonate
• Muscle relaxants (vecuronium or cisatracurium) after intubation confirmed correctly
• Maintain normothermia actively throughout

Gastrostomy Tube Management (if present)

• Leave open to air (not to suction) at the head of the table
• Anesthesiologist must ensure it does not kink
• Vent intermittently if gastric distention occurs during PPV
• Its presence makes controlled ventilation safer

Intraoperative Hazards

4. Postoperative Management

• Extubation decision is coordinated with the surgeon - based on lung condition and adequacy of repair
• Most neonates with pre-existing aspiration pneumonia require continued postoperative ventilation with PEEP
• Neonates in good condition with no complications may be extubated early
• Avoid neck extension and esophageal suctioning - may disrupt anastomosis
• No nasogastric tube instrumentation without surgical clearance
• Continue monitoring in NICU

Postoperative Analgesia

• Wound infiltration with local anaesthetic (surgeon-applied)
• Caudal epidural catheter threaded to thoracic level - excellent for multimodal analgesia
• Paravertebral catheter at the surgical level
• Systemic opioids (IV morphine infusion) with apnoea monitoring - neonates are at high risk for opioid-induced apnoea

Postoperative Complications

• Gastroesophageal reflux and recurrent aspiration pneumonia
• Anastomotic leak
• Anastomotic stricture
• Recurrent fistula
• Tracheal compression from the repaired segment

5. Summary Checklist for the Anaesthesiologist

• Echocardiogram reviewed (CHD, arch sidedness)
• Replogle tube in pouch on continuous suction
• Arterial line (right radial) pre-induction or awake
• Blood crossmatched and available
• Theatre warmed, warm fluids, overhead heater
• Avoid mask PPV before correct ETT placement
• ETT tip distal to fistula - confirmed by auscultation bilaterally
• Bronchoscopy to assess fistula (Fogarty balloon if needed)
• Pre- and post-ductal SpO2 probes
• Precordial stethoscope on left (dependent) axilla
• Gastrostomy tube open to air if present
• Maintain spontaneous ventilation until fistula ligated
• Postoperative analgesia plan (caudal/paravertebral + local infiltration)
• Extubation decision coordinated with surgeon