CHAPTER I

PRELIMINARY

Esophageal atresia is defined as a congenital abnormality in the form of a

continuity disorder in the esophageal lumen. Esophageal atresia can be accompanied
by a tracheoesophageal fistula, a connecting lumen between the proximal and or distal
parts of the esophagus with the airway (trachea). First introduced by Thomas Gibson
in 1967. It occurs in 2500-3000 live births, two to three times more common in
twins. 1,2,3
The etiology of esophageal atresia is multifactorial and remains
unknown. The association of esophageal atresia with various other congenital
abnormalities, indicates that these lesions occur due to a disturbance in
embryogenesis, the exact cause of which has not been identified. 2
Infants with esophageal atresia will show symptoms of hypersalivation and
shortness of breath caused by aspiration pneumonia. When the nasogastric tube
cannot pass through the esophagus, atresia can be suspected. Radiological
examination has an important role in diagnosing esophageal atresia, confirms
esophageal atresia with a fistula or without a fistula and diagnoses other anomalies
associated with VACTERL. 4.5 Knowledge and ability of an anesthesiologist in dealing
with patients with these disorders when they will it plays a very important role in the
success of the surgery. Understanding of complications that may occur and long-term
results and sequelae that arise after surgery, will determine the prognosis of these
patients 1
 CHAPTER II
LITERATURE REVIEW

I.Anatomy of the esophagus

The esophagus is the muscular tube that connects the pharynx to the
stomach. The length of the esophagus at birth varies between 8- 10 cm and at the age
of 15 years is around 19 cm. The esophagus extends from the lower border of the
cricoid cartilage (as high as the cervical vertebral body 6) to the gastric cardiac orifice
as high as the thoracic vertebral body. 6
Based on the region passed, the esophagus can be divided into cervical
esophagus, thoracic esophagus and abdominal esophagus. The cervical esophagus
starts from the tip of the oropharynx to the 6th cervical vertebral body. The thoracic
esophagus is along the mediastinum starting as high as the 10th thoracic vertebral
body across the diaphragm which is a strong muscular tissue and restricts the thorax
to the abdomen. The abdominal esophagus starts as high as the 11th thoracic vertebral
body, enters the stomach, forming a sharp angle called the cardiac angle . 1.6
The esophagus has a complex blood vessels according to the division of the
esophageal anatomy. The cervical esophagus gets blood flow from the inferior thyroid
artery. The thoracal esophagus gets blood flow from the branches of the thoracic aorta
and brachial artery. The abdominal esophagus gets blood from the left gastric artery
and the abdominal aorta in the lower left phrenic branch. Likewise with venous blood
flow. 1

II.Epidemiology
Esophageal atresia is congenital malformation that occurs in 2500-3000 live
births. Two to three times more common in twins. The incidence of esophageal atresia
in the United States is around one in 4500 births. Finland has a high incidence rate
which is one in 2440 births. 2.4
Esophageal atresia is more common in men than in women. Although some
cases are sporadic, a family history of esophageal atresia has been reported. About 6%
of babies with esophageal depression are twins. Older people who have one baby with
esophageal atresia, the next child is at risk of 0.5-2% having esophageal atresia. If
there is more than one family with esophageal atresia the risk of having the same
abnormality is around 20%. 4

III.Etiology
The association of esophageal atresia with various other congenital
abnormalities, indicates that these lesions occur due to a disturbance in
embryogenesis, the exact cause of which has not been identified. The presence of
organogenesis disorders in early pregnancy can cause simultaneous organ
development, such as heart, musculoskeletal, gastrointestinal and genitourinary. There
is a simultaneous pattern with the occurrence of esophageal atresia called VACTERL
and CHARGE. VACTERL stands for several organ abnormalities, namely the
vertebrae, anorectal malformations, cardiovascular malformations, esophageal atresia,
renal anomalies and limb defects . CHARGE is associated with colobomata, heart
disease, coana atresia, mental retardation, genital hypoplasia and ear
abnormalities. 4,9,10
The etiology of esophageal atresia is multifactorial and remains
unknown. Chromosomal abnormalities such as trisomy 18 and 21, the presence of
infective agents such as vitamin A deficiency and the use of high doses of
contraceptive pills containing progesterone during pregnancy are thought to be the
cause of esophageal atresia. 2,4,7

IV.Pathophysology
The esophagus and trachea originate from primitive foregut. Occurs during the
fourth and fifth week of embryonic development. Separation of tubular structures
occurs in the fourth week of pregnancy and is complete at 34-36 days. Trachea as the
ventral diverticulum of the primitive pharynx is the caudal part of the foregut. The
trachealoesofaeal septum develops in the place where the tracheoesophageal fold is
united. This septum divides the foregut into the ventral part of the laryngotracheal
tube and the dorsal (esophagus). Esophageal atresia occurs when
the tracheal septum deviates posteriorly. This deviation causes incomplete separation
of the esophagus from the laringotracheal tube and produces a tracheoesophageal
fistula simultaneously. 4.8
Esophageal atresia always affects the motility of the esophagus. Peristaltic
disorders usually occur in the esophageal distal segment. Whether motility
abnormality is a primary abnormality due to abnormal innervation such as the
occurrence of neuropeptide distribution abnormalities or secondary consequences of
vagal nerve damage that occurs during surgical repair is unclear. Pressure during
relaxation in the entire esophagus is significantly higher than normal patients and the
pressure on the distal esophageal spincther decreases. 2
In esophageal atresia there is also a tracheal abnormality in the form of
reduced tracheal cartilage and increased transverse muscular length on the posterior
tracheal wall. In advanced conditions can cause tracheomalasia with tracheal collapse
of about 1-2 cm from the fistula. Although some embryological theories have
revealed the process of forming tracheal malformations, not all of them can explain
variations in anatomic anomalies. There is a high incidence of damage to
mesenchymal tissue during the fourth week of pregnancy. 2.4

V.Classification
Differences in anatomical features of esophageal atresia with or without a
fistula trakeoesofagus makes a difference in terms of classification, but one
classification that is widely used and clinically practical is a classification system by
Gross and Vogt that distinguishes atresia the esophagus becomes 5 types as follows :

1. Type A: isolated esophageal atresia. The incidence is around 8% of all cases.

2. Type B: distal esophageal atresia with a connecting fistula the proximal part of the
esophagus with the trachea (tracheoesophageal fistula proximal) with an incidence of
0.8%.
3. Type C: the most common type is around 88.5% - 90% where there is a proximal
esophageal atresia accompanied by a tracheoesophageal fistula in the distal part.
4. Type D: esophageal atresia with a double tracheoesophageal fistula namely di the
proximal and distal part of the esophagus with an incidence rate of 1.4%.
5 . Type E: also called H-type where there is no esophageal atresia but there is a
tracheoesophageal fistula with a nearby incidence 4% of all cases.
6. Type F: Esophageal stenosis

VI.Clinical Presentation
Symptoms that can be seen in the first day after birth in the form of cannot
drink milk, choke or vomit and cannot swallow saliva so that hypersalivation
occurs. If accompanied by a tracheoesophageal fistula proximal (type B) aspiration of
breast milk can occur into the lungs because of all breast milk the baby swallows will
end up in the lungs so that the baby looks tight breath and cyanosis. The presence of
breast milk (food / foreign matter) in the lungs can cause pneumonia. Abdominal
distension can occur if there is a flow air from the trachea to the stomach through the
distal tracheoesophageal fistula (type C and D).Type D esophageal atresia in addition
to the presence of distal tracheoesophageal fistula as well there is a fistula in the
proximal part and is one of the difficult types diagnosed. The clinical symptoms can
be persistent asthma or cough because of aspiration in a few years. However, type D
exists fistulas provide a way for milk and food to reach the stomach through the
fistula proximal to the trachea and through the distal fistula back to the esophagus
and finally to the stomach.
Type E esophageal atresia or also called type H is a difficult type diagnosed
early and can be diagnosed after the baby grows into a child - child or adult. In this
type there is no esophageal atresia so that food can reach the stomach, however, food
can also enter lungs through a fistula. Likewise vice versa the air from the trachea
can enter the stomach through a fistula so that there is air in that amount a lot in the
abdomen and abdominal distension. Other typical symptoms in the form of frequent
choking when eating and drinking, and aspiration pneumonia which over and
over. For this reason, babies with esophageal atresia either with a fistula or do not
have high mortality

VII.Diagnosis
The diagnosis of esophageal atresia should be established as early as possible
to minimize pulmonary complications, can be established both prenatal and
postnatal. Prenatal diagnosis can be done by ultrasound examination of the
mother. The findings of polyhydramnios, reduced infant gut intraluminal fluid and
ketidakmampu a n detect gastric fetus on ultrasound can provide early clues
esophageal atresia.The presence of a pouch sign that appears as an echoic shadow in
the middle of the fetus at the age of 26 weeks of gestation also shows the presence of
esophageal atresia, but in examination it requiresexperience. The value of this
prenatal diagnosis is very low unless a pouch sign and polyhydramnios are found
simultaneously. Polyhydramnios without a pouch sign is a weak indication of
esophageal atresia.Only 1 in 12 patients with polyhydramnios with esophageal
atresia. Likewise, in the absence of gastric air, this can be found in other disorders. 1.10
Postnatal diagnosis of esophageal atresia can be made when there is
difficulty or inability of the nasogastric or orogastric tube to pass through the
esophagus. Normally the gastric cardiac in the baby is 17 cm from the baby's gums,
but in the case of esophageal atresia, the hose stops when entering 10-12 cm
long. Photographs of babygram X-rays show a circular nasogatric tube in the
proximal esophageal sac.To estimate the gap or distance between the esophageal
segments, the nasogastric tube is inserted as much as possible. The distance between
the end of the hose and Karina estimates the gap. If the distance of less than 2-2.5 cm
of the vertebral corpus is something that is advantageous in surgery. 1.4
Thoracic and abdominal radiographs are important to get a proper diagnosis
of esophageal atresia. In addition to evaluating the location of the nasogastric tube, it
can also assess the location of intestinal air distribution, aortic arch, aspiration
pneumonia, congenital heart disease and spinal anomalies. 1.10
Examination with barium is not indicated in establishing a diagnosis of
esophageal atresia because of the high risk of tr acheobronchitis chemical
aspiration 1.4 Cardiology assessment including echocardiography is a routine before
surgery to determine the presence of congenital heart abnormalities. 9
 VIII.Therapy
Infants with esophageal atresia require initial resuscitation. If respiratory
problems occur, the baby needs a ventilator. Babies using a ventilator must be
operated immediately because there is a risk of worsening respiratory problems and
gastric perforation. The surgery is performed less than 8 hours after using a
ventilator. 7
The most important thing for babies with esophageal atresia without a
ventilator is preventing aspiration of pharyngeal secretion and reflux of gastric
contents through a fistula. The first thing to do is periodically suction or aspiration
from the esophageal proximal sac using a low pressure double lumen catheter. Babies
are placed with the head higher to minimize gastric reflux. 7
Before the surgery blood tests are carried out such as complete blood count,
electrolytes, blood glucose, blood clotting and cross match. If a related abnormality
has been identified, then the severity isassessed before the surgery
is performed. Surgery is carried out by general anast esi with the installation of
endotracheal pipes . The purpose of the surgical procedure is to separate the fistula
and close it to the side of the trachea and connect the ends of the esophageal
segments. 9

IX.Management of Anesthesia
Neonates with TEF have a tendency to experience gastric distress and
pneumoperitoneum . Management of anesthesia and surgery will provide the main
function at the pulmonary vent without noventilation from the fistula. The anesthesia
technique used includes conscious tracheal intubation ( awake tracheal intubation )
and avoids the use of muscle relaxants and excessive positive ventilation pressure so
that existing fistulas can be identified and controlled 7.16 . The first step is to do
proximal esophageal suction, then the baby will be given preoxygenation for 3
minutes with spontaneous ventilation.Furthermore, awake intubation was performed
using endotracheal tube 3.0 - 3.5 mm (internal diameter) endotracheal tube with cuff
because cuff can be beneficial for closing the fistula. Assistant is needed to listen to
breath sounds. Intubation is usually done by inserting the endotracheal tube deep into
the right bronchus, then slowly pulling around 0.5-1.0 cm until the sound of the breath
sounds the same , the bevel of the tube hole is also directed anteriorly to avoid
intubation of the fistula .
Prevention of gastric distension can be achieved by the proper placement of
the endotracheal tube, or by making a gastrostomy hole in the preoperative period
with local anesthesia or shortly after induction where this
will reduce gastric pressure 7 .
 The patient will then be positioned lateral decubitus left or right. Breath
sounds should be re-examined to detect endobronchial intubation characterized by
loss of breath sounds in the left lung, cyanosis, bradycardia, and hypotension.
Preoperative preparation of neonates who will undergo surgery includes
stabilizing the general condition of the patient. The administration of preoperative
intravenous fluids must be adequate to prevent dehydration and
hypoglycemia 1,2 . Isotonic fluid ( normal saline ) is the main choice for correcting the
condition of hypovolemia, which is followed by administration of maintenance
fluids containing glucose (5% dextrose in ¼ normal saline ) as much as 5 mL / kgBW
/ hour. Sulfas atropine (0.1 mg / kg) is given before induction to block vagal tone. 6.16
Muscle paralysis is given after the fistula has been identified and ligated.
Inhalation induction is an alternative to conscious intubation. After the neonate is
under anesthesia, intubation can be carried out without muscle paralysis followed by
mild positive pressure ventilation. Narcotics is the choice for analgesic agents, which
are given together with volatile anesthetics for the maintenance of
anesthesia.Desaturation will occur when the surgeon blocks the development of the
lungs in order to attract the distal part of the esophagus for the anastamosis
process. The lungs need to be re-developed to restore saturation to normal values , this
can be done by giving positive end expiratory pressure (PEEP) or occasional positive
pressure ventilation for lung development. 16,17,18
After uncomplicated surgery the baby will be given reverse with neostigmine
methylsulfate ( 0.06 mg / kg) and atropine sulfate (0.2 mg / kg) IV and extubated by
simultaneously making suction in the trachea and esophagus. Patients with
preoperative and perioperative complications during surgery will be subjected to
ventilation ventilation with mechanical ventilation until the res function
function functions normally again. 16,17
CHAPTER II I
CASE REPORT

PRAANESTESIA EVALUATION
Patient Identity
Name : Baby Ni Wayan Sutini
No Medical Record : 17055781
Age : 0 days (28 December 2017 )
Gender : Women
Religion : Hindu
Tribe : Bali
Nationality : Indonesia
Address : Jl. R Tanah Lot Br Beraban Kediri Tabanan
Hospitalized : 2 8 December 201 7 at 8: 09 WITA
Diagnosis : Atresia esophagu s type C + anorectal malformation without fistula
J enis Operations : Th oracotomy + Repair Fistel + Colostomy
Date of operation : 29 December 201 7

1. Anamnesis / heteroanamnesis
Patients complain of froth through the mouth and did not leave
meconium since I was ir. Patients with cesarean birth history for indications of
KPD 13 hours at Kasih Ibu Hospital , immediately criedweakly . After birth
the patient was given breast milk , but immediately vomited. At Kasih
Hospital, the patient had OGT installed but was unable to enter, then the
patient was examined in the form of a Babygram and found to be suspected of
Trakeoesofagal fistula, then the patient was referred to Sanglah General
Hospital. The patient is the second child and the patient's birth weight is 3000
grams . The history of consumption of drugs during pregnancy is denied by
the patient's mother, and the infection during pregnancy is also denied. History
of routine antenatal care in obstetrician and ultrasoundevery month for three
times. At birth, the patient is said to immediately cry weakly and the amniotic
fluid is clear. Current therapy in surgical triage in the form of Dextose IVFD
12.5% 162 ml; nacl 3%12 ml; ca glukonas 3 ml; kcl 3 ml , aminofusin 60
ml; ampicilin 185 mg every 8 hours; amikacin 2 8 mg every 12 hours .

Present Status
Awareness : ATR is weak
Respiration : 45 x / minute
Pulse : 1 5 0 x / minute
Axilla temperature : 37.1 o C
Weight : 3 0 00 grams
Oxygen saturation : 97-98 % room water
Neonatal pain scale: 0

2. Physical status
1. Central nerve system : Normal, the conjunctival ictic
+/+
2. Circulation System : single heart s1 sound without
a murmur
 3. Respiration system : RR 4 8x / min
bronchovesicular without wheezing crackles, subcostal retraction
4. Hematology System : Normal
5. Gastro Intestinal System : BU (+) normal , distention
(-),
6. S ystem urogenital : spontaneous urination
7. Metabolic System : Normal
8. The stem muscle : Warm warm, capillary refill time
under 2 seconds

3. Supporting investigation
1. Hematology (28/12/201 7):
WBC 23.54 x10 3 / µL; HGB 20.68 g / dL; HCT 63.23%; PLT
219 x10 3 µL

2. Physiology of Hemostasis (12/28/2017 ) :

PT 18.1 seconds (10.8 - 14.4); APTT 37.4 seconds ( 24-36 ); INR 1, 5 8

3. Blood chemistry (12/28/2017 ) :

SGOT 152.6 U / L; SGPT 18.5 U / L; alb 4.1 g / dL; BUN 7.2 mg /
dL; Na 134 m mol / L; K 4.89 mmol / L; Cl 96.4 mmol / L; GDS
41 mg / dL.

4. Thorax photo AP (12/28/2018 ) : Suspected

Tracheoesophageal Fistula, Cor and pulmo do not appear abnormalities

5. BOF photos (12/28/2018): BOF photos do not

appear abnormalities

4. Conclusion: ASA 3 Physical Status

PROBLEM:

Actual Problems
- Neonate (1 day)
- VACTREL abnormalities include type C esophageal atresia and anorectal
malformation without fistula
- Leukocytosis (WBC 23.54 x1 0 3 / µL )
 - Transaminitis (SGOT 152,6)
- Length of Hemostasis Length (PPT 18.1; APTT 37.4: INR 1,58)

Potential Problems
- Hemodynamic disorders
- Spasms
- Aspiration
- Bradycardia
- Desaturation
- Hypothermia
- Hypoglycemia

5. PRAANESTESIA PREPARATION
 Informed consent regarding surgery and anesthesia, the risk of
anesthesia and the anesthesia plan that will be carried out and signed a
letter of agreement for the operation and anesthesia
 Physical preparation in the form of fasting continues from the
beginning of the birth
 Preparation for optimizing the general condition of patients in the
room (done by TS pediatrics )
 Preparation of colf blood PRC 2 each 25 mL

6. ANESTHESIA MANAGEMENT
Pre-anesthesia :
Patients were prepared to do general inhalation anesthesia by installing
endotracheal tube airway with preparation of sevoflurane, fentanyl ,
atracurium, tools for preparation of general anesthesia and emergency drugs.
In the preparation room :
At 08.0 0 WITA patients were admitted into the preparatory room in an
ink ubator with a central infusion line that had been installed on
the dextra brachial , infusion smoothing and microburet installation were
carried out, then given Ringerfundin liquid according to the hourly liquid
requirement

At 08 .3 0 WITA the patient is pushed into the operating room

In the operating room :
A patient arrived at the operating room at 08.3 0 WITA and the monitor was
installed, the pulse was 145-155 times per minute, the saturation was
96 %. After all anesthesia and resuscitation and anesthesia and resuscitation
drugs are ready, the patient is given preoxygenation with oxygen 6 liters /
minute. The patient was given premedication in the form of sulfas atrop in 0.1
mg intravenously at 08.4 0 WITA. Do pemberia n co-induction with
fentanyl 3 mcg slowly and induction with sevoflurane while maintaining the
patient's spontaneous breath and occasionally helped with
assisted ventilation.Three minutes k emudian obtained pulse 135 x / min with
97% saturation, do laryngoscopy Intu stale without muscle relaxant drug
administration with an endotracheal tube number 2, 5 without cuff.After
evaluating the development of symmetrical right and left lung , fixation was
carried out and followed by the installation of packing in the supraglottis
area. Maintenance of anesthesia withcompressed water , Oxygen,
sevoflurane . Breath control is done by spontaneous assisted breathing with
the provision of PEEP (positive end expiratory pressure) to prevent lung
collapse. Oxygen fraction is regulated until it reaches the saturation target
above 88%. The position of the patient durante was performed by
operating the left lateral decubitus . The principle principle of preventing
hypothermia is done by blanket warmer and infusion
warmer. Thor akotomi action and ana stomose pkl at 09:40 esophagus. The
operation lasts 3 hours 30 minutes with bleeding (± 5 cc). The duration of the
two operating rays was 89-97 % with an oxygen fraction of 50-8 %. Shortly
after the surgery ended, the patient was positioned supine, the patient
experienced a descent to the lowest number of 84 % even though 80% oxygen
fraction was given, manually ventilated with PEEP, peripheral
saturation treatment increased to 96 % with 60% oxygen fraction. Patients
were not extubated and planned to be taken to the NICU by controlled
ventilation. Maintenance of adequate fluid during surgery with crystalloid
fluid 17 0 ml . Urine production is 0.6 ml / kg /
hour. Postoperative analgesics with fentanyl 4 0mg / 24 hours via pump
syringe and 30 ml metamizole every 8 hours intravenously. patients were
treated after surgery at the NICU. At surgical durante, esophageal
atresia fistula is found in the distal trachea and is carried out end to end
esophageal anastomose.
7. NICU Follow Up

The day I
Therapy Laboratory
Physical status
CNS: DPO
Resp: On ventilator PCAC
FiO2 60% RR 40 Peep 6
SpO2 96 %
KV: Pulse 145 x / minute
GIT: distention -
UG: urine production:
0.3ml / kgbb / hour
Temperature: 38.2
Day II
Physical status
CNS: DPO Dextose IVFD 12.5% 153 AGD: pH 7.42; PO2 117.2;PCO2
Resp: On ventilator PCAC ml; nacl 3%
FiO2 50% RR 40 Peep 6 glukonas 3 ml; kcl 3 ml, 98.4 % ; BEecf -7.0; TCO2 18.3
SpO2 96%
KV: Pulse is 135x / minute
GIT: distention -
UG: urine production: 0.2
ml / kgbb / hour
Temperature: 37.8
Day III
Physical status
CNS: DPO
Resp: On ventilator PCAC
FiO2 40% RR 40 Peep 6
SpO2 95%
KV: Pulse 125x / minute
GIT: distention -
Dextose IVFD 12.5% 162 AGD: pH 7.37; PO2 129.3;PCO2
ml; nacl 3% 12 ml; ca 24.2; HCO3- 1 3.5; SO2C 98 ,
glukonas 3 ml; kcl 3 ml, 6 % ; BEecf -11.8; TCO2 14.3
aminofusin 6 0 ml;ampicilin Chemistry : BUN 30.5; SC 1.3 9
185 mg every 8
hours; amikacin 2 8 mg
every 12 hours ,
Fentanyl 40 mcg / 24
hours;Metamizole 30 mg
IV every 8 hours
Atracurium 1.5 mg
Therapy Laboratory
24 ml; ca 27.7 ; HC O3-17.5; SO2C
aminofusin 9 0 ml;ampicilin
185 mg every 8
hours; amikacin 2 8 mg
every 12 hours ,
Fentanyl 40 mcg / 24
hours;Metamizole 30 mg IV
every 8 hours
Midazolam 2 mg / hour
Albumin 0.6 ml / hour
Therapy Laboratory
Dextose IVFD 12.5% 153 AGD: pH 7.39; PO2 181.2;PCO2
ml; nacl 3% 24 ml; ca 29.3; HCO3-17.4; SO2C
glukonas 3 ml; kcl 3 ml, 99.3%; BEecf - 7.5; TCO2 18.3
aminofusin 120 Chemistry : Procalcitonin
ml;ampicilin 185 mg every 24,25;Alb 1.9; Na 127; K 5.01; Cl
8 hours; amikacin 2 8 mg 98.8;Ca 7.1 ; Alb 2.7
UG: urine production: 0.2 every 12 hours , DL: WBC 15.37; HB 11.09;HCT
ml / kgbb / hour Fentanyl 40 mcg / 24 3 4 , 31; PLT 10.76
Temperature: 38.3 hours;Metamizole 30 mg IV
every 8 hours
Midazolam 2 mg / hour
Albumin 0.6 ml / hour

Day IV
Therapy Laboratory
Physical status
CNS: DPO Dextose IVFD 12.5% 107 AGD: pH 7.31; PO2 126; PCO2
Resp: On ventilator PCAC ml; nacl 3% 24 ml; ca 38.4; HCO3-19.00; SO2C
FiO2 30% RR 40 Peep 6 glukonas 3 ml; kcl 3 ml, 98.3% ; BEecf - 7.2; TCO2 20.20
SpO2 95% aminofusin 120
KV: Pulse is 140x / minute ml;ampicilin 185 mg every
GIT: distention - 8 hours; amikacin 2 8 mg
UG: urine production: 0.2 every 12 hours ,
ml / kgbb / hour Fentanyl 40 mcg / 24
Temperature: 37.7 hours;Metamizole 30 mg IV
every 8
Midazolam 2 mg / hour
Albumin 0.6 ml / hour

Day V
Therapy Laboratory
Physical status
CNS: DPO Dextose IVFD 12.5% 147 AGD: pH 7.35 ; PO2 159.2;PCO2
Resp: On ventilator PCAC ml; nacl 3% 12 ml; ca 32.6; HCO3-17.6; SO2C
FiO2 30% RR 40 Peep 6 glukonas 3 ml; kcl 3 ml, 99.0 % ; BEecf - 8.0; TCO2 18.6
SpO2 95% aminofusin 120 Chemistry: Alb 2.2
KV: Pulse is 135x / minute ml;ampicilin 185 mg every
GIT: distention - 8 hours; amikacin 28 mg
UG: urine production: 0.3 every 12
ml / kgbb / hour Fentanyl 40 mcg /
Temperature: 37.9 24 hours;Metamizole 30 mg
IV every 8
Midazolam 2 mg / hour
Albumin 0.6 ml / hour
 Day VI
Therapy
Physical status
CNS: DPO Dextose IVFD 12.5% 138
Resp: On ventilator PC AC ml; nacl 3% 16 ml; ca
FiO2 30% RR 40 Peep 6 glukonas 3 ml; kcl 3
SpO2 96 % ml ;cefoperazone sulbactam
KV: Pulse is 14 5x / minute 185 mg every 8 17.91; PLT 13,17
GIT: distention - hours ; amikacin 28 mg
UG: urine production: 0.3 every 12
ml / kgbb / hour Fentanyl 40 mcg / 24
Temperature: 38 , 1 hours;Metamizole 30 mg IV
every 8
Midazolam 1 mg / hour
Albumin 0.6 ml / hour
Transfuse PRC 3x15 ml
Transusi 2x25 ml TC
Day VII
Therapy
Physical status
CNS: DPO Dextose IVFD 12.5% 138
Resp: On ventilator PCAC ml; nacl 3% 16 ml; ca
FiO2 30% RR 40 Peep glukonas 3 ml; kcl 3
6SpO2 95 % ml;cefoperazone sulbactam
KV: Pulse is 135 x / minute 185 mg every 8 90.5; Total cholesterol 35; HDL
GIT: distention - hours; amikacin 28 mg
UG: urine production: every 12
0.2ml / kgbb / hour Fentanyl 40 mcg / 24
Temperature: 38, 3 hours;Metamizole 30 mg IV
every 8
Albumin 0.6 ml / hour
Transfuse PRC 3x15 ml
Transusi TC 2x30 ml
Day VIII
Therapy
Laboratory
AGD: pH 6.84; PO2 55.90;PCO2
32.7; HCO3-5,4; SO2C
62.9 % ; BEecf -28.4; TCO2 6.4
DL: WBC 19.17; HB 6.61; HCT
Chemistry: bilirubin 18, 6 7;direct
bilirubin 15,61; indirect bilirubin
3.06; BUN 6 1.0; SC 0,9 9 ; Na
124; K 4.59; Cl 94,1;Alb
2,4; Procalcitonin 55.6
Physiology of hemostasis: PT
20.2; APTT 46.2; INR 1.8
Laboratory
AGD: pH 7.28; PO2 140.7;PCO2
33.5; HCO3-15.5; SO2C
98.5 % ; BEecf - 11.2; TCO2 16.6
Chemistry : Na 122; K 8.35; Cl
4; LDL 3; TG 61; Ca 8.6; GDS
10
DL: WBC 58.45; HB 6.16; HCT
18.05; PLT 14,57
Physiology of hemostasis: PT
45,9; APTT 6 4.7; INR 5 , 03
Laboratory
 Physical status
CNS: DPO Dextose IVFD 12.5% 138 AGD: pH 7, 1 5; PO2 56.4;PCO2
Resp: On ventilator PCAC ml; nacl 3% 16 ml; ca 37.8; HCO3-13.00; SO2C
FiO2 50% RR 40 Peep 6 glukonas 3 ml; kcl 3 81.0 % ; BEecf - 15.80; TCO2
SpO2 94% ml;cefoperazone sulbactam 14.2
KV: Pulse 120x / minute 185 mg every 8
GIT: distention - hours; amikacin 28 mg
UG: urine production: 0.15 every 12
ml / kgbb / hour Fentanyl 40 mcg / 24
Temperature: 38.7 hours;Metamizole 30 mg IV
every 8
Albumin 0.6 ml / hour
Transfuse PRC 3x15 ml
Transusi TC 2x30 ml

Day IX :
At 09.00 WITA patients were found in 50% desaturation and 40x /
minute bradycardia , 30 minutes of resuscitation were performed but the patient died
at 09.3 WITA.
 CHAPTER IV
DISCUSSION

Atresia is defined as a congenital disorder in the form of no normal opening of

a channel in the body. The fistula means an abnormal relationship between
two epithelial structures in the body. Atresia of the esophagus and the
esofageal tracheal fistula are congenital abnormalities characterized by incomplete
formation of the esophageal tubule or abnormal connections between the esophagus
and trachea.
Radiological examination has an important role in diagnosing esophageal
atresia, confirms esophageal atresia with a fistula or without a fistula and diagnoses
other anomalies associated with VACTERL. The first examination performed was a
chest rongent in AP and lateral projections and rongent of abdomen in AP projection
or a babygram. It is certain that the neck and trachea appear clear. The esophageal
proximal bag appears to be filled with air or secretion that appears as a posterior
tracheal mass, curved in the anterior trachea. If there is a connection between the
trachea and esophagus, the stomach will be filled with air. If there is no connection,
the intestine will be not filled with air. Five percent of infants with esophageal atresia
have other abnormalities involving the heart, the intestinal system, the vertebrae
which can also be seen in plain photo examinations.
In this case 0 day old baby with suspected esophageal atresia with proximal
and distal fistula. Saliva bubble flow through the mouth and the patient did not
excrete meconium since birth. Patients with cesarean birth history because of early
rupture of membrane at Kasih Ibu Hospital , immediately cried weakly . After birth
the patient was given breast milk , but immediately vomited. At Kasih Hospital the
patient had OGT installed but was unable to enter, then the patient was examined for
a babygram and it was found that the tracheoesophagal fistula was suspected .
Determining possible classification of esophageal atresia is type A, type B,
type C and type D. Type E can be excluded because in this type the nasogastric tube
can pass through the esophagus and be in the stomach. In type F the hose may still
pass stenosis to gastric. The tip of the nasogastric tube which is good at assessing
esophageal atresia is the tip in a circular position. Then the value of air in the stomach
is assessed. but in clinical peripheral saturation obtained in room air is 94-96%, so the
type of esophageal atresia is probably the C-type and D-type.
Type C esophageal atresia is the most frequent occurrence compared to other
types. Plain image will appear that the nasogastric tube cannot enter the stomach and
it appears that the stomach is filled with air. There is no picture of aspiration
pneumonia. Analyzing plain photographs can determine the type of esophageal atresia
correctly. In this case the projections obtained nasogastric tube as high as 3rd
Thoracal this case in accordance with the types of possible esophageal atresia type C
or type D but because of thoracic picture no picture of aspiration pneumonia but
clinical symptoms of distress indicate their uncertain breath then type C or D .
Some difficulties found during anesthesia management include ineffective
ventilation because the endotracheal tube is placed in the fistula, gastric dilatation,
comorbid other congenital diseases, especially the heart and previous pulmonary
aspiration. Management of anesthesia focuses on pulmonary ventilation without
fistula ventilation. The principle of ventilation in these patients is to provide a slightly
higher respiratory frequency with a smaller tidal volume. This is so that a minute of
ventilation is achieved as needed without giving excessive pressure so that it does not
obstruct the view of the operator's operation. This technique includes tracheal
intubation and avoids muscle paralysis and excessive positive ventilation until the
fistula is corrected as is done in these patients. In this patient the patient is given a
100% oxygen mask while maintaining spontaneous breathing and positive pressure
ventilation is given a minimum because the distension of the nose will aggravate both
compression and contralateral compression . Intubation is done n without giving
muscle relaxant. the patient is induced with sevoflurane until hypnosis then before
induction the patient has been remedied with sulfas atropine to suppress the vagal
response. Induction of anesthesia in these patients was carried out with sevoflurane
inhalation anesthetic at a concentration of 2.5% according to the concentration dose of
infant patients . Induction in pediatric patients is better to use an inhalation agent due
to a minute of high ventilation so that the distribution of the drug will be better and
the clearance is fast because it is through the diffusion process in the
lungs. Sevoflurane is chosen because it does not stimulate increased production of
respiratory tract secretions, so it does not increase the likelihood of aspiration in these
patients.
Breath control is maintained until the target saturation of blood money as
94 % in these patients saturation targeted saturation above 88% due to the saturation
of capital 94 - 96 % room air may have occurred in patients with aspiration
pneumonia. Giving intravenous fluids should be given a liquid containing glucose, but
in this patient crystalloid is given by considering crystalloid is the main fluid for
resuscitation in surgical durante, especially in operations with large insensible water
loss, namely gastrointestinal . . 1.6 This operation is performed by positioning the left
lateral decubitus via a thoracotomy in the right fourth rib gap. The time needed for
surgery is approximately 2-4 hours with an estimated bleeding of 10 ml / kg. Post-
surgery patients will be treated in intensive neonatal care .
 Hypothermia will increase oxygen consumption, so the ambient temperature is
warmed to 30 -40 centigrade because neonates are very at risk of hypothermia. Pain
can also increase oxygen consumption, the management of these patients is correct by
providing blanket warmer, infusion warmer and installing a temperature monitor. For
the treatment of pain, choose the use of fentanyl opioids to reduce sympathetic
stimulation. Fentanyl is the preferred analgesic opioid because fentanyl does not
reduce blood flow to the liver or reduce oxygen supply if given at moderate doses.
During lung surgery it will be retracted to facilitate the operating field of view.
This causes desaturation especially if the dependent lung has less optimal function. If
the patient does not tolerate operator manipulation, a temporary cessation of surgery
is needed to restore ventilation and oxygenation. In these patients, desaturation occurs
when the patient is positioned supine, this can occur because of atelectasis in the
dependent lung, this can be anticipated by giving PEEP to patients.
Monitors such as electrocardiogram, oxygen saturation, end tidal CO2 and
temperature must be installed. The precordial stethoscope is placed on the left
to monitor and monitor breath sounds and there is a possibility that the trachea tube is
displaced during surgery. In cases where the bronchoscopy is not done, another
method of tracheal pipe confirmation can be used after induction of right mainstream
intubation and then slowly withdrawing the tracheal tube until the breath sounds are
heard on the left side, this technique is done in patients. In patients with fistulas, cuff
pipes have the advantage of closing the fistula, but in this case due to the limitations
of the tool, it is not done. The bevel hole of the pipe remains directed to the anterior
side to avoid intubation of the fistula.
In post surgery, consideration for extubation must be carefully considered. In
patients with extubation about 30% will experience reintubation to clear secretions,
and tracheomalacia which can cause airway obstruction. In these patients the
ventilation control was chosen in advance considering the possibility of previous
aspiration pneumonia due to capital saturation of the water room below 95%. This is
also done to avoid and secure the airway in the event of complications such as
alasia tracheoma and anastomotic leakage.

CHAPTER V
CONCLUSION

A baby boy, 0 day old came to the hospital with discharge from the mouth and
no history of meconium excretion since birth. Patients with cesarean birth history for
premature rupture of membrane indication (13 hours) at Kasih Ibu Hospital and he
cried weakly immediately after delivery. After birth the patient was given breast
milk , but immediately vomited. At Kasih Hospital the patient had OGT installed but
was unable to enter, then the patient was examined for a babygram and found to be
suspected of tracheoesophagal fistula . The patient is diagnosed with esophageal
atresia with distal and proximal fistulas. Correction of the anastomose in this patient
is a big challenge for an anesthesiologist. Good management of anesthesia using non-
apnea sleep techniques without muscle relaxants and maintaining spontaneous
breathing with assisted ventilation can be an option in this case. Operation was going
smoothly with stable hemodynamic durante surgery.
Patient died after day 9 of care because of pneumonia which got
worse. Treating pneumonia in neonates requires a comprehensive neonatal
intensive care capability, in which there must be collaboration between the Pediatric
Anesthesist with Intencivist Pediatrician and Pediatric Surgeon so that patients with
critical post- end to end esophageal anastomoses can survive given Based on spitz
classification to determine continuity of live based on birth weight and cardiovascular
abnormalities in Group 1 if birth weight > 1500 grams without cardiovascular
abnormalities the mortality rate is only 3%.