revistachilenadeanestesia.

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Rev Chil Anest 2020; 49: 277-280

DOI: 10.25237 / revchilanestv49n02.13 Clinical case

Clinical case: anesthetic management in correction of

esophageal atresia in newborn

Clinical report: anesthetic management in correction of esophageal

atresia in a newborn
Daniel Rivera MD. one, Juan Parra MD. one, Danny Rodríguez MD. one

AbStrACt

Esophageal atresia (AE), with or without tracheoesophageal fistula (FTE), is a congenital Key words:
pathology that has a frequency of 1: 2,500 - 4,500 live births. It has been reported that Up to 11% of Esophageal atresia, newborn,
all cases are voluntarily terminated in the prenatal period, a 2% die in utero and 87% end up in anasthetic managment
viable live births. There is a predominance for male sex, week 38 being the most frequent
gestational age of documentation. The purpose of the clinical case described below is to highlight
the plan A successful anesthetic that was successfully in a fourth level university hospital, in a
full-term newborn with AE and FTE, taking into account the pre, intra and postoperative
recommendations.

summary

Esophageal atresia (AE), with or without tracheoesophageal fistula (FTE), is a congenital Keywords:
pathology that has a frequency of 1: 2,500 - 4,500 live births. It has been reported that up to Esophageal atresia,
11% of all cases end voluntarily in the prenatal period, 2% die in utero, and 87% end in viable newborn, anesthetic
live births. There is a predominance of the male sex, with week 38 being the most frequent management
gestational age for documentation. The purpose of the clinical case described below is to
highlight the plan. A successful anesthetic that was successful in a fourth level university
hospital, in a term newborn with EA and FTE, taking into account pre, intra and postoperative
recommendations.

one Hernando Moncaleano Perdomo University Hospital, Colombia.

Entry date: August 19, 2019 Acceptance date: September

22, 2019

OrCId
https://orcid.org/0000-0002-5221-1024

Correspondence:
Email: juansparra@gmail.com

277
 atresia - D. Rivera et al.

Introduction Lithos and the transthoracic echocardiogram did not suggest additional
associated congenital pathologies.
He is assessed by anesthesiology who considers that he can

L esophageal (FTE), is a congenital pathology that has a

frequency of 1:atresia
esophageal 2,500(AE),
- 4,500 live
with or birthstracheal
without [1]. It has been reported
fistula-
that up to 11% of all cases are terminated voluntarily in the
prenatal period, 2% die in utero and 87% end in viable live births.
There is a predominance of males, with week 38 being the most
frequent gestational age for documentation [2].
The most frequent form by Gross classification is type C in
86% of cases (AE + distal FTE). It is relevant that up to 60% of
cases have a congenital anomaly associated. Approximately
50% of patients may have VACTERL associated (vertebral
anomalies, anal atresia, tracheoesophageal fistula, radial,
cardiovascular, renal or extremity anomalies), additional studies
are imperative since they can modify both the anesthetic and
surgical plans in these patients.
be taken to correction of esophageal atresia and
tracheoesophageal fistula by thoracotomy (high surgical risk),
emphasizing the need to perform fiberoptic bronchoscopy
preoperatively, to define a definitive approach to the airway
according to level. of the FTE.
The neonate was transferred to surgery rooms, confirming
peripheral access with yelco # 24 in the functional left upper limb.
After basic monitoring (non-invasive blood pressure, oxygen
saturation, electrocardiogram, and temperature), inhalation induction
is done with sevorane. Under an adequate anesthetic plane and
spontaneous ventilation (supported by a facial mask), a fiberoptic
tracheoesophageal
bronchoscope (by fistula
mouth(C). Anesthetic
adapter) was management of esophageal
performed, showing the
presence of a posterior carinal tracheoesophageal fistula (Figure 1).
Admission to the gastric cavity is confirmed when the fiberoptic
bronchoscope is advanced by fistula light.

Confirmed bronchial lumens, fogarty catheter # 3 is advanced

The purpose of the clinical case that is presented below is to
highlight the successful anesthetic plan that was developed in a
fourth level care university hospital, in a full-term newborn with
AE and FTE, taking into account the pre-recommendations, intra
and postoperative.
through the vocal cords by direct laryngoscopy with straight blade #
00 (Cormack II). Adequate pulmonary isolation is confirmed by
fiberoptic bronchoscopy, a total fogarty catheter sleeve is insufflated
with 2.5 cm in the right source bronchus. After administration of
bolus of propofol (3 mg / kg), remifentanil (2 mcg / kg) and
rocuronium (0.6 mg / kg), a new laryngoscopy was performed,
advancing the orotracheal tube.

Clinical case

Male patient, without significant prenatal history, fruit of a

source bronchus (B), and lumen of the posterior carinal
37.3-week gestation by a 32-year-old mother, born by caesarean
section for polyhydramnios. Spontaneous neonatal adaptation,
APGAR 8-9-10 / 10, who during an esophageal permeability test
shows an impossibility of passing the orogastric tube considering
the high probability of esophageal atresia.

He was transferred to the Neonatal Intensive Care Unit for

continuous monitoring, where he started parenteral nutrition,
management of oral secretions with a double lumen probe with
irrigation and continuous aspiration, and multidisciplinary
management. Chest radiography showed the presence of the
orogastric tube at the T2-T3 level, in addition to air in the gastric
chamber, which is why, due to pulmonology, the presence of
tracheoesophageal fistula was considered. A diagnosis of
esophageal atresia is confirmed by pediatric surgery, indicating
the need for congenital defect correction by thoracotomy with
right lung isolation. Blood count, kidney function, electro-
Figure 1. Fiberoptic visualization of the left source bronchus (A), right

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Anesthetic management of esophageal atresia - D. Rivera et al.

# 3.0 with the balloon, fixing it at 8 cm after confirmation of capnography
and symmetric auscultation.
The patient is positioned in left lateral decubitus together
with the surgical team, protecting the pressure points and the
areas of decline. After asepsis and antisepsis, ultrasound-guided
blocking of the spinal erector was performed at the T5 level with
a 50-mm blocking needle, administering a total volume of 3 ml (1
ml of 0.5% bupivacaine).
+ 1 ml of 1% lidocaine with epinephrine + 1 ml of 0.9% saline)
without complications.
Balanced anesthetic maintenance with remifentanil is given
on average at 0.2 mcg / kg / min and sevorane maintaining
MAC> 0.6. Protective ventilation was maintained during lung
isolation (CV 4-6 ml / kg, FR> 25 rpm and permissive
hypercapnia) without ventilatory problems being documented
during the procedure. Analgesic support was given with ketamine
(0.25 mg / kg), dipyrone (50 mg / kg) and dexamethasone (0.15
mg / kg). Effective lung isolation with an adequate surgical field
was expressed by the surgical team. The surgical time was
approximately 2 hours and 30 minutes.
clinicians suggesting pain. The patient is discharged 48 hours
after the surgical procedure.
Discussion
It is essential to bear in mind that the approach of patients
with confirmed AE requires a multimodal approach in the pre,
intra and postoperative period (Table 1).
Among the preoperative recommendations, once AE is
suspected (newborns with polyhydramnios, no possibility of
passing an orogastric tube, absence of gastric bubble on prenatal
ultrasound) [3], the patient should be transferred to the Intensive
Care Unit. The priority will be to ensure venous access to initiate
maintenance parenteral fluids, ensure euvolemia and
normoglycemia. Adequate management of oral secretions should
be done since choking, respiratory distress and
bronchoaspiration can develop rapidly. Spontaneous ventilation
should be maintained whenever possible, given the risk of gastric
insufflation with non-invasive ventilatory support systems with
CPAP.

After the procedure, neuromuscular relaxation is reversed

with sugammadex at a dose of 2 mg / kg. The fogarty catheter was
removed and the patient was extuted after verifying adequate
ventilatory mechanics and level of alertness. She was transferred
to the Intensive Care Unit with a nasal cannula, without sig-
Among the complementary studies is the rea-

Table 1. Anesthetic Considerations for Pre, Intra, and Postoperative Management.

Preoperative anesthetic

considerations
Ensure venous access
Management of oral secretions (irrigation / aspiration system: replogle probe Admission to the
Neonatal Intensive Care Unit Non-invasive ventilatory assistance? (CPAP) → high risk of gastric
insufflation Prone and Trendelemburg to mitigate risk of bronchoaspiration Rule out associated
congenital anomalies (VACTERL and CHARGE)

Transthoracic echocardiogram, chest radiography, routine blood tests: complete blood count, kidney function, clotting times, electrolytes

Intraoperative
Fiberoptic bronchoscopy → assess FTE anatomy
Lung isolation technique: according to availability in each institution Multimodal analgesia → NSAIDs; opioids,
ketamine, regional blocks, and epidural analgesia

Postoperative ( thoracotomy)
Analgesia. Especially important for thoracostomies or drainage tubes. Mechanical ventilation? → weak evidence in protection of anastomosis. Early
extubation is preferred. VMNI alternative not studied

Fluid balance. Maintain euvolemia. Surveillance with urinary output (1 ml / kg / h), heart rate, MAP and paraclinical examinations

Early parenteral nutrition

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 Anesthetic management of esophageal atresia - D. Rivera et al.

The use of a transthoracic echocardiogram, which will rule out
the presence of congenital heart defects or a right aortic arch that
will define the surgical approach. Chest radiography will expose
the presence or not of a gastric bubble, which would confirm the
presence of FTE, which is essential in the approach to the
airway. Routine blood tests, aimed at ruling out associated
congenital pathologies, include a complete blood count, clotting
times, complete blood chemistry and blood group, predicting that
the procedure has a high risk of bleeding [1].
be aimed at personal experience. In our case, an erector spinal
block was chosen, considering that there are more and more
successful reports with this analgesic technique in neonates
brought to thoracotomy [7].
There are certain recommendations for the postoperative
management of patients undergoing thoracotomy corrections,
however, they depart from the purpose of this report (Table 1).

Among the intraoperative recommendations, the priority is to
perform a fiberoptic bronchoscopy since the presence of a
pericanial FTE alerts the anesthesiologist of possible ventilatory
difficulties during the procedure [5]. Likewise, assistance with
fiberoptic bronchoscopy for the location of devices for lung
isolation gains special importance [6].
Regarding analgesic strategies, management should be
directed towards a multimodal strategy: NSAIDs, opioids,
ketamine, regional blocks, and epidural analgesia. The analgesia
strategy should
Conclusions
We present the case of a neonate undergoing correction for
AE + FTE, taking into account the anesthetic plan for airway
management, pulmonary isolation, and the postoperative
analgesic plan. The frequency of EC is not negligible and can
occur in the professional practice of any general anesthesiologist
who works in a fourth-level hospital like ours. Hence the
importance of knowing the recommendations and the available
evidence, although scarce, of the approach of these patients.

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