P022: WHERE DID THAT AIR COME FROM? AN UNUSUAL CASE OF TRACHEOESOPHAGEAL FISTULA IN A NEONATE
Sayoni Saha, MD, MPH; Tyler Ray, MD; Karisa Walker, MD, MEd
University of Florida
Introduction/Background: Anesthetic management of a neonate with tracheoesophageal fistula (TEF) is particularly challenging due to the risk for ventilation through the fistula and gastric insufflation (Taneja & Saxena, 2014). A common approach involves maintaining spontaneous ventilation and careful visualization of fistula anatomy using a bronchoscope and placement of the ETT tip beyond the fistula. (Hozki et al., 1992). In this case a premature neonate with no prenatal diagnoses was delivered spontaneously at 34 weeks due to premature rupture of membranes. Shortly after birth, severe respiratory distress was noted. Attempts to pass suction into the child’s stomach were unsuccessful and met with resistance. The patient developed worsening respiratory distress and was intubated with a 3.0 uncuffed ETT and kept spontaneously ventilating. Given concerns for TEF and possible gastric perforation the patient was scheduled for surgery.
Methods: The patient arrived to the OR spontaneously ventilating via ETT and intravenous sedation was initiated with the surgical team at the bedside. Localization of the fistula was attempted using a 2.4 flexible bronchoscope passed via the ETT, however the fistula was unable to be visualized. On first attempt the bronchoscope was occluded by secretions and suctioned while spontaneous ventilation was maintained. On second attempt, the ETT was removed and a C-MAC Miller 1 blade and fiberoptic scope were used together to visualize the airway and advance an ETT. The ETT was visualized advancing through glottis; however, ventilation became acutely impossible. At this time the ETT was removed, and low-pressure CPAP was applied. The patient returned to spontaneous ventilation without evidence of bronchospasm or laryngospasm. At this time the patient’s abdomen was noted to be increasingly distended and ventilation became difficult. The decision was made with the surgical team to decompress the peritoneum. The skin was prepped in a sterile fashion and a 24g angiocath was placed through the abdominal wall perpendicularly into the peritoneal cavity through a point just below the right costal margin in mid-clavicular line. Air was aspirated from the peritoneum. Following decompression, a C-MAC Miller 1 was utilized to place a 3.0 cuffed ETT and maintain in position at 7 cm. Anesthesia was then induced via inhalational technique and spontaneous ventilation was maintained until the TEF was occluded.
Results and Conclusions: This case represents an unexpected case of non-prenatally diagnosed TEF, presenting with gastric rupture leading to pneumoperitoneum, which is a grave neonatal surgical emergency. Our initial plan, which would have allowed our team to take over the patient’s ventilation, was not successful and prompted deterioration of the patient’s clinical condition. Decompression of the peritoneum became acutely necessary. Our case illustrates the technique for, and utility of timely needle decompression in the setting of pneumoperitoneum. Although not optimal to conduct an exploratory laparotomy with spontaneous ventilation, this was the safest option for this neonate.