Tracheoesophageal Fistula Repair (Neonate)
Patient phenotype
Neonate, often premature, day 1-3 of life. VACTERL association (Vertebral, Anal, Cardiac, TE, Renal, Limb) common. May have other anomalies including cardiac (workup mandatory before OR).
Procedure
Right thoracotomy or thoracoscopic. Most common type (Gross C, ~85%): proximal esophageal pouch + distal TEF. Surgeon ligates fistula + creates esophageal anastomosis. 2-4 hours. Lateral position.
Anesthetic plan
GETA. Awake or asleep intubation depending on anatomy. ETT positioned distal to fistula (above carina) — confirm with auscultation + bronchoscopy. OG suction in upper pouch (Replogle tube). Avoid bag-mask ventilation pre-intubation (gastric distension via fistula).
Setup
- ·Neonatal circuit, warmed humidified
- ·Microcuff ETT (or uncuffed) sized 3.0-3.5
- ·Bronchoscope (1.8 mm) for ETT positioning
- ·Replogle tube to upper pouch on continuous suction
- ·PIV (umbilical or peripheral)
- ·A-line if hemodynamically unstable
- ·Warmer + fluid warmer (small volumes)
- ·Echo report reviewed (cardiac anomaly)
Biggest concerns by phase
VACTERL workup — especially cardiac
Echo MANDATORY before OR (~25% have CHD; some lethal). Renal US, spine x-ray, anal exam. CHD changes anesthetic plan dramatically (ductal-dependent lesions, etc.).
Avoid positive pressure ventilation pre-intubation
Bag-mask → air through fistula → gastric distension → diaphragmatic splinting + aspiration. Spontaneous ventilation maintained until ETT past fistula. Gentle inhalational induction OR awake intubation.
ETT position — distal to fistula, proximal to carina
Goal: tip in distal trachea but above bifurcation, beyond fistula opening. Bronchoscopy confirms. May need to mainstem then withdraw to optimal position.
OLV in tiny patient
Surgical retraction + insufflation = effective single-lung ventilation. Hypoxia common. Permissive hypercapnia. Communicate with surgeon for re-expansion.
Hypothermia + hypoglycemia
Neonate physiology: huge surface area, low glucose stores. Maintain temp 36.5-37.5, glucose 60-100. Warmed everything.
Postop ventilation
Most stay intubated 24-48h on NICU vent. Avoid neck flexion (anastomosis tension). Sometimes anchored chin-to-chest with tape.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Day-old, 2.4 kg neonate, prenatal polyhydramnios, abdominal x-ray no air in stomach, NG can't pass beyond 10 cm. Echo shows VSD (small, hemodynamically insignificant). TEF repair planned. Plan for induction?
What an examiner probes for
- ▹Maintain spontaneous ventilation until ETT past fistula
- ▹Bronchoscopy confirmation of ETT position
- ▹Replogle tube to upper pouch
- ▹Avoids high-pressure mask vent
- ▹Plans postop intubation + ventilation
Sources
- Coté Peds Anesthesia 6e Ch 22
- Smith's Anesthesia Infants/Children
Anatomy reference
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