Anesthesia management of esophagotracheal fistula (below)

Click on the blue text to follow our review of the case mentioned in the previous article before reading this chapter under anesthesia management of esophagotracheal fistula
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Note: Retention of spontaneous breathing before the ligation of the fistula, the purpose of retaining spontaneous breathing: theoretically, the negative pressure in the thoracic cavity makes it easier for air to enter the lungs rather than ventilate the fistula
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Xin Zhong et al reported 18 cases of neonatal esophageal atresia and tracheoesophageal fistula perioperative clinical data review of one-lung ventilation, including 11 males and 7 females
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Age 6 hours ~ 10 days, weight 1380 ~ 3100g
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American Society of Anesthesiologists (ASA) grade II in 13 cases and grade III in 5 cases
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16 cases had different degrees of pulmonary infection, 8 cases were premature immature infants or low birth weight infants (<2500g), and 2 cases were accompanied by other malformations
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Intratracheal intubation with combined intravenous inhalation anesthesia and the method of retaining spontaneous breathing before fistula ligation did not cause severe respiratory depression and avoided the occurrence of reflux aspiration
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The method of preserving spontaneous breathing has been described in detail in the previous article
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The next part emphasizes the details
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Before the operation, the patient is routinely brought into the room with a gastric tube to suction gastric juice, hoping to improve lung compliance
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Emphasize the importance of preoperative fiberoptic bronchoscopy: 1.
Observe the location and size of the fistula, and determine the difficulty of anesthesia and the anesthesia plan
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2.
It may be overlooked and missed before operation, whether there are multiple fistulas, and the missed fistulas are not ligated, which affects the prognosis
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3.
Whether combined with tracheal dysplasia or abnormal bronchial morphology
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Such as softening of the trachea, softening of the larynx
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Make better predictions and decisions about surgical options and extubation time
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4.
If conditions permit for older children, after changing the body position, determine whether the catheter is in the correct position between the fistula and the carina
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However, the fiberoptic bronchoscope is directly too large.
The smallest 2.
8mm fiberoptic bronchoscope in our hospital cannot pass through a 3.
5-inch ordinary balloon catheter.
Neonates, especially those born prematurely, cannot receive a tracheal catheter and a fiberoptic bronchoscope in the airway at the same time
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This is where auscultation becomes important
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In this case, the fistula was 8.
8 mm away from the carina.
Considering that the fistula was close to the carina, it was difficult for the tracheal tube to get stuck in the fistula and carina.
One-lung ventilation was considered first
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Choose 3.
0 ordinary tracheal tube without cuff, and try to insert it into the left side of the child by auscultation and changing the position of the child
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After three unsuccessful attempts, the anesthesia method was changed
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Although this patient failed single-lung ventilation, there are some tips for collecting successful cases of single-lung insertion in the past to share
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Or friends who have a better plan can also recommend learning it
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Left insertion skills: preoperative CT evaluation, the angular position relationship between the left bronchus and the carina, and the diameter of the left main bronchus are helpful for predicting the success rate of single lung insertion
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1.
Thermoforming
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A guide wire can be used to shape the left tube like a double-lumen catheter, and then soaked in hot saline for a few minutes
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This maintenance time is limited
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Seek rapid intubation success
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2.
Adjust the slope to the left
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3.
The patient is in the right lateral decubitus position with pressure on the thorax
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In this case, a single lung failed and the catheter was retracted into the main airway
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Retention is maintained by inhalation, considering that the depth of anesthesia is easy to control
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With the change of surgical stimulation, the depth of anesthesia is deepened at this time, the circulation is inhibited, and an appropriate amount of vasoactive drugs is administered
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The deepening of anesthesia will also lead to insufficient ventilation, and it is difficult to maintain spontaneous breathing
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At this time, it can be appropriately assisted ventilation, pay attention to control the gas pressure, and frequent assisted ventilation can easily lose spontaneous breathing
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Ligate the fistula as soon as possible
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After the fistula is ligated, muscle relaxation and positive pressure ventilation can be administered
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After the operation, the patient was sent to the NICU with a tube for further treatment
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 Other concerns are the concerns of general anesthesia for neonates and premature infants: 1.
Premature infants or low birth weight infants are prone to hypoglycemia or hypocalcemia.
Before and during surgery, frequent inspections are needed to correct them in time
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2.
Keep your body temperature warm
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A heated warm mattress, heated and humidified breathing circuit and heated veins and warm flush water will help prevent heat loss
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3.
The catheter is fixed, because the body position is changed also to see and confirm the correct position
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4.
Neonatal blood transfusion needs, fluid management,
etc.

 Reference books: Gregory's Pediatric Anesthesia Selected Typical Cases of Pediatric Surgery Anesthesia Editor-in-Chief: Zhang Jianmin (Courtesy: Wu Yajun Typesetting: Rou Rou) Scan the code to get the treasure