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ESOPHAGEAL ATRESIA

Identity

Name : Ahmad jaya


age : 17 days
sex : boy
Anamnesa

17 days old boy, with 9 days Post Gastrotomy


Boy was delivered by hermina hospital after been
treated for 8 days. Patien was admitted in the NICU for 6
days, with complain frequent vomit after oral feeding and
lot of saliva.
Boy was term infant born from 20 yo mother, P3A0,
spontaneous birth assissted by midwife, immediately
cried, birth weight 2900 gr, Apgar score 8/9
There is no other coexingting abnormalities
Physical examination

GC : crying, active
HR 152 x/mnt,RR:48 x/mnt,suhu: 37.2C
BB : 3300 Gram
Head : anemis(-),ikterik (-), suction reflex
(+), nostril breathing (-),
salivasi(+). OGT was attached.
Neck : lymph nodes enlargement (-)
Chest : Simetris, subcostal retraction (-).
Heart : I-II Heart sound, murmur (-).gallop (-)
Lung : Sonor+/+,vesikuler +/+,slem -/-
ronki -/-, Wheezing -/-
Abdomen : distension (-), peristaltic(+), surgical
wound covered by verband, abdominal catheter attached
draining out brownish-yellow fluid

Anus : (+)

Ekstremity: warm, perfusion normal, adequate beat


PEMERIKSAAN PENUNJANG

Plain radiograph
Chest:- esophageal atresia
- Segmental pneumonia in superior lobe right lung
(aspiration?)
- Normal heart size
Abdomen: - minimal air-filling in pelvis/rectum
- air-filled small intestine
Conclussion : torako abdomen VACTERL disease

Laboratory finding:
Hb 12.1/38/11600/341000
Electrolit : Na 135 K 5.7
Blood glucose : 75

ASA III
ANESTHETIC MANAGEMENT

Maintain head up position


OGT attached
Frequent suctioning
Blood should be available
Prepared warm mattras and light warmer
Fluid Maintenance with D5 NS 450 cc in 24 hours

Preanesthetic Management

Preoxygenation
Monitoring : saturation , ECG and placed precordial
stethoscope on left axillary area
Intraoperative

Awake intubation with spontaneous ventilation

Maintenance anesthesia with sevoflurane 3,2 vol % in


conjunction with oxygen and air
After intubation give atrakurium 1.5 mg
Give fentanyl 4 mcg before incision
Fluid Maintenance with warm D5 NS 26 cc/hour

Change position from supine to left lateral decubitus


to perform right thoracotomy to do fistula ligation and
esophageal anastomosis (transthorakal extrapleura).
DISCUSSION
INCIDENCE
Is the most frequent congenital anomalies 1:4000
neonatus
90% with trachoesophageal fistula

25% coexisting with other congenital abnormalities


VATER (vertebral defect, imperforate anus,
trachoesophageal fistula, renal dysplasia)
VACTERL (VATER + cardiac and limb anomalies)
20% coexisting with congenital heart disease
30-40% patients were born premature
Prognostic can be vary depend on birth weight
and coexisting congenital anomalies 50% -
100%
CLASSIFICATION

90% were type C is the combination of an upper


esophagus that ends in a blind pouch and a lower
esophagus that connects to the trachea on posterior
side near carina
SIGN AND SYMPTOMS
Classic 3 Cs during oral feeding :
Coughing
Chocking
Cianosis

Oral catheter cannot be passed into the stomach


On Plain radiograph :
NGT coiling in esophageal pouch
Air-filled stomach

Patients are often present with dehydration and


malnourished due to poor oral intake, and
pneumonia
ANESTHETIC MANAGEMENT
PREOPERATIF
Principle :
Maintaining a patent airway
Preventing aspiration of secretions

Head up position
All intake nutrition given by parenteral route

Continuous suctioning of the proximal


esophageal segment
MANAJEMEN ANESTESI
Gastrotomy
Improve patients condition definitive repair
can be delayed
Rehydration
Treat pneumonia
OPERATIVE
Preoxygenation
Proper placement of the tracheal tube should be
above the carina but below the TEF
If possible do awake intubation with spontaneous
ventilation
If inhalation induction is chosen intubated without using
muscle relaxants
If induction by the intravenous route is chosen minimize
peak inspiratory pressure and potential gastric distention
Muscle relaxant can be administered after the airway
secured and ventilation is satisfactory
Airways atrategies to ensure adequate mechanical
ventilation :
One lung ventilation
Proper placement of the tracheal tube distal the TEF
Fogarty catheter occlusion
Fiberoptic tracheoscopy
Monitoring systemic blood pressure and arterial
blood gas concentration using catheter in a
peripheral artery
Placement of precordial stethoscope in the left
axillary area
Surgical retraction Desaturation, hypotension dan
bradicardi
Frequent tracheal suctioning
Blood should be available
Hypothermia should be avoided
POST OPERATIVE
Oral suction should not exceed 7 cm from lips.
Antibiotic and analgesia
Intake nutrition
Post operative complication
Gastroesophageal reflux
Pneumonia aspiration
Tracheal compression
Anastomosis leakage
Post operative extubation is determined by
complication related to airway
Tracheobronchomalacia
Laryngeal nerve injury vocal cord paresis
Recurrent fistula
TERIMA KASIH