Anesthesia Management for Esophageal Atresia

INTRODUCTION

Esophageal atresia (EA) is a congenital anomaly characterized by the discontinuity of the esophagus, frequently accompanied by a tracheoesophageal fistula (TEF) [1]. This condition arises from disrupted separation of the trachea and esophagus during the 4th to 6th weeks of gestation [2]. With a prevalence of 1 in 2,500–4,500 live births, EA is often associated with maternal polyhydramnios and other congenital anomalies, such as the VACTERL syndrome [3,4].

Neonates with EA typically present with hypersalivation, vomiting during feeding, and cyanosis due to aspiration [5]. Diagnosis is confirmed by the inability to pass a nasogastric tube beyond the proximal esophagus, corroborated by chest radiography revealing air in the stomach or intestines in cases of distal TEF [4]. Anesthetic management in EA, particularly in neonates, is complex due to immature physiology and a high risk of aspiration [6]. Narrow airways, an anterior larynx, and reduced lung capacity predispose patients to hypoxemia [7]. Preoperative stabilization involves esophageal decompression, respiratory monitoring, and echocardiography to evaluate for associated cardiac anomalies [2-4].

Careful anesthetic induction is critical, avoiding positive pressure ventilation prior to intubation to minimize aspiration risk [6]. Regional anesthesia, such as caudal block, is often employed for postoperative pain management. Postoperatively, patients require intensive care in the neonatal intensive care unit (NICU) with vigilant monitoring of respiratory function, hemodynamics, and complications like anastomotic leaks [8]. This report aims to provide a comprehensive overview of anesthesia management in EA, emphasizing the importance of a multidisciplinary approach to optimize clinical outcomes.

CASE DESCRIPTION

A 9-day-old male neonate was referred to the Anesthesiology and Intensive Care Department at Zainoel Abidin General Hospital, Banda Aceh, from Subulussalam Hospital with complaints of persistent hypersalivation, vomiting during feeding, and interrupted suckling, worsening over the past three days. The patient was born full-term via spontaneous vaginal delivery assisted by a midwife, with a birth weight of 2,250 grams, Apgar scores of 7/8, and clear amniotic fluid. No history of allergies, diabetes, hypertension, or prior relevant medical conditions was reported. Four days prior, the patient underwent emergency gastrostomy and esophagostomy for decompression, with a planned thoracotomy and esophageal repair for esophageal atresia (EA).

Physical examination revealed a moderately ill neonate with compos mentis consciousness, respiratory rate of 55 breaths/min, oxygen saturation of 96% on a 3 L/min simple mask, and temperature of 36.7°C. Hemodynamic parameters included blood pressure of 89/62 mmHg and heart rate of 169 beats/min, with no murmurs or gallops. Abdominal examination showed normal bowel sounds without distension, and urine output was adequate (>0.5 cc/kg/h). Laboratory findings indicated anemia (hemoglobin 11.4 g/dL, hematocrit 31%), elevated liver enzymes (SGOT 85 U/L, SGPT 160 U/L), and mild metabolic disturbances (ureum 57 mg/dL, creatinine 0.63 mg/dL), with normal electrolytes (Table 1). Radiological imaging confirmed a gastric tube halting at the T2 vertebra, consistent with EA, while echocardiography revealed a patent foramen ovale (PFO) and a 6.5 mm patent ductus arteriosus (PDA), suggesting VACTERL association. The patient was classified as ASA III.

Table 1: Laboratory Findings

Parameter	Result	Normal Range	Interpretation
Hemoglobin (Hb)	11.4 g/dL	13.5–18 g/dL	Low
Hematocrit (Ht)	31%	38–52%	Low
Leukocytes	11.43 x10³/µL	4–11 x10³/µL	Elevated
Platelets	205 x10³/µL	150–400 x10³/µL	Normal
SGOT	85 U/L	10–40 U/L	Elevated
SGPT	160 U/L	10–40 U/L	Elevated
Urea	57 mg/dL	15–45 mg/dL	Elevated
Creatinine	0.63 mg/dL	0.2–0.5 mg/dL	Elevated
Sodium (Na)	140 mmol/L	135–145 mmol/L	Normal
Potassium (K)	4.6 mmol/L	3.5–5.0 mmol/L	Normal
Chloride (Cl)	105 mmol/L	98–107 mmol/L	Normal

Noted: Laboratory results indicate anemia, hepatic dysfunction, and mild renal impairment, consistent with neonatal stress and esophageal atresia (EA). Normal electrolytes support preoperative stability.

​​Preoperative management included 4-hour fasting, fluid optimization, and NICU Level 3 monitoring. General anesthesia was selected, with induction using sulfas atropine 0.05 mg, midazolam 1 mg, fentanyl 6 mcg, propofol 3 mg, and ketamine 3 mg to maintain hemodynamic stability. Intubation was performed with a 2.5 uncuffed endotracheal tube, carefully positioned to ensure equal bilateral breath sounds. A central venous catheter (CVC No. 3) was placed in the right subclavian vein. The patient was positioned in the right lateral decubitus for thoracotomy and esophageal repair via the Foker technique. Intraoperative warming maintained a temperature of 37°C, with 40 cc fasting replacement fluid and 10 cc/h maintenance fluid. Anesthesia was maintained with sevoflurane (1–2%) in 45–60% oxygen at a 2 L/min fresh gas flow. The 3-hour procedure resulted in 30 cc blood loss, managed with 100 cc 1% dextrose and 30 cc packed red cells. Urine output was 25 cc, indicating adequate renal perfusion.

Table 2: Postoperative Follow-Up (Selected Days)

Day	Therapy	Vital Signs	Laboratory Findings
1	IVFD NS 5 cc/h, Aminosteril 10% 5 cc/h, Lipid 20% 2.1 cc/h, Midazolam 2 cc/h, Dobutamine 1 cc/h, Epinephrine 1 cc/h, Amikacin 65 mg/30h, Metronidazole 20 mg/8h, Vancomycin 30 mg/12h, Metamizole 40 mg/8h, Paracetamol 40 mg/8h, Furosemide 1.5 mg/24h	BP: 84/44 mmHg, HR: 165 bpm, SpO₂: 100% (Vent: PIns 20 cmH₂O, FiO₂ 80%, PEEP 5), Temp: 37.1°C, Urine: 6.8 cc/h	Hb/Ht: 13.1/36, Urea/Cr: 6/0.29, Na/K/Cl: 140/3.0/110, Albumin: 2.38, Ca: 7.3, SGOT/SGPT: 39/20, pH: 7.443, PCO₂: 33, PO₂: 165
3	As Day 1, Midazolam 0.3 mg/kg/h, Dobutamine 0.375 mg/kg/h, Epinephrine 3.75 mcg/kg/h	BP: Stable, HR: 130 bpm, SpO₂: 93–94% (Vent: FiO₂ 70%), Temp: 37.3°C, Urine: 4.08 cc/h	Not reported
7	As Day 6, Albumin 20% 15 cc/24h	BP: Stable, HR: 116 bpm, SpO₂: 98–99% (Vent: PIns 18 cmH₂O, FiO₂ 70%), Temp: 37.1°C, Urine: 5.49 cc/h	Urea/Cr: 39/0.34, Na/K/Cl: 138/2.8/106, SGOT/SGPT: 9/3, pH: 7.456, PCO₂: 28.8, PO₂: 147
11	As Day 10, Fluconazole 30 mg/24h, Tigecycline 3 mg/12h, Dexamethasone 0.2 mg/12h	BP: Stable, HR: 98 bpm, SpO₂: 94% (Vent: FiO₂ 50%), Temp: 36.4°C, Urine: 195 cc/h	Not reported

Noted: Postoperative management ensured hemodynamic stability and adequate renal perfusion. Transient desaturation on day 2 was managed with ventilator adjustments. Antibiotic and inotropic support minimized complications, with improving laboratory parameters by day 7.

Postoperatively, the patient was transferred to NICU Level 3 in stable condition (blood pressure 84/44 mmHg, heart rate 138 beats/min, oxygen saturation 99%) on pressure control ventilation (inspiratory pressure 21 cmH₂O, PEEP 5 cmH₂O, FiO₂ 50%). Norepinephrine (0.1 mcg/kg/min) supported circulation. On day 2, desaturation to 83% with bilateral ronchi prompted increased FiO₂ to 60% and ventilator adjustments. Parenteral nutrition (NS+KCl+Ca, aminosteril 10%, lipid 20%) and broad-spectrum antibiotics (amikacin, meropenem, metronidazole) were administered, with midazolam for sedation. Follow-up over 11 days showed stable hemodynamics, adequate urine output, and gradual ventilator weaning (Table 2), with no anastomotic complications observed.

DISCUSSION

The anesthetic management of esophageal atresia (EA) with tracheoesophageal fistula (TEF) in a 9-day-old neonate, as detailed in this case, requires meticulous coordination among anesthesiology, pediatric surgery, neonatology, and intensive care teams to address the inherent complexities of the condition [9]. The presence of associated congenital anomalies, such as patent foramen ovale (PFO) and patent ductus arteriosus (PDA), classified the patient as ASA III, necessitating comprehensive preoperative evaluation due to the frequent association with VACTERL syndrome, which includes vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb anomalies [10]. This case highlights the critical need for tailored perioperative strategies to mitigate risks of aspiration, hemodynamic instability, and pulmonary complications.

Preoperative stabilization focused on minimizing aspiration risk and optimizing physiological status. The patient’s symptoms of hypersalivation and regurgitation, driven by air entry into the gastrointestinal tract via the TEF, were managed with nasogastric tube decompression to prevent aspiration pneumonia [6]. Intravenous fluid therapy ensured electrolyte and hydration balance, while echocardiography confirmed PFO and PDA, which could exacerbate systemic perfusion challenges during anesthesia [4]. A 4-hour fasting period was strictly enforced to reduce secondary aspiration risk [7]. The choice of induction agents—fentanyl, propofol, and ketamine—was deliberate, with ketamine’s cardioprotective properties minimizing myocardial depression in the context of PDA and PFO, thus maintaining hemodynamic stability [9].

Intraoperative management prioritized airway and ventilatory precision. Intubation with a 2.5 uncuffed endotracheal tube was performed cautiously to avoid gastric insufflation through the TEF, using assist/control pressure ventilation with a PEEP of 5 cmH₂O to maintain alveolar stability and prevent atelectasis [7]. Sevoflurane (1–2%) ensured safe maintenance anesthesia with minimal cardiodepressant effects, suitable for neonatal physiology [2]. During the thoracotomy and Foker technique repair, hemodynamic stability was supported with 1% dextrose and blood transfusion for a 30 cc blood loss, while active warming to 37°C prevented hypothermia, which could exacerbate coagulopathy and delay anesthetic drug metabolism [3].

Postoperative care in the NICU involved mechanical ventilation (initial settings: inspiratory pressure 21 cmH₂O, PEEP 5 cmH₂O, FiO₂ 50%) to support oxygenation and prevent alveolar collapse, with arterial blood gas monitoring to assess ventilatory efficacy [7]. Norepinephrine titration maintained systemic perfusion despite PDA-related circulatory challenges [2]. On postoperative day 2, desaturation to 83% with bilateral ronchi suggested aspiration pneumonia or pulmonary complications, common in EA due to esophageal tissue fragility or residual secretions [3,4]. Increasing FiO₂ to 60% and optimizing ventilation improved oxygenation, while broad-spectrum antibiotics (amikacin, meropenem, metronidazole) addressed potential sepsis and secondary infections [2-4]. Continuous monitoring for anastomotic leaks, indicated by increased secretions or abdominal distension, was critical [4]. The complexity of EA underscores the necessity of a multidisciplinary approach. Comprehensive preoperative planning, precise ventilatory management, rigorous hemodynamic monitoring, and intensive postoperative care were pivotal in reducing morbidity in this neonate [6]. This case exemplifies the importance of understanding neonatal physiology, managing aspiration risks, and implementing vigilant ventilatory strategies to achieve favorable outcomes in this life-threatening condition.

CONCLUSION

Anesthetic management of esophageal atresia with tracheoesophageal fistula in a 9-day-old neonate requires a multidisciplinary approach. Preoperative esophageal decompression and fluid correction ensured safety. Intraoperative general anesthesia with caudal block and optimized ventilation supported Foker technique repair, maintaining hemodynamic stability. Postoperative NICU care with ventilation and antibiotics managed complications like desaturation. Comprehensive planning and vigilant monitoring minimized morbidity, achieving favorable outcomes.

DECLARATIONS

None

CONSENT FOR PUBLICATION

The Authors agree to be published in the Journal of Society Medicine.

FUNDING

None

COMPETING INTERESTS

The authors declare no conflicts of interest in this case report.

AUTHORS’ CONTRIBUTIONS

All authors made substantial contributions to the case report. DFN was responsible for patient management, data collection, and initial drafting of the manuscript. All authors reviewed and approved the final version of the manuscript, ensuring its accuracy and integrity, and are accountable for all aspects of the work.

ACKNOWLEDGMENTS

None

REFERENCE

1. Marthendro T, Irawan D, Muharrami V, Hidayat N, Ananda P. Anesthesia management of patients with esophageal atresia/tracheoesophageal fistula undergoing thoracostomy and esophagostomy procedures. J La Medihealtico. 2024;5(5):960-6. doi: 10.37899/journallamedihealtico.v5i5.1597.
2. Sudjud R, Bisri T, Boom CE. Anesthetic consideration on neonatal patient with esophageal atresia. Open J Anesthesiol. 2016;6(9):128-36. doi: 10.4236/ojanes.2016.69022.
3. de Graaff JC, Johansen MF, Hensgens M, Engelhardt T. Safety and quality in perioperative anesthesia care: update on safety in pediatric anesthesia. Best Pract Res Clin Anaesthesiol. 2021;35(1):27-39. doi: 10.1016/j.bpa.2020.12.007.
4. Tokarska K, Rogula W, Tokarz A, Tarsa M, Urban W, Górecki W. Guidelines for treatment of esophageal atresia in the light of most recent publications. Pol Przegl Chir. 2022;95(1):46-52. doi: 10.5604/01.3001.0015.8208.
5. Choumanova I, Arinola S, Faye E. Anesthetic management of tracheo-oesophageal fistula/oesophageal atresia. Pediatr Anesth Tutorial Week. 2017;Tutorial 364.
6. Bhirowo BK, Vitraludyono R. Anesthesia management of esophagostomy for the patient with double outlet right ventricle. J Anesth Pain. 2021;2(2):89-92. doi: 10.21776/ub.jap.2021.002.02.06.
7. Adithya KT, Setijanto E. Anesthetic management and perioperative care in neonates with esophageal atresia: a case report. J Anesthesiol Clin Res. 2024;5(3):642-4. doi: 10.37275/jacr.v5i3.590.
8. Kuncoro KE, Widyastuti Y. Delayed referral and anesthetic management of esophageal atresia: a challenge for multidisciplinary approach? Malays J Med Health Sci. 2020;16(Suppl 3):115-7.
9. van Hoorn CE, Costerus SA, Lau J, Wijnen RMH, Vlot J, Tibboel D, et al. Perioperative management of esophageal atresia/tracheo-esophageal fistula: an analysis of data of 101 consecutive patients. Pediatr Anesth. 2019;29(10):1024-32. doi: 10.1111/pan.13711.