1 - Anestesiologia, Lisboa, Hospital da Luz Lisboa;
2 - Anestesiologia, Évora, Hospital Espírito Santo de Évora;
3 - Anestesiologia, Lisboa, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central
- Poster published and presented at European Society of Anesthesiology and Intensive Care Congress
Background Tracheoesophageal fistula (TEF) is an abnormal connection between trachea and esophagus. We present a rare case of a battery swallow-induced TEF in a pediatric patient.
Case-report A 4-year-old child with a known history of battery ingestion 2 years before, with significant weight loss and recurrent respiratory tract infections, was transferred from a low-income country to our hospital presenting with severe dehydration and malnutrition. Chest x-ray showed left lung heterogeneous opacities and a radiopaque foreign body in the esophagus. The patient was scheduled for a central venous line insertion under general anesthesia and arrived at our operating room with stable vitals, but with signs of dehydration and respiratory distress. After preoxygenation, general anesthesia was induced with ketamine, propofol and rocuronium. We performed a videolaryngoscopy with visualization of the cords and intubation with a 4.5mm cuffed endotracheal tube (ETT). However, after connecting the patient to the ventilator, there was no thoracic expansion, no capnography curve and the stomach was inflating. A new laryngoscopy was performed and ETT’s position confirmed. Despite an increase in FiO2 and high ventilatory pressures, we were not able to ventilate the patient, oxygen saturation dropped quickly, and she went into cardiac arrest. We promptly started resuscitation and the patient recovered after the second cycle of CPR. As we suspected the presence of a TEF, we did a selective intubation to the right bronchus which allowed clinical improvement. The patient was transported ventilated to the intensive care unit and the presence of TEF was confirmed by bronchofibroscopy. Later she was submitted to surgical correction of the TEF, without complications.
Conclusion TEF has significant anesthetic and airway management implications, especially if positive pressure ventilation is required. Differential diagnosis of hypoxemia and lack of end-tidal CO2 after intubation permitted the presumption of a TEF, and resolution of the problem with right endobronchial intubation. Clinical expertise and team leadership were crucial in this crisis management.
Key Words: Airway, Anaesthesia, Pediatrics, Tracheosophageal Fistula