78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024

Case description:

•Newborn male, 3340g

•39w6d

VACTERL association (anal atresia, tracheoesophageal fistula, renal abnormalities and polydactyly

Surgery:

•Surgical repair oftracheoesophageal fístula type C + repair of imperforate anus

•2nd day of life

Preoperative period:

•Multidisciplinary discussion

•Risks of air leak, gastric and boweldistension following positive pressure ventilation in an alreadydistended abdomen.

Intraoperative period:

Diverting colostomy under regional anesthesia:

- Ultrasound-guided single-shot caudal block + ketamine anddexmedetomidine sedation

Thorascopic TEF repair undergeneral anesthesia:

- Intubation under spontaneousventilation

- Maintenance with fentanyl, ketamine, dexmedetomidine

Several pauses to optimizeventilation and hemodynamics

Postoperative period:

•Transfered to NICU

•Extubated and Initiated enteral feeding on the 7th postoperativeday

Discussion:

•Variable anatomy and physiologythat can complicate airwaymanagement and increaseanesthetic risk +

•Concurrent surgical correction ofTEF and anal imperforation

Crucial to preserve spontaneousventilation – the negative pressure redirects air influxtowards the lungs rather thanthrough the fistula.

Ultrasound caudal block + Intravenous sedation withdexmedetomidine and ketamine:

Sedative and analgesic effects + preservation of airway reflexes andrespiratory drive

Learning objective:

In patients with tracheoesophagealfistula and anal imperforation, thecombination of ketamine anddexmedetomidine along withregional anesthesia is a goodalternative to avoid positive-pressure ventilation.

78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024

Navigating the Anesthetic Challenges of VACTERL Association: A Delicate Balancing Act

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