The pitfalls of endotracheal intubation beyond the fistula in babies with type C esophageal atresia

The intraoperative management of a neonate with esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) is a true anesthetic challenge. Pediatric anesthesia textbooks recommend a distal tracheal intubation beyond the fistula and spontaneous ventilation, if possible, until surgical control of the fistula is achieved to minimize gastric distention. A full-term neonate with Trisomy 21 presented with an EATEF and was transferred to the operating theater for repair after appropriate evaluation. After induction of anesthesia, a size 3.0 endotracheal tube was inserted orally with confirmation of its position by good air entry and chest movement bilaterally. After positioning for thoracotomy, the patient desaturated and became bradycardic with abdominal distention. Despite reintubation, gastric needle decompression, and bilateral pleural aspiration to exclude pneumothorax, cardiopulmonary resuscitation was unsuccessful and the child died. Autopsy revealed the endotracheal tube in the trachea with its distal end passing through a large distal TEF. Preoperative bronchoscopy may help the team to assess the size and location of the distal TEF and plan for the best anesthetic strategy. It may also be useful to confirm tube location after endotracheal intubation and intraoperatively in the event of cardiorespiratory instability.