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Neonatal Case Study

Neonatal Case Study. Tracheoesophageal Fistula Melissa Reljac -Smith. OBJECTIVE. Outline the importance of early diagnose and p lan of care for neonatal clinical patient with tracheoesophageal fistula. . PATIENT. Male infant 37.1 week gestation 2946 g (6lbs 8 oz )

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Neonatal Case Study

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  1. Neonatal Case Study Tracheoesophageal Fistula Melissa Reljac-Smith

  2. OBJECTIVE • Outline the importance of early diagnose and plan of care for neonatal clinical patient with tracheoesophageal fistula.

  3. PATIENT • Male infant • 37.1 week gestation • 2946 g (6lbs 8 oz) • C-Section for failure to progress

  4. MATERNAL AND FETAL RISK AND COMPLICATIONS • Maternal- • mild anemia that was treated with iron and prenatal vitamins. • UTI- The infection was treated with antibiotics • Prenatal screening laboratory tests were unremarkable. • Prenatal ultrasound showed polyhydramnios

  5. DELIVERY AND STABILIZATION • Uneventful delivery • Infant emerged vigorous • Apgars 9/9 • Routine positioning, warm and dry • Infant transferred to Newborn Nursery

  6. ADMISSION ASSESSMENT AND DIAGNOSTICS • NNP called to Newborn Nursery with complaint of increased work of breathing and spits with feeds • Infant transferred to NICU • Initial NICU admission assessment completed at 6 hrs of life. • Vitals- T 98.6, HR 152, RR 72, O2 Sat 90%, BP Mean 44 • Slightly lethargic • Mild retractions with crackles on auscultation • Increased oral secretions noted. • Void/Stool in the first 4 hrs of life • OG tube unable to pass • Oral feed of 15 ml was given in NBN; Infant having spits

  7. PRIMARY ADMISSION DIAGNOSIS • Tracheoesphageal Fistula • Rule out sepsis

  8. ETIOLOGY AND PATHOPHYSIOLOGY • TEF occur in the 4- to 6-week-old embryo • The caudal part of the foregut forms a ventral diverticulum that becomes the trachea. • Many anatomic variations of esophageal atresia with or without a TEF may occur. • The most common anomaly consists of a blind esophageal pouch and a distal TEF. • Pure esophageal atresia without a TEF is the second most common form. • The third most common anomaly is the H-type fistula, which consists of a TEF without esophageal atresia. • Approximately 17-70% of children with TEFs have associated developmental anomalies: • include Down syndrome, duodenal atresia, and cardiovascular defects

  9. INITIAL PLAN OF CARE Management focused on minimizing risk of aspiration and avoiding GI distention (Cloherty, Eichenwald, Hansen & Stark, 2012) • Repogle on continuous suction • NPO • Head of bed evaluated 30 degrees • CXR • O2- NC • IV fluids- 120 ml/kg/day D10W • Sepsis RO- CBC, Blood Culture • Antibiotics- Ampicillin/Gentamycin • ECHO • Renal Ultrasound • Chromosome • Notify Pediatric surgeon

  10. DIAGNOSTIC AND SURGICAL • Many diagnostic methods: (Gomella, Cunningham & Eyal, 2010) • -Esophagram • -Contrast Studies • -Endoscopic • Surgical(Johnson, 1989) • - Cervical Approach

  11. COURSE BY SYSTEMS • Vital Signs: WNL • FOC: 34/ Length 45.7 cm/Weight 2946 gm • General appearance – Alert and active, good tone, full range of motion and spontaneous movements • Skin – Pink, no rashes/ abrasions, good skin turgor color • Head and neck: Symmetrical, Fontanels soft, clavicles intact. Eyes- Pupils reactive and equal. Palate intact.

  12. COURSE BY SYSTEMS • Respiratory: Bilateral breath sounds course and equal, tachypnea, mild retractions. • Cardiovascular: Normal rate and rhythm, positive femoral pulses • Abdomen – Positive bowel sounds all four quadrants, soft and full, no presence of masses or hernias, TracheoesophagealFistula per C-XRAY and contrast study. • Genitals and anus – Voiding and stooling, normal male genitals

  13. EVIDENCE BASED STUDIES • Esophageal Atresia and Tracheoesophageal Fistula: Supportive Measures That Affect Survival (Koop) • 24 year study • Early diagnosis and transportation to a pediatric facility • Diagnostic X-RAY decreased incidence of pneumonia and a reduced mortality. • Changing surgical techniques • Clearly the target for improvement in survival is the prevention of and the improvement in treatment of pneumonia and sepsis.

  14. EVIDENCE BASED STUDIES • Esophageal Atresia and Tracheoesophageal Fistula: Preoperative Assessment and Reduced Mortality (Stothert) • One hundred twenty nine infants • Overall mortality was 38% • Factors for classification • Improved survival rate of 90%

  15. SUMMARY Early diagnostics and advancement in surgical care have improved the outcome of infants with tracheoesophageal fistula. Current research is continuing to explore different diagnostic and surgical procedures. This research will only increase the survival rate and educate medical staff on peroperative care.

  16. REFERENCES • Cloherty, J. P., Eichenwald, E. C., Hansen, A. R., & Stark, A. R. (2012). Manual of neonatal care. (7TH ed.). Lippincott Williams & Wilkins. • Gomella, T. L., Cunningham, M. D., & Eyal, F. (2010). Neonatology, management, procedures, on-call problems, diseases and drugs. McGraw-Hill Professional. • Stothert, J. (n.d.). •esophageal atresia and tracheoesophageal fistula: Preoperative assessment and reduced mortality. •From the Departments of Surgery, Saint Louis University and Cardinal Glennon Memorial Hospital for Children, St. Louis, MO ,

  17. REFERENCES • Koop, E. (n.d.). Esophageal atresia and tracheoesophageal fistula: Supportive measures that affect survival . 1.Departments of Surgery and Anesthesia, Children's Hospital of Philadelphia, and the Harrison Department of Surgical Research, University of Pennsylvania, Philadelphia , • Johnson, A. (1989). •esophageal atresia with double fistula: The missed anomaly. •Departments of Surgery and Radiology, University of Virginia School of Medicine, Charlottesville, VA the Department of Pediatric Surgery, National Medical Center, Duarte, CA ,

  18. REFERENCES • Tsai, J. (1997, 02). Esophageal atresia and tracheoesophageal fistula: Surgical experience over two decades. • Kaviani, A. (n.d.). Neonatal tracheoesophageal anomalies. •Children's Hospital Boston and Harvard Medical School, USA, Retrieved from http://www.sciencedirect.com/science/article/pii/B0123868602007632 • Holder, T. (1997). Esophageal atresia and tracheoesophageal fistula a survey of its members by the surgical section of the american academy of pediatrics. Pediatrics, Retrieved from http://pediatrics.aappublications.org/content/34/4/542

  19. REFERENCES • Riazulhaq M, Elhassan E. Early recognition of H-type tracheoesophagealfistula. APSP J Case Rep 2012; 3: 4 • Karnak I, Senocak ME, Hicsonmez A, Buyukpamukcu N. The diagnosis and treatment of H-Type tracheoesophageal fistula. J PediatrSurg 1997;32:1670-4.

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