Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 0 0 2026 05 23 1466 1466 Sonal Khatavkar Department of Anaesthesiology, Hospital and Research Centre, Dr Dypatil Medical College, Pimpri Pune, India. Pratikshya Nath Department of Anaesthesiology, Hospital and Research Centre, Dr Dypatil Medical College, Pimpri Pune, India. 2025 10 27 2025 11 29 Tracheoesophageal fistula (TEF) with esophageal atresia poses significant anesthetic challenges in neonates, especially when compounded by congenital anomalies such as cardiac defects. The anesthetic approach must balance airway management, hemodynamic stability, and postoperative recovery. We describe the perioperative care of a 2‑day‑old term female infant with type C TEF, imperforate anus, and associated cardiac malformations, including a small‑to‑moderate post‑muscular ventricular septal defect (VSD) and patent foramen ovale (PFO) with left‑to‑right shunt. In this case, the use of caudal epidural analgesia constituted a key component of management in this case. A caudal epidural catheter was placed at induction, and postoperative ropivacaine infusion provided effective analgesia, eliminating the need for systemic opioids. This minimized the risk of respiratory depression, enabled early extubation, and supported hemodynamic stability. The neonate remained stable intraoperatively on controlled ventilation with low‑dose inotropes and experienced an uneventful recovery. This case underscores the utility of regional analgesic techniques in high‑risk neonatal TEF repair and 2D echo findings from prior reports that highlight both simple, resource‑adapted airway strategies and comprehensive anesthetic planning to optimize outcomes in fragile neonates. Caudal epidural analgesia, when applied judiciously, enhances perioperative stability and reduces respiratory and cardiovascular complications, making it an invaluable component of multimodal neonatal anesthesia. https://aacc.tums.ac.ir/index.php/aacc/article/view/1466