Congenital Diaphragmatic Hernia
Background
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Diaphragmatic hernia with intestinal contents in chest
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90% left sided
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Lung will be underdeveloped & newborn could have persistent pulmonary hypertension
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Delayed surgery is preferred to stabilize prior to closure
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Conventional ventilation with permissive hypercapnia is now favoured
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Other therapies:
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Surfactant
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High-frequency oscillatory ventilation, in addition to nitric oxide
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Considerations
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Emergency situation
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Critically ill neonate
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Hypoplastic lungs:
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Respiratory insufficiency (hypoxemia, hypercarbia, acidosis)
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Permissive hypercarbia may be required
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Consider HVO or ECMO
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Pulmonary hypertension:
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Potential for RV failure/↓ cardiac output
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Consider inhaled nitric oxide
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Transitional circulation:
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Potential for R→L & L→R shunting
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PDA
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Delayed surgical repair, resuscitation is first priority
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NICU required
Resuscitation
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Call NICU
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Indication for immediate intubation (no bag mask ventilation)
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NG to decompress stomach
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ABG, chest x-ray, echocardiogram
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Umblical artery/vein lines
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Lung protective ventilation strategy:
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Target SaO2 > 85% & permissive hypercapnia (PaCO2 <65 mmHg, pH >7.25)
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PCV or PSV PIP < 25 cmH2O
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Inspiratory time 0.35 s
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PEEP 3-5 mmHg
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RR < 65
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Consider HVO, iNO or ECMO
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Pulmonary hypertension:
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Consider inhaled nitric oxide
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Inotropes
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Fluid: target MAP 45-50 mmHg
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Sedation: opioids & benzodiazepines, thoracic epidural
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Avoid NMB