Anaesthetic Management of a Neonate with Congenital Diaphragmatic Hernia

Abstract

Abstract: Introduction: Congenital diaphragmatic hernia (CDH) is an anatomical structural defect that allows passage of the abdominal viscera into the chest cavity. A Bochdalek hernia is a defect in the posterior left side of the diaphragm. Between 80 and 90 % of congenital diaphragmatic hernias are of this type. Objectives: An anesthetic, respiratory, and perioperative management of a neonate with CDH and patent ductus arteriosus (PDA) is presented. Case report: In this case presentation of a two-day old male neonate who was born preterm at 35 gestational weeks due to maternal asphyxia, intubation was performed and mechanical ventilation was started, inotropic and vasopressor support as well due to hemodynamic instability. After appropriate diagnostic procedures, CDH is confirmed, with herniation of the stomach: spleen, left, liver lob in the thoracic cavity, and left lung hypoplasia. The neonate is taken to the operating room for diaphragmatic defect repair surgery. After correction of the defect, closure was started. Due to increased IAP, hemodynamic instability with low arterial blood pressure and pulmonary hypertension reversed the shunt through PDA from left to right, and the baby deteriorated. Immediate resuscitation with adrenalin and phenylephrine was started. The surgical wound was opened and temporary closure technique by negative pressure with vacuum-assisted closure therapy (VAC) was placed, after which the baby stabilized. Conclusion : The management of CDH in neonates who also have PDA is a multidisciplinary and major challenge. The severity of pulmonary hypoplasia, pulmonary hypertension, persistent fetal circulation (PFC), associated malformations, and iatrogenic lung injury associated with aggressive mechanical ventilation are major factors, which contribute to the mortality and morbidity in babies with CDH. The perioperative management of pulmonary hypertension, lung hypoplasia, and physiologic stabilization by a highly skilled anesthesia team also plays an important role in the final therapeutic outcome. Despite advances in anesthetic and surgical management, the survival rate of CDH infants remains 60-70%.