Congenital Diaphragmatic Hernia Repair
Patient phenotype
Neonate, day 1-7 of life. CDH = abdominal contents in chest → pulmonary hypoplasia + pulmonary HTN. Severity ranges from mild to lethal. Often on HFOV or ECMO before repair. Repair is delayed until physiology stable.
Procedure
Subcostal abdominal or thoracic approach. Reduce abdominal contents from chest, repair diaphragm primarily or with patch. ~2-4 hours. Often performed at bedside in NICU (especially if on ECMO).
Anesthetic plan
GETA. Often already intubated, on iNO, on inotropes. Maintain pulmonary HTN management throughout. Permissive hypercapnia. Preductal SpO2 target 85-95%.
Setup
- ·All neonatal NICU monitors + ventilator
- ·Pre + post-ductal pulse ox (right hand pre-ductal)
- ·iNO 20-40 ppm
- ·Surfactant if administered
- ·Inotrope infusions: epi, dopamine, milrinone
- ·Vasopressin or NE (right ventricular protection)
- ·ECMO available + on standby
- ·Forced air warmer (microenvironment)
Biggest concerns by phase
Pulmonary HTN dominates outcome
Hypoplastic lung + abnormal pulmonary vasculature → severe pulm HTN → R-to-L shunt at ductus → preductal/postductal SpO2 difference. Avoid pulmonary vasoconstrictors (hypoxia, hypercapnia, acidosis, high PIP, cold, pain).
Hemodynamic + ventilatory continuity
Don't disrupt established physiology. Same vent settings, same iNO, same inotropes. Add anesthesia gently: small fentanyl, low-dose volatile or TIVA, cisatracurium.
Permissive hypercapnia + lung-protective vent
PIP < 25, PEEP 5, TV 4-6 mL/kg, RR for ETCO₂ 50-60 (permissive). Higher pressures = pneumothorax + worsens pulmonary HTN.
Reduction + abdominal closure
Returning bowel to abdomen → abdominal compartment syndrome → splints diaphragm → worsens vent. Surgeon may use silo (staged closure). Watch for sudden compliance drop.
Pulmonary hypertensive crisis
Sudden SpO2 drop, BP drop, RV strain. Treatment: 100% O2, hyperventilate, iNO up, milrinone, NE, deepen anesthesia, sedation. Prepare for ECMO if refractory.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
5-day-old term neonate with L CDH on HFOV, iNO 20 ppm, dopamine 5 mcg/kg/min, preductal SpO2 92, postductal 78. Repair scheduled. Plan?
What an examiner probes for
- ▹Continues current vent + iNO + inotropes
- ▹Adds gentle anesthesia (fentanyl + cis + low volatile)
- ▹Maintains permissive hypercapnia + low PIP
- ▹Anticipates pulmonary HTN crisis + treatment
- ▹ECMO availability + threshold
Sources
- Coté Peds Anesthesia 6e Ch 22
- AAP CDH Guidelines
Anatomy reference
Sourced reference images. 4 matches for "diaphragm thoracic abdomen neonatal".
Browse the full image library →
