Neonatal Emergencies

Neonatal Emergencies
Joy Loy MD
March 2009
Objectives
Participants will be able to
1. discuss the underlying pathophysiology of selected neonatal emergencies, 2. explain the anesthetic implications and 3. describe safe anesthetic plans for each.
Preoperative Evaluation
Maternal and perinatal history
Recreational drug use
Birth history
Minimum labs: glucose and CBC Look for associated anomalies
Cardiac and respiratory status

Metabolic and electrolyte imbalance Hydration status Coagulation profile IV access
Pyloric Stenosis
Pyloric Stenosis
Most common GI obstructive anomaly in neonates
Hypertrophy of the muscular layer of the pylorus

A medical emergency but not a true surgical emergency Incidence: 1 3 :1,000 live births 2 - 5x more common in first born, M > F (4:1)
Pyloric Stenosis
Etiology : unknown
? acquired condition with hereditary

predisposition Symptoms are apparent between 2nd-6th wk of life
Presents with nonbilious projectile vomiting, signs of dehydration, jaundice (2%)
Pyloric Stenosis
Physical Exam visible gastric peristalsis palpable olive-shaped mass to the right of the epigastric area signs of dehydration
Labs: CBC ABG
serum electrolytes BUN
EKG
Pyloric Stenosis
Diagnosis
history and physical exam abdominal ultrasound upper GI series with barium contrast not recommended pathological pyloric wall thickness 4 mm pyloric length of > 16 cm
Pyloric Stenosis Metabolic Abnormalities

hyponatremia
hypochloremia
hypokalemia
1 metabolic alkalosis
compensatory respiratory acidosis

paradoxical acidic urine
Pyloric Stenosis
Preoperative Preparation supportive treatment
surgical management
check lab indices for safe anesthesia
Pyloric Stenosis
Preoperative Preparation
Supportive therapy
Correction of fluid deficits
maintenance: D5 0.2% NaCl + KCl
20 - 40 mEq/L
replacement: LR, albumin, normal saline
Correction of electrolyte imbalance

Prevention of aspiration : NGT
Pyloric Stenosis
Surgical Management Pyloromyotomy definitive treatment open or laparoscopic Lab indices for safe anesthesia serum Cl >100 mEq/L HCO3 < 28 mEq/L
Pyloric Stenosis
Anesthetic Concerns pulmonary aspiration severe dehydration
metabolic alkalosis
Pyloric Stenosis
Intraoperative Management
Monitors : ASA standard
Decompress the stomach

GA: Induction: controversial awake intubation rapid sequence IV induction and intubation with cricoid pressure inhalation induction with cricoid pressure muscle relaxant
Pyloric Stenosis Intraoperative Management
Cook-Sather, 1998 (CHOP)

prospective, nonrandomized study awake vs paralyzed intubation (RSI and MRSI) faster and more successful tracheal intubation with muscle paralysis awake intubation does not protect from bradycardia and desaturation
Pyloric Stenosis
Maintenance
IV narcotics: rarely needed inhalational agents
Postop pain relief

acetaminophen 30-40 mg/kg PR caudal epidural LA infiltration of surgical incision
Pyloric Stenosis
Extubate awake Postoperative concerns respiratory depression and apnea hypoglycemia
Congenital Diaphragmatic Hernia

a problem unresolved

Herniation of abdominal viscera into the thorax Result from failure of the pleuroperitoneal canal to close at ~ 8th wk of gestation or early
return of midgut to the peritoneal cavity

Most challenging and frustrating of all neonatal surgical emergencies
Congenital Diaphragmatic Hernia 50% mortality regardless of the method of treatment Incidence: 1:2,000-5,000 live births
M<F 1:1.8, frequently full term

Etiology: unknown no genetic factors have been implicated Antenatal history: polyhydramnios

Classification
Absent diaphragm : rare
Diaphragmatic hernia 80% posterolateral L >R (Bochdalek) 2% anterior (Morgagni)
15 - 20% paraesophageal
Eventration (15 - 20%)
Associated anomalies (20-50%)
cardiovascular
CNS
13 - 23%
28%
gastrointestinal
genitourinary
increase the mortality rate
20%
15%
Classic Triad Dyspnea
Cyanosis
Apparent dextrocardia
Physical Exam scaphoid abdomen and barrel chest bowel sounds in the chest displaced heart sounds Laboratory Studies CBC ABG
electrolytes
glucose
calcium
Diagnosis: chest x-ray

loops of bowel in the chest mediastinal shift
absent lung markings
IMMEDIATE Intubation + Stomach Decompression
Determinants of Survival degree of pulmonary hypoplasia

ipsilateral lung > contralateral lung
development pulmonary vasculature
Goals of Management maximize arterial oxygenation

mechanical ventilation: use low inflating pressures
increases pulmonary blood flow
prevention of pain
fentanyl infusion 3-10 mcg/kg/hr
correction of acidosis
Standard Management Strategy

Reduce pulmonary HTN
Moderate alkalosis pCO2 < 40 mmHg
PaO2 >100 mmHg
Recent Strategy
Permissive hypercapnia and hypoxemia Pressure-limited ventilation (<25 cmH2O) Postductal pCO2 40-65 mmHg Preductal SpO2 85-90%
Postductal SpO2 ignored unless pH is

< 7.20 or pCO2 > 65
Congenital Diaphragmatic Hernia Bohn (1986) reevaluation of the traditional mad dash surgical strategy
recommended 24 48 hrs medical stabilization

assessment of efficacy of delayed approach
infants unresponsive to initial therapy will fail to survive with surgery or any other treatment including ECMO
The Relationship Between PaCO2 and Ventilation Parameters in Predicting Survival in CHD Arterial CO2 accurately reflects the degree of lung development
Poor survival in the presence of severe pulmonary hypoplasia

CO2 retention and severe preductal shunting have 90% mortality
Bohn, DJ, et al J of Pedia Surg 19: 666-671, 1884

nomogram: to predict the degree of pulmonary hypoplasia in the infants and chance of survival used the preop PaCO2 and an index of ventilation (Vi) If PaCO2 < 40 and Vi < 1000: survival almost universal If PaCO2 > 40 and Vi > 1000: death virtually inevitable Vi = mean airway pressure x respiratory rate
Relationship of Alveolar-arterial Oxygen Tension Difference in Diaphragmatic Hernia in the Newborn

A-aDO2 on 100% O2 < 400 mmHg: usually survive 400 - 500 mmHg: intermediate chance > 500 mmHg: unlikely to survive
Harrington J, et al Anesthesiology 56: 473-476, 1982
Acid Base Balance and Blood Gases in Prognosis and Therapy of CHD High Mortality pH < 7.0 pCO2 >60 mmHg pO2 < 50 mmHg
Boix-Ochoa J, et al J Pediatric Surg 9:49-57, 1974
Indications of Surgical Repair Reversal of ductal shunting O2 index of < 40 Arterial pCO2 maintainable under 40 mmHg Hemodynamic stability
Look for associated anomalies
Labs: CBC, electrolytes, ABG, glucose,

blood type and crossmatch
Ancillary procedures: CXR, Echo

Venous access: upper extremities preferred Prevention of hypothermia
Intraoperative Management Monitors: ASA standard invasive : arterial line CVP foley catheter * 2 pulse oximeters: preductal and postductal
* precordial stethoscope on the right axilla
NGT to decompress the stomach Adequate IV access
Intraoperative Management Induction awake intubation rapid sequence IV induction and intubation with assisted or controlled ventilation * avoid mask ventilation or PPV before intubation Supine position, left subcostal incision
Intraoperative
Maintenance of anesthesia
volatile agents + IV narcotics + muscle relaxants
TIVA avoid nitrous oxide avoid increase in PVR leading to RL shunting: hypoxia, acidosis, hypothermia, pain
treat metabolic acidosis

replace significant blood loss
Intraoperative Mechanical Ventilation adjust FiO2 to achieve PaO2 80 -100 mmHg
SpO2 95 - 98%
small tidal volume to keep airway pressure < 20-30 cm H2O high respiratory rate 60-120 /min to PaCO2 25-30 mm Hg
Congenital Diaphragmatic Hernia Intraoperative Surgical repair primary closure staged procedure Transabdominal subcostal incision
Thoracoscopic repair has been reported
Intraoperative
Potential Problems
Hypoxemia
distension of stomach
1 pulmonary hypoplasia / pulmonary HTN
Contralateral pneumothorax
Hypotension or IVC compression

Cardiac arrest
Postoperative Care
Ventilatory support Close fluid management Hemodynamic monitoring
Honeymoon Period followed by deterioration

increase abdominal pressure
impaired peripheral and visceral perfusion

limited diaphragmatic excursion worsening of pulmonary compliance
Management of PPHN
Minimize ETT suctioning Vasodilators : rarely effective
tolazoline nitroglycerin isoproterenol SNP PGE1
Inhaled nitric oxide

endothelium - derived relaxing factor (EDRF) selective pulmonary vasodilation rapidly metabolized has not been shown to improve survival
Extracorporeal Membrane Oxygenation (ECMO) Use: controversial Allows the lungs to develop & restructure Expensive improved survival in neonates with > 80% mortality
Criteria for ECMO Gestational age 34 wks Reversible disease process present Weight 2000 grams Predicted mortality 80% estimated by oxygenation index of > 40
FiO2 x mean airway pressure x 100
PaO2
Contraindications
Gestational age < 34 wks Weight < 2000 grams Preexisting intracranial hemorrhage ( grade II) Aggressive respiratory treatment > 1 wk Congenital heart disease Congenital or neurological abnormality incompatible with good outcome
TracheoEsophageal Fistula (TEF)
Tracheoesophageal Fistula
Incidence: 1:4000 live births
M > F (25:3) 10-40% are preterm
Antenatal history: polyhydramnios (60%)

Etiology: failure in mesenchymal separation of upper foregut
Clinical Presentation
choking on 1st feed
coughing cyanosis excessive salivation aspiration pneumonia
Diagnosis
inability to pass a suction catheter

into the stomach
CXR: coiled orogastric tube in the

cervical pouch; air in the stomach and intestine
Esophageal Atresia
Turnage RH, et al, Sabiston Textbook of Surgery,17th Ed. 2004
TracheoEsophageal Fistula
5 Types (Gross and Vogt)
7.7%
0.8%
86%
0.7%
4.2%
Gregory GA, ed, Pediatric Anesthesia, 3rd edition, 1996
35-65% have associated anomalies VATER and VACTERL V A vertebral anomalies or VSD anorectal malformation
C
T E R L
cardiac anomalies (common)

TEF esophageal atresia renal abnormalities limb/radial malformation
Minimize pulmonary complication

npo head-up position sump tube (repogle) on low continuous suction
gastrostomy under local anesthesia
CXR, abdominal x-ray, renal ultrasound
12-L EKG and Echocardiogram : mandatory

IV access arterial line
Tracheoesophageal Fistula Preoperative Preparation
Laboratory studies CBC Electrolytes Glucose Calcium ABGs
Preoperative Preparation 24-48 hr medical stabilization Antibiotics: ampicillin and gentamicin Ensure availability of blood in the OR Optimize volume status and metabolic state Intubation preferably in the operating room under controlled situation
Main Concern
oxygenation and ventilation

securing the airway
Monitors
ASA standard
invasive : arterial line

* precordial stethoscope in the L axillary area
Anesthetic Technique classic approach

GA without muscle paralysis
combined light GA + epidural (Bosenberg)
GA with muscle paralysis
Induction awake intubation rapid sequence IV induction inhalation induction spontaneous ventilation without muscle relaxant
Assessment of ETT position

Goal: ETT just above the carina and just below the fistula Right mainstem intubation and withdraw ETT until bilateral breath sounds Left mainstem intubation: poorly tolerated due to insufficient pulmonary reserve
Tracheoesophageal Fistula Intraoperative Management If g-tube present, place end of g-tube under water seal: ETT above fistula (+) bubbles
Connect capnograph to
g-tube: (+) ETCO2 if ETT above the fistula ? rigid bronchoscopy - not proven
Berry FA, Anesthetic Management of Difficult and Routine Pediatric Patients, 2nd Ed. 1990
Beware of gastric distention

gentle positive pressure ventilation
gastrostomy: open if present
TEF + RDS combination

now what???!!
gastrostomy under local anesthesia fogarty embolectomy catheter
Lateral decubitus position Posterolateral thoracotomy Maintenance of Anesthesia Narcotic technique Inhalation technique + regional anesthesia ? Use of nitrous oxide
Surgical repair
ligation of fistula
check air leak in suture line esophageal repair identify the pouch placement of feeding tube chest tube placement and closure of thoracic cavity
Intraoperative problems Endobronchial intubation Intubation of fistula Obstruction of ETT
V/Q mismatch
lateral decubitus position
nondependent lung retraction
Vagal response to tracheal manipulation Return to transitional circulation and shunting
Postoperative Management
Early extubation desirable
caution: disruption of surgical repair with

reintubation Postop Pain Management 1. IV narcotics 2. epidural infusion: 0.1% bupivacaine + fentanyl 0.5 mcg/ml at 01.-0.2 ml/kg/hr 3. rectal Tylenol + LA infiltration of incision
Main Cause of Mortality associated anomalies
survival rates 85-90% Long Term Complications

GE reflux
anastomotic stricture
tracheomalacia
Abdominal Wall Defects

Gastroschisis
Omphalocoele
Gastroschisis Greek word for belly cleft Evisceration of gut through a 2-3 cm defect in the anterior abdominal wall lateral to the umbilicus, usually on the right
Absence of covering or sac

chemical peritonitis infection
ECF loss
heat loss
Incidence: 1:15,000-30,000 live births
Gastroschisis
Gastroschisis
Etiology
exact cause unknown Theories intrauterine occlusion of omphalomesenteric artery ischemia and atrophy of abdominal muscles early fetal rupture of an omphalocoele
Gastroschisis
rupture of umbilical cord at the site
of the resorbed right umbilical vein

? Maternal: smoking, ETOH,
recreational drugs, medications (NSAIDS, pseudoephredrine) associated anomalies - rare
Omphalocoele
Omphalocoele
External herniation of abdominal viscera into the base of the umbilical cord through a central defect Defect: small or large Umbilical cord is inserted into the apex of the lesion Presence of covering or sac (amnion and peritoneum) Incidence: 1-5,000-10,000 live births
Omphalocoele
Omphalocoele
Etiology
incomplete return of the gut to the abdominal cavity due to an abdominal lateral fold defect Failure of migration and fusion of cranial, caudal and/or lateral folds of the embryonic disc at ~ 3rd wk of gestation
Omphalocoele
Cranial Fold : Pentalogy of Cantrell Epigastric omphalocoele Sternum cleft
Diaphragmatic defect
Ectopia cordis Cardiac anomaly
Omphalocoele
Lateral Fold omphalocoele with cord coming of the
center of the sac

Caudal Fold Hypogastric omphalocoele Extrophy of the bladder Imperforate anus Colonic agenesis Vesicointestinal fistula
Omphalocoele Associated Congenital Anomalies: 75-80% chromosomal: trisomy 13, 15, 21
cardiac anomalies: 20%

craniofacial gastrointestinal Beckwith-Wiedeman Syndrome
omphalocoele visceromegaly macroglossia microcephaly hypoglycemia hyperviscosity
Pentalogy of Cantrell
Omphalocoele
Survival: 20% with heart disease
70% without heart disease

Major cause of mortality cardiac defects prematurity Definitive Treatment: surgical repair
Gastroschisis Incidence Peritoneal covering/sac Location of defect Herniated bowel 1:15,000-30,000 absent periumbilical matted, edematous
Omphalocoele 1:6,000 present within the umbilical cord normal
Associated anomalies
low (10-15%)
intestinal atresia (15%)
high (40-60%)
congenital heart dis. Beckwith-Weidman syndrome
Gastroschisis
Omphalocoele
Preoperative Management
Anesthetic Concerns
Hydration / fluid status
warm moist sterile saline-soaked gauze plastic bowel bag
initial fluid requirement 10 -15 ml/kg/hr; higher with gastroschisis 100-200 ml/kg/hr
Heat loss : neutral thermal environment Difficulties of surgical closure Associated congenital anomalies & prematurity
Infection and postop nutrition Postoperative ventilation Airway Metabolic status
Aspiration precautions
Direct trauma to herniated organ
Lab workup CBC Electrolytes and Glucose ABG
Ancillary Procedures
CXR
Echocardiography
Intraoperative Management Premedication: atropine IV access: 2 large bore IVs preferably above the diaphragm Monitors: ASA standard : 2 pulse oximeters
invasive: arterial line

CVP foley catheter intraop airway pressures
Choice of Anesthesia
general anesthesia spinal (reported) in selected patients
Induction
decompress the stomach rapid sequence IV induction with cricoid pressure or inhalation induction and intubation or awake intubation
Maintenance of Anesthesia
Opiate technique or judicious use of
inhalational agents Avoid nitrous oxide Adjust FiO2: PaO2 50-70 mmHg SpO2 97-98% term
87-92% preterm
Muscle relaxant facilitates abdominal closure
Prevent hypothermia
full access body hugger
increase room temp fluid warmer
heating blanket
plastic wrap
Fluid requirement
maintenance: D5 0.2% NS
3rd space loss replacement

isotonic fluid 10 -15 ml/kg/hr blood loss from adhesions
Surgical Closure
optimal method remains controversial
1) primary fascial closure : 80% intraop and postop muscle paralysis 2) staged repair
silicone elastometer pouch

primary skin closure
Closure dependent on the 1) size of the defect 2) development of abdominal wall 3) presence of associated anomalies
Primary Closure monitor: airway pressure, O2 saturation and ABG tight abdominal closure
1) impairs diaphragmatic excursion ventilatory compromise 2) impedes venous return profound hypotension
3) aortocaval compression bowel ischemia, CO,

renal and hepatic dysfunction, wound dehiscence
Unsafe for Primary Abdominal Closure

Intragastric pressure > 20 cmH2O Intravesical pressure > 20 cmH2O Change in CVP 4 mmHg ETCO2 50 mmHg Peak inspiratory pressure 35 cmH2O
Abdominal Wall Defects Intraoperative Management
Staged Reduction
Dacron reinforced silastic silo
Gradual reduction over 1- 2 weeks Ketamine or opioid muscle relaxant in intubated patients or Titration of ketamine 0.5 -1 mg/kg IV with spontaneous breathing unintubated infants Final closure in the OR
Abdominal Wall Defects Intraoperative Management
Silo closure
To extubate or not to extubate?

Size of patient
Intraoperative events Prematurity Associated pathology Hemodynamic status Magnitude of the abdominal defect Type of repair
Postoperative Management
NICU Postop ventilation in most neonates for 24-48 hrs Fluid requirements may remain high Prolonged postop ileus: TPN or PPN
Prevent infection: higher with silo

Watch for circulatory compromise cyanotic lower limbs Postop HTN due to renal perfusion and activation of renin-angiotensin-aldosterone
Early Postoperative Complications
Necrotizing enterocolitis
Renal insufficiency
Pneumonia
Abdominal wall breakdown
PDA
GE reflux
Necrotizing Enterocolitis (NEC)
Life-threatening intestinal inflammation or injury Caused by bacterial invasion of previously
injured or ischemic bowel wall

Incidence: 5 -10% in infants <1500g birth
weight
Mortality rate: 10 - 30%
Single most important factor
PREMATURITY
Can occur in:
premature infants
LBW infants
Full term infants

fed and unfed infants

Other factors ischemia bacterial infection GI endotoxemia
enteral feeding
use of hyperosmolar formula congenital heart disease hx of umbilical arterial catheterization hx of exchange transfusion
Early signs
gastric residuals with feedings temperature instability poor feeding bilious vomiting lethargy
mucoid or bloody stool

apnea and bradycardia
Necrotizing Enterocolitis
Late Signs Hemodynamic instability Anemia
Thrombocytopenia
Coagulopathy, DIC
Prerenal azotemia
Metabolic acidosis
Physical Exam distended and tender abdomen Labs: CBC electrolytes and glucose platelets and coagulation profile
DIC profile
ABG
Abdominal X-ray
signs of bowel obstruction ileus with edematous bowel
Pneumatosis intestinalis
or intramural air (arrow)
portal vein air

pneumoperitoneum
Medical Management
initial treatment, for 7-10 days

75% successful Surgical Treatment
10 - 50% mortality
Medical Management
No enteral feedings for 10-14 days NGT on intermittent suction Hydration and correction of electrolytes Ventilatory support Antibiotics Blood and platelet transfusion if needed
Surgical Indications
Absolute Indications
1) bowel perforation
new mx: peritoneal drains under

local anesthesia
2) intestinal gangrene
Relative Indications
clinical condition
metabolic acidosis
respiratory failure oliguria, hypovolemia thrombocytopenia leucopenia, leukocytosis
air in the portal vein

bowel wall edema persistent dilated bowel loops
Necrotizing Enterocolitis
Non-Surgical Indications severe GI hemorrhage abdominal tenderness intestinal obstruction gasless abdomen with ascites
Necrotizing Enterocolitis (NEC) Preoperative Management
Anesthetic Concerns
Fluid/volume status
Significant 3rd space loss Full stomach / pulmonary aspiration Metabolic abnormalities acidosis, hyperglycemia
Necrotizing Enterocolitis (NEC) Preoperative Management
Electrolyte imbalance: hyperkalemia
Coagulopathy: thrombocytopenia
Respiratory failure Sepsis / hemodynamic instability
inotropic support dopamine infusion
Adequate IV access
Monitors:
ASA standard
invasive: arterial line, CVP

foley catheter
Induction
rapid sequence if not intubated
Maintenance of Anesthesia
Narcotic based technique Avoid nitrous oxide Inhalational agents poorly tolerated
Massive fluid requirements

PRBC, FFP and platelets transfusion
Avoid hypothermia
Give blood early when indicated
Postop Management
NICU Postop ventilation required Continue resuscitation Parenteral Nutrition
Summary
Almost all neonatal surgical emergencies are really urgencies
Immaturity of organ system in neonates

alters pharmacology and physiology Thorough preop assessment is required in all neonates One anomaly mandates a search for others
Murmurs necessitate a cardiology consult
Successful perioperative outcome depends on open communication and teamwork between neonatologist, anesthesiologist and surgeon Initial resuscitation of neonatal surgical candidates includes:
airway protection adequate IV access fluid resuscitation temperature stabilization gastric decompression administration of antibiotics identify associated anomalies
Omphalocoele
Embryology Failure of the midgut to return to the abdominal cavity by the 10th wk of gestation

Neonatal Emergencies

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Neonatal Emergencies

Cardiac and respiratory status

Hypertrophy of the muscular layer of the pylorus

? acquired condition with hereditary

Presents with nonbilious projectile vomiting, signs of dehydration, jaundice (2%)

Labs: CBC ABG

serum electrolytes BUN

Pyloric Stenosis Metabolic Abnormalities

compensatory respiratory acidosis

Correction of electrolyte imbalance

Anesthetic Concerns pulmonary aspiration severe dehydration

Decompress the stomach

Pyloric Stenosis Intraoperative Management

Cook-Sather, 1998 (CHOP)

Postop pain relief

Congenital Diaphragmatic Hernia

Congenital Diaphragmatic Hernia

return of midgut to the peritoneal cavity

M<F 1:1.8, frequently full term

Congenital Diaphragmatic Hernia

Congenital Diaphragmatic Hernia

Associated anomalies (20-50%)

Congenital Diaphragmatic Hernia

Classic Triad Dyspnea

Congenital Diaphragmatic Hernia

Congenital Diaphragmatic Hernia

Diagnosis: chest x-ray

absent lung markings

Congenital Diaphragmatic Hernia

IMMEDIATE Intubation + Stomach Decompression

Congenital Diaphragmatic Hernia

Determinants of Survival degree of pulmonary hypoplasia

development pulmonary vasculature

Congenital Diaphragmatic Hernia

Goals of Management maximize arterial oxygenation

increases pulmonary blood flow

Congenital Diaphragmatic Hernia

Standard Management Strategy

PaO2 >100 mmHg

Congenital Diaphragmatic Hernia

Postductal SpO2 ignored unless pH is

recommended 24 48 hrs medical stabilization

Congenital Diaphragmatic Hernia

Poor survival in the presence of severe pulmonary hypoplasia

Congenital Diaphragmatic Hernia

Congenital Diaphragmatic Hernia

Relationship of Alveolar-arterial Oxygen Tension Difference in Diaphragmatic Hernia in the Newborn

Congenital Diaphragmatic Hernia

Congenital Diaphragmatic Hernia

Congenital Diaphragmatic Hernia

Look for associated anomalies

Labs: CBC, electrolytes, ABG, glucose,

Ancillary procedures: CXR, Echo

Congenital Diaphragmatic Hernia

NGT to decompress the stomach Adequate IV access

Congenital Diaphragmatic Hernia

Congenital Diaphragmatic Hernia

treat metabolic acidosis

Congenital Diaphragmatic Hernia

Intraoperative Mechanical Ventilation adjust FiO2 to achieve PaO2 80 -100 mmHg

Thoracoscopic repair has been reported

Congenital Diaphragmatic Hernia

1 pulmonary hypoplasia / pulmonary HTN

Hypotension or IVC compression