|Year : 2013 | Volume
| Issue : 3 | Page : 281-283
Anesthetic management of a case of congenital diaphragmatic hernia; delayed diagnosis
Smita Joshi, Arun George
Department of Anesthesia, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||5-Jul-2013|
Department of Anesthesia, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Congenital diaphragmatic hernia results from the anomalous closure of pericardioperitoneal canal. There are various challenges faced by anesthesiologists during management of such cases which include intraoperative complications including hypoxia and hypercarbia, which leads to pulmonary hypertension and right to left shunt. Mortality remains high because of associated pulmonary hypoplasia and pulmonary hypertension. Here, we describe anesthetic management of a 2-month-old female child with difficulty in breathing since birth following feeding, due to congenital diaphragmatic hernia.
Keywords: Congenital diaphragmatic hernia, hypoxia, pulmonary hypertension, pulmonary hypoplasia
|How to cite this article:|
Joshi S, George A. Anesthetic management of a case of congenital diaphragmatic hernia; delayed diagnosis. Med J DY Patil Univ 2013;6:281-3
|How to cite this URL:|
Joshi S, George A. Anesthetic management of a case of congenital diaphragmatic hernia; delayed diagnosis. Med J DY Patil Univ [serial online] 2013 [cited 2017 Apr 30];6:281-3. Available from: http://www.mjdrdypu.org/text.asp?2013/6/3/281/114644
| Introduction|| |
Congenital diaphragmatic hernia is a neonatal surgical emergency. This malformation occurs in 1 in 2,500 live births and affects left side 4 to 8 times more than the right. ,,, It results from anomalous closure of pericardioperitoneal canal.  Consequently, abdominal organs develop in the pleural cavity, impairing the growth of the ipsilateral lung.  In 90% of the cases the hernia is on the left side through foramen of Bochdalek. 
Infants with severe hypoplasia exhibit symptoms in the first few minutes to hours of life. Patients with herniation are occurring late in gestation with less severe hypoplasia usually present late. Classic triad of CDH includes; cyanosis, dyspnea, andapparentdextrocardia.  Physical examination shows; scaphoid abdomen, bulging chest, decreased breath sounds, right displaced heart sounds, and bowel sounds in chest.  Radiographic examination shows; bowel gas pattern in the chest, mediastinal shift, and little lung tissue at the costophrenic sulcus.  Ultrasonography is vital for antenatal diagnosis of CDH. 
| Case Report|| |
A 2-month-old female child weighing 2.5 kg presented with difficulty in breathing after feeding since birth. On physical examination, child was conscious and comfortable, with mild peripheral cyanosis. Pulse rate was 120/min, respiratory rate 50/min, SpO 2 91% on room air. On examination the patient had a scaphoid abdomen. Respiratory system auscultation showed air entry reduced bilaterally, more on left side. Heart sounds were heard on right side of the chest. Chest X-ray [Figure 1] showed right mediastinal shift with stomach and bowel loops in left hemithorax. Echocardiography was normal with an ejection fraction of 70%.
|Figure 1: Chest X-ray showing gas bubble in left hemithorax and right mediastinal shift|
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Monitors were connected including pulse oximeter (SpO 2 ), electrocardiogram (ECG), and end tidal carbon dioxide (EtCO 2 ). The stomach tube was aspirated to empty the stomach. Preoxygenation with 100% oxygen was given for 3 min. Injection (Inj.) Fentany l 5 μg intravenously (IV) was given for analgesia. Induction was done with oxygen and sevoflurane on spontaneous respiration. Following induction, muscle relaxation was achieved using Inj. succinylcholine chloride 5 mg IV. A 3.5 uncuffedPortex endotracheal tube was passed orally [Figure 2]. Patient was maintained on oxygen, sevoflurane, Inj. fentanyl IV, and Inj. rocuronium IV as a long acting muscle relaxant. The patient was ventilated with a pediatric bains circuit. Intraoperatively, patient was normothermic, pulse rate was maintained around 130/min, SpO 2 was 99%, and ECG was within normal limits.
Following surgical correction [Figure 3] and [Figure 4], the baby was shifted to NICU. She was put on synchronized intermittent mechanical ventilation (SIMV) mode with fractional inspired oxygen concentration (FiO 2 ) of 60%. Peak inspiratory pressure (PiP) was 20-25 cmH 2 O, positive end-expiratory pressure (PEEP) was 5 cmH 2 O and inspiratory:expiratory (I:E) ratio was 1:2.4. Postsurgical chest X-ray showed both the lungs to be well-expanded. The baby was kept on ventilator support for 5 days to allow time for diaphragmatic wound healing and adequate ventilation during the crucial post operative period. The baby was extubated on the 5 th postoperative day and was subsequently discharged.
| Discussion|| |
CDH has a high mortality rate of 62%.  The degreeofpulmonary hypoplasia and associated abnormalities are predictive of survival of the baby. They also influence the development of chronic restrictive lung disease in survivors. Early antenatal diagnosis, with proper perioperative management is vital for good prognosis. Nitrous oxide (N 2 O) should be avoided as it diffuses inside the viscera and exaggerates lung compression.  Challenges faced by us during management of this case, included the possibility for reversal of shunt in the presence of already existent pulmonary hypoplasia, pulmonary hypertension, and systemic hypotension due to mediastinal shift. The primary pulmonary hypoplasia and pulmonary hypertension would lead to hypoxemia. Therefore, ventilation with low tidal volume and careful intraoperative monitoring of SpO 2 , EtCO 2 and intraoperative airway pressures is important to prevent hypoxemia. The intraoperative airway pressure was maintained at <25 cmH 2 O.
Postoperative ventilation can be associated with barotrauma. Hence, low inspiratory pressure (<25 cmH 2 O) and low tidal volumes should be set.  Infants with large defects may not tolerate primary closure of abdomen.  In such cases, the viscera needs to be covered with a silastic pouch initially and the abdomen is stretched and then closed at a later stage.  This gives time for gradual healing.
| Conclusion|| |
Early antenatal diagnosis, avoiding high airway pressures during ventilation, and hemodynamical stability can lead to better outcome. In cases of severe lung hypoplasia and pulmonary hypertension where PaCO 2 >50 mmHg at FiO 2 of 1.0, extracorporal membrane oxygenation (ECMO) should be initiated early to prevent lung injury.  The concept of permissive hypercarbia (PaCO 2 of 45-55 mmHg and pH of 7-7.3) and gentle ventilation may have the most significant impact on survival in neonates with CDH. 
| References|| |
|1.||Boulay G, Simon L, Hamza J. Normal and abnormal prenatal development. In: Bissonnette B, editor. Pediatric Anesthesia, Principles and Practice. 1 st ed. vol. 9. New York, McGraw-Hill Professional; 2001. p. 987-8. |
|2.||Raab EL, Kelly LK, Friedlich PS, Ramanathan R, Seri I. Neonatal respiratory failure. In: Nicols DG, editor. Rogers text book of pediatric intensive care. 4 th ed. Philadelphia, Lippincott Williams and Wilkins; 2008. p. 707-8. |
|3.||Kote CJ. Pediatric Anesthesia (specific neonatal and surgical procedures). In: Miller RD, editor. Millers Anesthesia. 7 th ed. Philadelphia, Churchill Livingstone; 2010. p. 2590-1. |
|4.||Gosche JR, Islam S, Boulanger SC. Congenital diaphragmatic hernia: Searching for answers. Am J Surg 2005;190:324-32. |
|5.||Brett CM, Davis PJ, Bikhazi G. Anesthesia for neonates and premature infants. In: Motoyama EK, Davis P, editors. Smiths Anesthesia for infants and children. 7 th ed. Philadelphia, Mosby; 2005. p. 545-6. |
|6.||Soliman D, Cladis F, Davis P. The pediatric patient. In: Fleisher LA, editor. Anesthesia and uncommon diseases. 5 th ed. Philadelphia: Saunders; 2005. p. 627-9. |
|7.||Lee C, Luginbuehl I, Bissonette B, Mason L. Pediatric diseases. In: Hines RL, Marschall KE, editors. Stoelting's Anesthesia and Co existing diseases. 5 th ed. Philadelphia, Saunders; 2008. p. 593-4. |
|8.||Roberts Jr JD, Romanell TM, Todres D. Neonatal Emergencies. In: Cote CJ, Lerman J, Todres ID, editors. A practice of Anesthesia for infants and children. 4 th ed. Philadelphia: Saunders; 2008. p. 758-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]