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| CASE REPORT |
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| Year : 2021 | Volume
: 5
| Issue : 1 | Page : 53-56 |
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Anesthesia management of congenital diaphragmatic hernia in neonates
Harry Pranata, Putu Kurniyanta
of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Denpasar, Indonesia
| Date of Submission | 19-Aug-2020 |
| Date of Decision | 11-Oct-2020 |
| Date of Acceptance | 20-Oct-2020 |
| Date of Web Publication | 8-Feb-2021 |
Correspondence Address:
Dr. Harry Pranata
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232
Indonesia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/BJOA.BJOA_192_20
Congenital diaphragmatic hernia (CDH) is an emergency case in neonates. The prevalence of CDH is 1 in 2500 births and occurs 4–8 times more commonly on left side than right side. CDH is usually worsened by pulmonary hypoplasia and pulmonary hypertension. It is characterized by respiratory failure and bowel sound in the chest area and mostly requires surgical procedure. This case report discusses a neonate with congenital left diaphragmatic hernia who underwent surgical procedure to close the defect. Patients present with cyanosis and shortness of breath, are early intubated, and are mechanically ventilated in neonatal intensive care unit (NICU). In the present case, the surgical procedure lasted approximately 2 h with general anesthesia, with hemodynamic stability during the surgery. The patient was thereafter intubated and treated at the NICU for close monitoring.
Keywords: Diaphragmatic hernia, pulmonary hypertension, pulmonary hypoplasia
How to cite this article:
Pranata H, Kurniyanta P. Anesthesia management of congenital diaphragmatic hernia in neonates. Bali J Anaesthesiol 2021;5:53-6 |
| Introduction | |  |
Congenital diaphragmatic hernia (CDH) is an emergency condition for neonates. CDH is considered a congenital malformation and has become a challenge to physicians for comprehensive management. The prevalence of CDH is 1 in 2500 births and occurs 4–8 times more commonly on left side than right side. CDH is a birth defect in the diaphragm where abdominal organs can pass through the defect in the diaphragm and upwards into a baby's chest. These conditions could disturb the development of one side of the lung. In most cases of hernia, around 90% occur in the left side through Bochdalek's foramen. CDH is usually aggravated by pulmonary hypertension and related to cardiopulmonary dysfunction. Cardiopulmonary dysfunction is generally caused by hypoplasia and pulmonary hypertension more commonly compared to the mass effect of herniated viscera. Based on literatures, CDH has a high mortality rate. The severity of pulmonary hypoplasia and congenital abnormalities determines the survival rate of CDH patients. These complexities lead to another condition called chronic restrictive lung.[1],[2]
Infants with CDH will generate symptoms in minutes until hours after birth. CDH at the end of the gestation with mild hypoplasia usually occurs late and can influence the outcome. The classic triad of CDH consists of cyanosis, dyspnea, and dextrocardia. Scaphoid abdominal, decreased breath sound, right shifting cardiac sound, and the peristaltic sound in the chest cavity are some signs that indicate CDH. On the other hand, radiography shows bowel gas in the chest cavity, shifting of mediastinum, and small lung tissue at the costophrenic sulci. Therefore, antenatal ultrasound is one of the most important diagnostic modalities in the early diagnosis of CDH.[2],[3]
The challenge encountered in CDH includes respiratory distress which is related to the hypoplasia of lung parenchyma,hypoxemia, hypercarbia, metabolic acidosis, pulmonaryhypertension, shunting from right to left, andproblems ininfants themselves such as bradycardia, hypoglycemia, andhypothermia. Since 1980, emergency procedure is the standard therapy of CDH in order to revive the respiratory function and recoiling ability of the lung.[1],[4]
Intraoperative management should ensure adequate gas exchange, close monitoring, prevention of aspiration, and pain management after procedure. Monitoring of circulation should ideally be using invasive approach. Nitrous oxide should be avoided because of its ability to diffuse into the viscera and increase compression in the lung. CDH patients should be admitted in the intensive care unit after the procedure to monitor the lung. The earlier the diagnosis particularly with antenatal care, the better the prognosis of the patient.[3],[5]
| Case Report | | |
A 25-day-old male was referred from a district hospital to Sanglah General Hospital in Denpasar, Bali, Indonesia, with a diagnosis of CDH. The patient's parents reported that since birth, the patient was treated at the neonatal intensive care unit (NICU) with the complaints of cyanosis and shortness of breath. The birth weight of the patient was 3200 g; the baby was born at full term by cesarean delivery in a district hospital and immediately cried. The patient was the third child. The patient's current weight is 3900 g. Antenatal care was checked routinely during pregnancy. Both history of illness and infection during pregnancy were denied. Chest X-ray and abdominal X-ray were done and diaphragmatic hernia was found. The patient was intubated and treated at the NICU using a ventilator. On further examination, the patient was diagnosed with congenital hernia in the left diaphragm (suspected Bochdalek hernia) and was planned for a laparotomy hernial repair.
The preoperative mechanical ventilator setting was as follow: pressure control, peak inspiratory pressure of 18 mmHg, positive end-expiratory pressure of 6 mmHg, respiratory rate of 50 times/min, inspiration: expiration ratio of 1:2, and inspired oxygen fraction of 30%. There was retraction in the chest and bowel sounds were heard in the left lung during physical examination. There were neither rhonchi sound nor wheezing sounds, with oxygen saturation ranging from 92% to 94%. Cardiac examination showed a normal heart with a frequency of 140–160 beats/min with a regular heart rate. On abdominal examination, the abdomen looked scaphoid, with a nonpalpable liver and spleen. The bowel sounds are still positive.
Laboratory examination revealed that the results of blood gas analysis were within normal limits. Chest X-ray revealed intestinal loops in the left hemithorax that shift the mediastinum to the right, as shown in [Figure 1], whereas the abdominal X-ray confirmed a left diaphragmatic hernia [Figure 2]. | Figure 2: Left diaphragmatic hernia that urges the structure of the right mediastinum
Click here to view |
Preoperative preparation included a blanket warmer, temperature setting, STATIC, emergency medicine, and patient monitoring equipment. The patient was shifted to the operating room, where the symmetrical nature of the chest expansion was rechecked. An aspirated orogastric tube was mounted for emptying the stomach, with 0.1-mg atropine sulfate as a premedication inducted with sevoflurane and O2. We utilized oxygen and air mixture, sevoflurane, and intermittent fentanyl and atracurium to maintain anesthesia. The surgery lasted for approximately 2 h. During the surgery, the heart rate was stable (130–150 beats/min) and oxygen saturation ranged from 96% to 99%. Ringer lactate (110 mL) was given, with the amount of bleeding at ±15 cc. Postanesthetic induction, the patient was treated at the NICU with ventilator support.
The postoperative outcome revealed a 5-cm intestine in the left diaphragm, which was repositioned into the intra-abdominal space, and the diaphragm was sutured. The left lung had expanded and recoiled to the normal state and twe found no intestinal sound on chest auscultation, as shown in [Figure 3]. 24 h postoperatively, the patient was given 20-μg fentanyl and paracetamol 40 mg every 6 h intravenously as an analgesic. | Figure 3: A part of the intestine in the left lung that urges the right mediastinum
Click here to view |
| Discussion | | |
CDH is a congenital abnormality due to closure of the pericardio-peritoneal canal, causing the abdominal organs to develop in the ipsilateral lung. The incidence of CDH is 1 out of 2500 births accompanied by other anomalies. The Bochdalek hernia most commonly occurs in CDH patients. The prevalence of CDH on the left side is 4–8 times more common than that on the right side. Patients with CDH have clinical symptoms such as respiratory distress, cyanosis, abnormal chest development, and pulmonary sounds in the ipsilateral region. The diagnosis of CDH is confirmed on chest radiography examination.[6]
Complications that arise in patients with CDH include respiratory distress associated with pulmonary parenchymal hypoplasia, hypoxemia, metabolic acidosis, pulmonary hypertension, and right-to-left shunting. Management includes early intubation, mechanical ventilation, venous access, fluid resuscitation, antibiotic administration, and installation of nasogastric/orogastric tubes for decompression.[7] In the presented case above, the patient was intubated and treated at the NICU before surgery. Blood gas analysis was performed and checked periodically during treatment. An orogastric tube was inserted and periodic suction was done to prevent aspiration. Parenteral nutrition was given during the treatment to optimize the patient's condition before performing the surgery. The advantage of optimizing patients at the NICU is to reduce the risk of pulmonary hypertension. In this patient, laparotomy hernial repair was performed with the aim of improving the respiratory status, making the lungs expand again and increasing the patient's life expectancy.[3],[8]
Intraoperative management of our patient included a close monitoring, adequate oxygenation, aspiration prevention, and postoperative pain control. In infants, bradycardia and hypothermia can occur more commonly during surgery. Infant anesthesia is recommended under general inhalation anesthesia with controlled breathing.[9] In this case, the operating room temperature was adjusted and a blanket warmer was installed to prevent hypothermia in the patient. The patient was given a premedication of atropine 0.1 mg intravenously, with the aim of preventing bradycardia due to anesthesia.
The postoperative outcome revealed a 5-cm intestine in the left diaphragm, which was repositioned into the intra-abdominal space, and the diaphragm was sutured. The left lung had expanded and recoiled to the normal state and there is no sound of intestines on the chest area. Ventilation and oxygenation were adequately controlled to prevent barotrauma. Electrocardiography, pulse oximetry, end-tidal CO2, and urinary catheters were used for monitoring during the surgery. The occurrence of bleeding was monitored by the amount of gauze and blood in the suction. Urine production was monitored to assess the adequacy of fluid in surgery. The bleeding in this case was around 15 mL, with 110 mL of fluid administered during the surgery.[1],[3]
The patient was treated in the NICU and intubated with close monitoring post surgery. The patient remained intubated with ventilatory support until improved lung development. Fentanyl and paracetamol were administered as analgesic support after the surgery.[4],[5]
| Conclusion | | |
Patients with diaphragmatic hernia require multidisciplinary surgical management including anesthesiology, perinatology, and pediatric surgery. Anesthesia management in diaphragmatic hernias requires special attention because patients have lung problems with the possibility of pulmonary hypoplasia. Infant anesthesia requires close monitoring, good airway management, hypothermia prevention, and fluid balance. Patients also require close monitoring after surgery, so patients are considered to be treated in the NICU. Monitoring respiratory function with mechanical assistance, periodic gas analysis, and radiological examinations is required to assess patient's respiratory function.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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