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Case Report

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

ABSTRACT Access this article online

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Congenital diaphragmatic hernia results from the anomalous Website:
closure of pericardioperitoneal canal. There are various www.mjdrdypu.org
challenges faced by anesthesiologists during management
of such cases which include intraoperative complications DOI:
including hypoxia and hypercarbia, which leads to pulmonary
10.4103/0975-2870.114644
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 costophrenic sulcus.[5] Ultrasonography is vital for antenatal
birth following feeding, due to congenital diaphragmatic diagnosis of CDH.[5]
hernia.

Keywords: Congenital diaphragmatic hernia, hypoxia,

pulmonary hypertension, pulmonary hypoplasia
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.[1‑4]
It results from anomalous closure of pericardioperitoneal
canal.[2] Consequently, abdominal organs develop in the
pleural cavity, impairing the growth of the ipsilateral lung.[1]
In 90% of the cases the hernia is on the left side through
foramen of Bochdalek.[3]
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.[5] Physical examination
shows; scaphoid abdomen, bulging chest, decreased breath
sounds, right displaced heart sounds, and bowel sounds in
chest.[5] Radiographic examination shows; bowel gas pattern
in the chest, mediastinal shift, and little lung tissue at the
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, SpO2 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%.
Anesthetic Management
Monitors were connected including pulse oximeter (SpO2),
electrocardiogram (ECG), and end tidal carbon
dioxide (EtCO2). 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

Address for correspondence:

Dr. Arun George, Department of Anesthesia, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharashtra, India.
E‑mail: arun.george.dr@gmail.com

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Joshi and George: Anesthetic management of a case of congenital diaphragmatic hernia

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, SpO2 was 99%, and ECG was
within normal limits.
Surgical Procedure
Following surgical correction [Figures 3 and 4], the
baby was shifted to NICU. She was put on synchronized
intermittent mechanical ventilation  (SIMV) mode with
fractional inspired oxygen concentration  (FiO2) of 60%.
Peak inspiratory pressure  (PiP) was 20‑25 cmH 2 O,
positive end‑expiratory pressure (PEEP) was 5 cmH2O 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 5th postoperative day and was
subsequently discharged.
Discussion
CDH has a hi gh mortali ty rate of 62%. [6 ] 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 (N2O)
should be avoided as it diffuses inside the viscera and
exaggerates lung compression.[5] 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 SpO2,

Figure 1: Chest X‑ray showing gas bubble in left hemithorax and right
mediastinal shift Figure 2: Chest X‑ray showing nasogastric tube in the stomach

Figure 3: Viscera delivered from thoracic cavity Figure 4: Diaphragm closed with prolene

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Joshi and George: Anesthetic management of a case of congenital diaphragmatic hernia
EtCO2 and intraoperative airway pressures is important to
prevent hypoxemia. The intraoperative airway pressure
was maintained at <25 cmH2O.
Postoperative ventilation can be associated with barotrauma.
Hence, low inspiratory pressure (<25 cmH2O) and low tidal
volumes should be set.[7] Infants with large defects may not
tolerate primary closure of abdomen.[2] 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.[1]
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 PaCO2 >50 mmHg at FiO2
of 1.0, extracorporal membrane oxygenation (ECMO) should
be initiated early to prevent lung injury.[8] The concept of
permissive hypercarbia (PaCO2 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.[6]
References
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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.
Source of Support: Nil. Conflict of Interest: None declared.