What are the anesthetic considerations for the neonate with CDH?

What are the anesthetic considerations for the neonate with CDH?

Once the patient is stabilized, surgery may be scheduled. A transabdominal approach is the technique preferred by most surgeons. The abdominal organs are reduced and the diaphragm is either repaired primarily or with a synthetic patch. In most cases, the abdomen can be closed primarily but in some instances a Silastic pouch may need to be created.

The anesthetic management of these patients includes the continuation of the measures instituted preoperatively to improve oxygenation and ventilation and to promote a decrease in PVR. This includes hyperventilation to achieve a PaCO₂ of 25–30 mmHg, oxygenation so that the arterial oxygen tension (PaO₂) is greater than 80 torr, and a pH greater than 7.5. To decrease the need for excessive ventila-tor pressures, small tidal volumes and rapid respiratory rates may be necessary. Pharmacologic infusions should be continued. Arterial blood gases should be monitored fre-quently and any changes in ventilation, oxygenation, and acid–base balance should be treated expeditiously. It is important to avoid hypoxia and acidosis, which would lead to an increase in PVR that would be very difficult to reverse. Measures to prevent hypothermia are also impor-tant in the management of these patients.

All anesthetic agents may be used in these neonates with the exception of nitrous oxide. Nitrous oxide may cause intestinal distention, which may further compromise the neonate and impede abdominal closure. However, depend-ing on the cardiovascular stability of the neonate, inhalation agents may not be tolerated well. In most cases, an oxygen-opioid-muscle relaxant combination would be optimal.