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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

Quick Response Code:
Congenital diaphragmatic hernia results from the anomalous Website:
closure of pericardioperitoneal canal. There are various
challenges faced by anesthesiologists during management
of such cases which include intraoperative complications DOI:
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 costophrenic sulcus.[5] Ultrasonography is vital for antenatal
birth following feeding, due to congenital diaphragmatic diagnosis of CDH.[5]

Keywords: Congenital diaphragmatic hernia, hypoxia,

Case Report
pulmonary hypertension, pulmonary hypoplasia
A 2‑month‑old female child weighing 2.5 kg presented with
difficulty in breathing after feeding since birth. On physical
Introduction examination, child was conscious and comfortable, with mild
peripheral cyanosis. Pulse rate was 120/min, respiratory rate
Congenital diaphragmatic hernia is a neonatal surgical 50/min, SpO2 91% on room air. On examination the patient
emergency. This malformation occurs in 1 in 2,500 live had a scaphoid abdomen. Respiratory system auscultation
births and affects left side 4 to 8 times more than the right.[1‑4] showed air entry reduced bilaterally, more on left side. Heart
It results from anomalous closure of pericardioperitoneal sounds were heard on right side of the chest. Chest X‑ray
canal.[2] Consequently, abdominal organs develop in the [Figure 1] showed right mediastinal shift with stomach
pleural cavity, impairing the growth of the ipsilateral lung.[1] and bowel loops in left hemithorax. Echocardiography was
In 90% of the cases the hernia is on the left side through normal with an ejection fraction of 70%.
foramen of Bochdalek.[3]
Anesthetic Management
Infants with severe hypoplasia exhibit symptoms in the Monitors were connected including pulse oximeter (SpO2),
first few minutes to hours of life. Patients with herniation electrocardiogram (ECG), and end tidal carbon
are occurring late in gestation with less severe hypoplasia dioxide (EtCO2). The stomach tube was aspirated to empty
usually present late. Classic triad of CDH includes; cyanosis, the stomach. Preoxygenation with 100% oxygen was given
dyspnea, andapparentdextrocardia.[5] Physical examination for 3 min. Injection (Inj.) Fentany l 5 µg intravenously (IV)
shows; scaphoid abdomen, bulging chest, decreased breath was given for analgesia. Induction was done with oxygen
sounds, right displaced heart sounds, and bowel sounds in and sevoflurane on spontaneous respiration. Following
chest.[5] Radiographic examination shows; bowel gas pattern induction, muscle relaxation was achieved using Inj.
in the chest, mediastinal shift, and little lung tissue at the 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.

Medical Journal of Dr. D.Y. Patil University | July-September 2013 | Vol 6 | Issue 3 281
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Joshi and George: Anesthetic management of a case of congenital diaphragmatic hernia

endotracheal tube was passed orally [Figure 2]. Patient baby was extubated on the 5th postoperative day and was
was maintained on oxygen, sevoflurane, Inj. fentanyl IV, subsequently discharged.
and Inj. rocuronium IV as a long acting muscle relaxant.
The patient was ventilated with a pediatric bains circuit. Discussion
Intraoperatively, patient was normothermic, pulse rate was
maintained around 130/min, SpO2 was 99%, and ECG was CDH has a hi gh mortali ty rate of 62%. [6 ] The
within normal limits. degreeofpulmonary hypoplasia and associated abnormalities
are predictive of survival of the baby. They also influence the
Surgical Procedure development of chronic restrictive lung disease in survivors.
Following surgical correction [Figures 3 and 4], the Early antenatal diagnosis, with proper perioperative
baby was shifted to NICU. She was put on synchronized management is vital for good prognosis. Nitrous oxide (N2O)
intermittent mechanical ventilation  (SIMV) mode with should be avoided as it diffuses inside the viscera and
fractional inspired oxygen concentration  (FiO2) of 60%. exaggerates lung compression.[5] Challenges faced by us
Peak inspiratory pressure  (PiP) was 20‑25 cmH 2 O, during management of this case, included the possibility
positive end‑expiratory pressure (PEEP) was 5 cmH2O and for reversal of shunt in the presence of already existent
inspiratory:expiratory  (I:E) ratio was 1:2.4. Postsurgical pulmonary hypoplasia, pulmonary hypertension, and
chest X‑ray showed both the lungs to be well‑expanded. systemic hypotension due to mediastinal shift. The primary
The baby was kept on ventilator support for 5 days to pulmonary hypoplasia and pulmonary hypertension would
allow time for diaphragmatic wound healing and adequate lead to hypoxemia. Therefore, ventilation with low tidal
ventilation during the crucial post operative period. The 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 Principles and Practice. 1st ed. vol. 9. New York, McGraw‑Hill
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References 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.
1. Boulay G, Simon L, Hamza J. Normal and abnormal prenatal
development. In: Bissonnette B, editor. Pediatric Anesthesia, Source of Support: Nil. Conflict of Interest: None declared.

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