12 HERNIA DIAFRAGMATICA-BATAM.pdf

HERNIA DIAFRAGMATICA ANESTHESIA PERSPECTIVE

IRA PITALOKA

Departemen Anestesiologi dan Reanimasi Divisi Anestesi Pediatri

Fakultas Kedokteran Universitas Airlangga SURABAYA

INTRODUCTION � Congenital Hernia Diafragmatica result

from the anomalies closure of pericardioperitoneal canal.

� Chalenging for anesthesiologist

� Many complications in management preoperatively until post-operatively

� Mortality remain high due to pulmonary hypoplasia and pulmonary hypertention.

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EPIDEMILOGY � This is a neonatal surgery emergency.

� Occurs in 1:2500 live births and affect left side 4 to 8 times than the right side.

�  90% of the cases the hernia are on the posterolaterally and 80% are left side through foramen of Bochdalek

� There are 3 types : 1.  The posterolateral Bochdalek hernia 2.  The anterior Morgagni hernia 3.  The hiatus hernia 9/11/15 CPPU Indonesia Batam 3

ETIOLOGY


Etiology is unclear, 2% is occur with familial association. About 40% of CHD patient have associated with major congenital anomalies.

Pathophysiology

� The affected lung is intrinsically abnormal, all stages of lung development being affected.

� The lungs have underdeveloped airways, abnormal differentiation of type II pneumocytes, and a reduced number of pulmonary arteries perunit lung volume.


Pathophysiology

� Intrapulmonary arteries become excessively muscularized during gestation with thickened adventitia and media;more over ,muscularization extends more peripherally.

� These pulmonar vessels display anabnormal response to vasoactive substance.


ANTENATAL DIAGNOSIS and MANAGEMENT

� Routine ultrasound scan in the second trimester of pregnant woman have increase the antenatal detection rate of CHD.

� Morphological and immaturity of the affected lung in patient with CHD suggest that surfactant deficiency may play a role in the pathophysiology of the condition.

� The beneficial effect of prenatal use of corticosteroid for infant with CHD remain unproven.


DIAGNOSIS

� Classic Triad of CHD include : respiratory distress(dyspneu), cyanosis, and apparent dextrocardia sometimes with cardiovascular insufisiency. � Physical examination : scaphois abdomen, barrel-shaped chest, decreased breath sound, right displace heart sound and bowel sounds in chest.

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DIAGNOSIS � Radiographic

examination

1.shows bowel gas pattern in the chest

2. mediastinal shift

3. little lung tissue

at the costophenic

sulcus 9/11/15 CPPU Indonesia Batam 9


Diagnosis � Laboratories :

1.  BGA to assess pH,pO2,pCO2

2.  Lactate to assessing circulatory insuficiency or severe hypoxemia associated with tissue hypoxia

3.  Level of electrolite


POSTNATAL RESUSCITATION and STABILIZATION

� Routine caesarean delivery of prenatally diagnosis of CHD doesnot confer any benefits over vaginal delivery.

� Delivery should be as close to term (37-38 weeks) as possible to maximize pulmonary maturity and in the centre that has the experienced personnel and resources necessary to care for the critically ill neonate.

� AVOID bag and mask ventilation to prevent gut distention.


Management Post Natal Care � The infant should be intubated and ventilated,

� Large bore orogastric tube is passed to decompress the intrathoracic bowel.

� AVOID BAROTRAUMA, peak ispiratory pressure should not exceed 25cmH2O.

� FiO2 should be adjusted so the preductal arterial saturation (SaO2) are 85%-95%. 70% only the first 2 hours post natal.

� Tolerating permissive hypercapnea (45-60mmHg) 9/11/15 CPPU Indonesia Batam 13




POSTNATAL RESUSCITATION and STABILIZATION

� In cases hypotension or organ hypoperfusion give cristaloid 10-20cc/kg 1-2 times

� Sedation and analgesia should be given

� Routine surfactant is not recommended


Management Post Natal Care � High Frequency Oscilation (HFO) still controversies.

Can provide adequate gas exchange when using mean pressure no higher than 15 cmH2O.

No RCT comparing conventional ventilation and HFOV.

�  Survival in infant with CHD improve considerably since the avoidance of hyperventilation and barotrauma, wheather this gentle ventilation achieve with conventional or HFOV.


Management Post Natal Care �  Send the neonate to NICU/PICU where arterial and

venous accees are establish,

� Routine blood test include BGA,lactate and serum electrolite, monitoring oxygenation,blood pressure and glucose and electrolite.

� Chest –ray

� Optimalisation of clinical parameter before embarking on surgical repair is necessary to ensure best outcome of patient.


Management of Pulmonary Vascular tone

� All infants with CHD have an abnormallity of vascular resistance need ECHO for estimate the severity of pulmonar hypertention.

� No difference between using inhaled nitric oxide(selective pulmonary vasodilator) and ECMO (extra corporel membrane oxygenation) in improve the PHT

� There are reported that higher mortality in using ECMO for the fisrt of life for CHD infant.



When Sugical can Perform

�  Stabilize until at least 24-48 hours after administration, for clinical stabilization and a fall of pulmonary vascular resistance.



References

1.  Robin H Steinhorn,MD.Pediatric Congenital Diaphragmatic Hernia : Practice Essentials, Background,Pathophysiology. Medscape Reference, Drugs and Procedures.Updated April 25,2014.

2.  Mauriuz Mielniczuk.et al. Curent Guideline on Management of Congenital Diafragmatic Hernia.Anesthesiology Intensive Therapy 2012,vol 44,232-237.ISSN 1642-5758.

3.  Hannah King MB,ChB FRCA.et al. Congenital Diafragmatic Hernia in the Neonate. Continuing Anesthesia Critical Care Pain,vol.5 No. 5.2005.


Ro Thorax


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12 HERNIA DIAFRAGMATICA-BATAM.pdf