Infant with Congenital Diaphragmatic Hernia Clinical Pathway, Pre and Post-operative Care — Inpatient and ICU

Daily Interdisciplinary Assessment to Determine Readiness for CDH Repair

Interdisciplinary A.M. Rounds

  • Neonatology
  • General Surgery
  • Nursing
  • Respiratory Therapy
  • Nutrition
  • Pharmacy
  • ECMO Team, if applicable

Newborn/Infant Intensive Care Unit Optimal Care Guidelines: CDH

Goal

  • Review the following physiologic goals to determine if the infant is ready for repair
  • Timing is coordinated by Neonatology Attending and General Surgery Attending
  • Team may modify individual physiologic targets
  • Repair on ECMO is done as clinically indicated
Physiologic Goals/Surgical Readiness
Hemodynamic
  • Dopamine and epinephrine at low rates without frequent adjustments
  • Cardiac function and pulmonary hypertension optimized
  • Resolved severe cyanotic episodes (pre and post-ductal saturation < 85%) or ductal shunting events (saturation difference more than 10% pre and post-ductal)
Respiratory
  • Target PaCO2 40-65 mmHg
  • Target pH > 7.3, lower threshold of 7.2 can be tolerated if reassuring clinical status
  • FiO2 < 50%
Pulmonary HTN
  • Nursing assessments indicate tolerance to care
  • Resolved severe cyanotic episodes (pre and post-ductal saturation < 85%) or ductal shunting events (saturation difference more than 10% pre and post-ductal)
  • Hgb ≥ 12 mg/dL
Fluid and Nutrition
  • Minimal edema
  • Tolerance of fluid volume adequate to meet calorie needs, 90-120 kcal/ kg
Infectious Disease
  • No infectious concerns
  • New onset left shift warrants further discussion
Vascular Access
  • Adequate access – Umbilical lines require surgical attending approval
  • Arterial UAC or PAL (Pre-ductal preferred)
    Central Venous DL PICC (Lower extremity preferred)
    Peripheral Venous PIV x 1 for anesthesia access and blood product administration