Repair of congenital diaphragmatic hernia under high-frequency oscillatory ventilation in high-risk patients: an opportunity for earlier repair while minimizing lung injury

A Delicate Balance: Anesthetic Management for Neonatal Congenital Diaphragmatic Hernia Repair

Congenital diaphragmatic hernia (CDH) presents significant challenges in neonatal management, particularly in the context of anesthesia. This case report details the successful anesthetic management of a five-day-old neonate with left-sided CDH requiring thoracoscopic repair. A five-day-old neonate, delivered via emergency cesarean section due to breech presentation, presented with severe respiratory distress and was diagnosed with left-sided CDH. Initial evaluation revealed respiratory acidosis and moderate pulmonary hypertension. Preoperative stabilization included high-frequency oscillatory ventilation and intravenous infusions of milrinone and vasopressin. Induction was achieved with ketamine and midazolam, along with a left-sided erector spinae block for analgesia. Anesthesia was maintained with intermittent fentanyl boluses during the eight-hour surgery. Ventilation was closely monitored and adjusted for changes in carbon dioxide levels. The surgery was successful, with stable hemodynamics and a smooth recovery. Effective anesthesia in neonates with CDH requires careful preoperative planning and intraoperative vigilance. This case underscores the importance of tailored anesthetic strategies to enhance safety and promote recovery in high-risk pediatric surgeries.

Use of intraoperative high frequency oscillatory ventilation in neonates with pulmonary hypoplasia

High-frequency oscillatory ventilation (HFOV) is a ventilatory modality widely used in neonatal intensive care units. Its main indication is restrictive lung pathology with difficult gas exchange using conventional mechanical ventilation (CMV). Patients receiving CMV require high intensity care, and immature lungs can be at risk for barotrauma and volutrauma. The few studies that have explored the use of HFOV in the operating room are mainly limited to HFVO during congenital diaphragmatic hernia repair. Limited experience of this ventilatory method in the operating room may be a disadvantage for the anesthesiologist. However, it is important to remember the benefits of this technique as a lung protection strategy. We report two cases of neonatal pulmonary hypoplasia of different etiology in which good oxygenation and ventilation was achieved with intraoperative HFOV.