HERNIA DIAFRAGMATICA ANESTHESIA PERSPECTIVE IRA PITALOKA Departemen Anestesiologi dan Reanimasi Divisi Anestesi Pediatri Fakultas Kedokteran Universitas Airlangga SURABAYA
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
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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.
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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.
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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.
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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
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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
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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.
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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
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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
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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.
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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.
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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.
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When Sugical can Perform
� Stabilize until at least 24-48 hours after administration, for clinical stabilization and a fall of pulmonary vascular resistance.
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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.
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Ro Thorax
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