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Congenital Diaphragmatic Hernia - Neonatal - Preoperative ICU Bedside Management

Congenital Diaphragmatic Hernia - Neonatal - Preoperative ICU Bedside Management - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Neonatology, Related


Patient Transferred (from outside hospital)
Head of patient at foot of bed (ECMO position); Ventilator on patient’s left
Confirm ETT, NG/OG and UAC position (on daily CXR)
Confirm UVC positioning (on CXR, ultrasound or echo).
Consider PICC or CVL if additional access, higher concentration fluids/high
dose medications required, or low-lying UVC
Congenital Diaphragmatic
Hernia – Neonatal –
Preoperative ICU Bedside
Management
Analgesia & Sedation
Target SBS score -2 or N-PASS score -1
• Morphine 10 mcg/kg/hr
(bolus 0.1 mg/kg/hr; 0.1 mg/kg q2 PRN)
• Fentanyl 1-2 mcg/kg/hr
(bolus 1 mcg/kg q2 PRN)
Avoid neuromuscular blockade
Initial Conventional Ventilator Settings (SIMV)
• NO GOAL tidal volume
• PIP 15-25
• PEEP 3-5
• RR 40-60
• iTime 0.3-0.5
• FiO2- titrate to pre-ductal SaO2 > 95%
• Wean no faster than 2-5% every 30-60 minutes
• Goal 0.6 by 12 hours and 0.4 by 48 hours
Targets
Pre-ductal SaO2: 90-95%
pCO2: 45-60 mmHg
pH > 7.25
Triggers for Ventilator Changes
• Paradoxical chest wall movement
• Significant increase in retractions
• Pre-ductal SaO2 < 80
• pCO2 > 60 (pH < 7.25)
• Sustained pre-post ductal SaO2 difference >10%
Changes for Hypoxemia, Hypercarbia or Resp. Distress
• Evaluate: sedation, position of patient and ETT, need
for suctioning, adequacy of bowel decompression.
• Increase rate up to 60
• May need to decrease I-Time (0.3-0.4s)
• Decrease PEEP (to increase tidal volume without
increasing PIP)
Pulmonary Hypertension
DO NOT hyperventilate.
Indications for treatment (one or more):
• Pre-ductal SpO2 < 90% with FiO2 80-100%
• Oxygenation Index > 25
• Post-ductal SaO2 < 70% with evidence of
end-organ dysfunction
• Systemic or near-systemic RV pressures and
depressed RV dysfunction or supra-systemic
to near-systemic right-sided pressures with
borderline oxygenation on echo
Management:
• Start inhaled nitric oxide (iNO) at 20 ppm
• Assess iNO response within 30-60 minutes
• Wean for lack of response, improved
pulmonary HTN and RV function, or after
FiO2 weaned to 0.4-0.55
High Frequency Oscillator Ventilation (HFOV)
Indications:
• Failure to improve over 30 minutes on conv. vent (PIP
> 25 and rate > 60) while maximizing sedation,
position, and pulmonary toilette
• Failure to oxygenate despite conv. vent + iNO
• Pneumothorax
Initial settings:
• MAP 14-16, Hz 10-12, Amplitude 30-40
• Goal rib expansion: 8-10 ribs on CDH contralateral side
Hemodynamic Management
Consider transfusion of pRBCs if Hct < 35%
Goal mean BP 40 (if PPHN BP 45-50)
• Saline bolus for hypotension (not colloid)
• Persistent hypotension:
• Dopamine 5 mcg/kg/min
• Add epinephrine (0.03 mcg/kg/min)
if dopamine > 20 mcg/kg/min
• Consider milrinone if RV dysfunction
Pulmonary hypertension with good BPs
• Milrinone (0.5 mcg/kg/min if poor response
to iNO and BP adequate)
• Dobutamine (3-7 mcg/kg/min if poor
response to iNO and BP adequate) Congenital Diaphragmatic Hernia – Neonatal – Inpatient Clinical Practice Guideline
Nursing Care
Minimize stimulation (reduce noise and light, coordinate and
cluster assessments)
Avoid routine suctioning unless clinically indicated
Renal and cerebral NIRS monitoring
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org