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

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.