Infant with Congenital Diaphragmatic Hernia, Pre and Post-operative Care — Universal Care Before Surgical Repair: Sedation — Clinical Pathway: Inpatient and ICU

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

Universal Care for Infants with CDH Before Surgical Repair: Sedation

Universal care considerations apply to all infants independent of acuity level.

Goals

  • Optimize sedation to minimize reactivity related to pulmonary hypertension
  • Titrate infusions, minimize medication boluses as able
Drug Initial Infusion Dose PRN/Bolus Dose (IV)
1st Line
  • Fentanyl
    • On admission to 24 hrs of life
 1 mcg/kg/hr 1 mcg/kg/dose
  • Morphine
    • At 12-24+ hrs transition from fentanyl infusion to morphine due to tachyphylaxis
  • 0.01 mg/kg/hr
  • Trial prn dose, assess for hypotension
  • If fentanyl infusion is ≥ 2 mcg/kg/hr, higher morphine dosing likely required based on calculated opioid conversion
 0.1 mg/kg/dose
2nd Line Dexmedetomidine
  • 0.3 mcg/kg/hr
  • No loading dose
  • Monitor for transient hypotension and bradycardia
  • Discuss need in 1st 24-48 hrs of life, can worsen hemodynamics in unstable infant
3rd Line Midazolam
  • 0.05 mg/kg/dose
  • Monitor for transient hypotension
4th Line Midazolam
  • 0.01 mg/kg/hr
  • Caution in younger gestational ages
Alternative Hydromorphone
  • If morphine dose > 0.06 mg/kg/hr reached and still ineffective, discuss option of rotating to a hydromorphone infusion
  • Ideally, transition with clinical pharmacy partnership as dose-dependent on current morphine dose