Infant with Congenital Diaphragmatic Hernia, Pre and Post-operative Care — Day of CDH Repair — Clinical Pathway: Inpatient and ICU

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

Day of CDH Repair

Room/Environment Preparation
  • Set up room using Pediatric Anesthesiology: Congenital Diaphragmatic Hernia Repair Guidelines diagram
  • Establish anesthesia workspace -specific location will depend on N/IICU room
  • N/IICU off-site anesthesia cart
  • iStat
  • Hotline rapid infuser
  • Computer with EHR Anesthesia for documentation
  • Forced air warming unit (i.e., Bair hugger)
  • Trash – utilize trash can if space allows; plastic bag taped to cart/yellow bin are alternative options
  • Ensure access to PIV, arterial line, infusion pumps, ventilator, and endotracheal tube
    • For intraoperative suctioning, beware potential malposition and occlusion
      under drape
  • Identify free port on the central venous line for additional infusions
  • See specific surgical equipment in Neonatal Surgical Nursing Care Checklist: Set up for surgical cases in the N/IICU
  • Ensure surgical headlamps and charged batteries at the bedside
Preparing the Infant
  • Review Neonatal Surgical Nursing Care Checklist: Set up for Surgical Cases in
    the N/IICU
  • Hold TPN and start OR fluids
  • Pre-/post-ductal saturations are being monitored (probe location: preductal on right hand, post-ductal on either foot)
  • BP cuff on patient
  • EKG leads on infant’s shoulders
  • Bovie pad placed on infant’s lower back
  • An in situ umbilical arterial catheter can be used for arterial access and should be secured with a small Tegaderm at the 6 o’clock position
  • Monitor displaying only patient’s vitals with audible saturation volume on preductal oxygen saturation
  • Rectal temperature probe
  • Forced air warming unit (i.e., Bair hugger)
  • Position infant with head towards room headwall
  • Blood Products
    • Confirm 1 unit pRBCs, divided into 2 aliquots, is available at bedside and checked prior to incision
    • Blood at bedside expires after 4 hrs
  • Team and Role Introductions
    • General Surgery, OR team, Anesthesia, Neonatology
Anesthesia Team Medications
  • IV Bolus meds, prepare unit doses
    • Fentanyl: general dose range 10-100 mcg/kg, titrate to effect
    • Vecuronium
    • Epinephrine
    • Succinylcholine
    • Atropine
    • Dopamine
    • Consider Ketamine and/or propofol
    • Cefazolin: Ordered by N/IICU Team
  • IV Infusions
    • Dopamine 1-20 mcg/kg/min, titrate to desired effect
    • Epinephrine 0.01-1 mcg/kg/min, titrate to desired effect
Airway/Ventilation
  • Confirm ETT size, positioning (recent CXR), ventilator settings and leak with the respiratory therapist
  • Locate Mapleson on a free-flowing O2 source
  • Appropriately sized facemask, suction, laryngoscope, and extra ETTs available
  • Conventional Ventilation
    • Use in-line ETCO2 monitoring
    • Use pressure mode with frequent volume monitoring
  • HFOV
    • Use TCOM, ensure not in operative field
    • Correlate TCOM with initial blood gas at start of case and every 30 mins