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CDH Management Protocol. Antepartum (Fetal Center). Level III ultrasound LHR - Routinely calculated (? PLUG if < 0.5) O/E LHR - Routinely calculated up to 32 weeks Both LHR results will be listed on the bottom of the front StarPanel page Cardiac echo - Routine

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Antepartum fetal center
Antepartum (Fetal Center)

  • Level III ultrasound

  • LHR- Routinely calculated (? PLUG if < 0.5)

  • O/E LHR - Routinely calculated up to 32 weeks

  • Both LHR results will be listed on the bottom of the front StarPanel page

  • Cardiac echo - Routine

  • Liver position – Determined and reported

  • Multidisciplinary consults – MFM, NICU, PedSurg, Genetics, etc


Antepartum fetal center1
Antepartum (Fetal Center)

  • Fetal MRI – Not standard (QLI)

  • Follow-up – Monthly – BPP 2/wk at 34 wks

  • Timing of delivery – Induction at 39 wks

  • Antenatal steroids – For labor EGA < 34 wks

  • Calculate LHR or O/E LHR:

    http://www.perinatology.com/calculators/ LHR.htm


Delivery room
Delivery Room

  • Airway Management – No bag valve mask or CPAP. Immediate ETT

  • GI decompression – Replogle tube following airway

  • Ventilatory Pressures - 20-25/5-6

  • FiO2(initial) – 100%

  • Transport Vent - 20-25/5-6 x 40 It=0.35, FiO2=1

  • SaO2 target - preductal increase no faster than NRP guidelines, wean FiO2 when preductal SaO2 up to >85%

  • iNO – if baby requires FiO2 of 100% and pre-ductal sats < 90%


Nicu stablilization
NICU Stablilization

  • SaO2 (preductal) - >70% x 1 hour, >85% by 2 hours, goal 90-95%

  • Studies- Routine ECHO, HUS, cultures, PT/PTT, CBC, CRP, state screen, cortisol, karyotype & microarray

  • Access – attempt single lumen UAC before peripheral a-line

    • Single attempt UVC, if unsuccessful convert to emergent position, discuss PICC vs. Cook vs. other with team based on stability

  • Sedation - fentanyl 1mcg/kg/hr – additional dose for cardiac echo – add Versed as needed

  • Analgesia- fentanyl 1mcg/kg/hr

  • Paralysis - avoid


Initial ventilation strategy
Initial Ventilation Strategy

  • IMV - Initial settings PCV 22/5 x 40 It = 0.35

    • Max RATE = 60

    • Max PIP = 25

  • Oxygenation

    • Preductalsat > 70%x 1 hour, by 2 hours >85% with adequate delivery based on lactate, goal 90-95%

    • Post ductal PaO2 >40 (consider >35 with adequate preductal SaO2 and lactate)

  • Ventilation – Goal = pCO2 50-65pH - Goal = 7.2 – 7.35

  • Perfusion– O2 delivery with lactate < 3 mmol/L; transiently (2 hours) tolerable lactate >3, but <5

  • Weaning

    • wean PIP first with adequate tidal volume, then rate to SIMV when on low rate, volume based on PFT TV on prior setting, target 4-5 cc/kg

    • FiO2 to keep SaO2 90-95%

    • Wean PEEP slowly (decrease by 0.5 q4h) if FiO2<0.60 with 8 rib expansion


High frequency ventilation
High Frequency Ventilation

  • Criteria to Convert from CV to HFV

    • PaCO2 > 65 with acidosis on PIP 25 and rate 60

    • Pre-SaO2<70% or post-ductal PaO2<40

  • HFV initial settings

    • HFOVMAP=IMV MAP + 2

    • Delta P = PIP, “adequate bounce”

    • Starting frequency 10 Hz

  • Weaning

    • Wean MAP slowly (decrease by 0.5 q4h) if FiO2<0.60

    • Wean frequency first to 10, then delta P to PaCO2 50-65

    • FiO2 to keep SaO2 90-95%


Cdh patient management
CDH Patient Management

  • Systemic Hypotension- Criteria for treatment - Abnormal MAP for age

    • NS bolus, pRBC’s if Hct<40, FFP for abnormal initial coagulation studies – combined up to 40ml/kg in first 2 hours

    • Dopamine and Dobutamine - begin at 5/5 and increase as needed

  • Pulmonary Hypertension- Criteria for treatment – Pre ductal SaO2<70% or post-ductal PaO2<40 AND echocardiographic evidence of PH

    • iNO

      • iNO at 20ppm, wean when FiO2<0.6 and adequate oxygenation

    • Prostacyclin

      • Reserved for rescue post-ECMO or where ECMO contraindicated

      • Consider inhaled for sustained hypoxemia on iNO if adequate ventilation and adequate contralateral lung recruitment can be achieved on conventional ventilator. Note: potential for platelet/bleeding effect

    • Catecholamines

      • to correct systemic hypotension into normal range after volume expansion and oxygen carrying capacity optimized

    • Milrinone

      • RV dysfunction/dilation and additional afterload reduction after iNO

    • Prostaglandin

      • Prostaglandin for RV overload with restrictive PDA


Cdh patient management1
CDH Patient Management

  • Fluid Management

    - Initial 90 ml/kg with early protein

    - Avoid fluid overload

    - Furosemide for fluid overload when hemodynamicallystable

  • Laboratory Management

    - Hematocrit > 40%

    - Heparin assay (anti Xa) q6h, ATIII level QD(on ECMO)

    - Platelet count > 100,000 perioperatively (on ECMO)

    - TEG with clinical bleeding (on ECMO)

  • Antibiotics

    - No specific indication for antibiotics with CDH alone

    - Evaluate maternal risk factors, initial sepsis screen

    - Start prior to cannulation

  • Sedation

    - As clinically indicated

    - Paralysis should be avoided if possible, use with caution


Criteria for ecmo
Criteria for ECMO

  • SaO2<85% on HFOV and iNO

  • HFOV MAP>17

  • OI>40 consistent (3 post-ductal BG over 2 hours)

  • Inadequate oxygen delivery, pH<7.20, lactate>5 despite adequate volume expansion and pulmonary recruitment

  • Respiratory acidosis despite optimized HFOV pH<7.20, PaCO2>70

  • Hypotension resistant to fluid and inotropic support with UOP<0.5ml/kg/hr

  • Impending ventricular failure on ECHO with evidence of inadequate oxygen delivery

  • Preductal sat <70 for 1 hour

  • Attending to Attending Notification (both neonatology and ped surgery)


Ecmo contraindications
ECMO Contraindications

  • IVH Grade 2 or greater

  • Lethal chromosomal anomalies/syndromes

  • Complex congenital heart disease (single ventricle physiology)

  • EGA < 34 wks


Cdh ecmo
CDH ECMO

  • Echocardiographic Surveillance:

    • Cardiology to have Attending ECHO read upon arrival in NICU

    • Serial exams with at least one additional ECHO at 48h on ECMO

  • ECMO Cannulation

    • Routine use of VA ECMO in CDH

    • Place 8 Fr arterial cannula

    • 12 Fr venous cannula or smaller

  • Duration of ECMO Run

    • Duration of ECMO based upon a multidisciplinary review of the course and projected outcome / assessment of futility

    • Periodic trial of lower flows/trial off with echo assessment of PH

  • Decannulation

    • Consider when trial off-EMCO suggests native gas exchange and CV function is sufficient

    • Consider targeting higher PaCO2 range for final 3-7 days of ECMO run

    • Routine carotid artery repair unless contraindicated / unfeasible

    • Routine Broviacplacement


Cdh repair no ecmo
CDH Repair (no ECMO)

  • FiO2<0.5

  • Normal BP for EGA

  • Lactate <3

  • Pre-operative ECHO required demonstrating improvement in pulmonary hypertension and good right ventricular function

  • UOP > 2ml/kg/hr

  • Chest Tube – Consider no use of routine chest tube when repaired off ECMO


Cdh repair ecmo
CDH Repair (ECMO)

  • Timing of repair will be based upon an ECHO after 48h on ECMO (maintain inflation until ECHO)

    • If there ISimprovement in the pulmonary HTN (less than systemic) – delay repair (with a close eye on volume status), consider repair off ECMO

    • If there is NOimprovement in the pulmonary HTN after 48h ECMO support – move towards early repair in 24-48h

    • If successfully weaned off ECMO – timing of surgery same as non ECMO babies (echo driven decisions)

  • Peri-Operative Anticoagulation Management

    • Hold heparin infusion 1 hour pre-op, during the case and 1 hour post-op

    • Restart heparin drip at pre-op rate, no bolus

  • Chest tube – Routine placement of chest tube (15f Blake drain) for repair done on ECMO

  • Temporary/Staged Abdominal Closure


Outcomes
Outcomes

  • Routine analysis of institutional CDH registry data and morbidity assessment every 10 cases or6 months (whichever occurs first) with departmental presentations


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