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Page5/Case 03/01


DIAGNOSIS

Congenital diaphragmatic hernia

The transport team was called, the patient was stabilised, and then transported to a tertiary care centre.

On arrival the vital signs were as follows:
T° 36, HR 140/150, Mean Arterial Pressure 40/45

His medications included:
Pavulon + Morphine 0.02mg/Kg/h, Dopamine 10mcg/Kg/'

He was placed on High Frequency Oscillatory Ventilation (HFOV) with the following settings: FIO2 100%, MAP 14 cmH2O, AMP 40 cmH2O, Frequency 7 Hz (420/minute).

His fluids were 65ml/Kg/day.

Antibiotics included ampicilin+gentamicin

DO YOU HAVE THE SAME VENTILATORY SUPPORT APPROACH AT YOUR CENTRE?



Since permissive hypercapnia ventilatory strategy was adopted in 1991 by Boston group, to minimise barotrauma, survival improved from 57% to 84% in this institution. Initially was started by Wung et al, for the management of infants with severe respiratory failure and persistence of fetal circulation without hyperventilation. (Pediatrics 76:488-494, 1985).

Basically this strategy limits peak inspiratory pressures (PIP) to 30cm H2O and positive end-expiratory pressure (PEEP) to 5cm H2O.
– Mean airway pressure was limited to 12 cm H2O.
– Ventilatory adjustments were based on maintaining preductal O2 saturation of 90% or greater without metabolic acidosis.
– Patients who did not maintain a preductal saturation of 90% or developed metabolic acidosis were placed on ECMO.
– Neither high frequency ventilation, nor hyperventilation with conventional ventilator, were used in an attempt to avoid ECMO (Boston CDH group).

In our centre, high frequency ventilation is used electively in these patients, as the first line ventilatory strategy.

Subsequent course:

Due to cardiovascular instability, he was started on Dopamine 20 mcg/Kg/' and Epinephrine 0.3 mcg/Kg/'.

Alkalinization with HCO3- 5 mmol/Kg/h was attempted.

His arterial blood gases were as follows: PO2 174 mmHg (Sat 100 %), PCO2 40 mmHg, pH 7.50

DO YOU AGREE WITH ALKALINIZATION?




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