A 2-day-old neonate with a prenatal diagnosis of left-sided congenital diaphragmatic hernia (CDH) is born. She has severe respiratory distress. What is the correct management sequence?
- A Emergency surgery within 6 hours to reduce herniated contents and repair diaphragm
- B ECMO initiation first, then surgery within 24 hours
- C Immediate intubation, gentle ventilation, stabilization, and delayed surgery after optimization ✓
- D High-frequency oscillatory ventilation (HFOV) for 72 hours then surgery
Explanation
Current CDH management follows a 'delayed repair' strategy: initial resuscitation with immediate intubation, gentle ventilation (tidal volumes 3–5 mL/kg, permissive hypercapnia PaCO2 45–60 mmHg), avoiding bag-mask ventilation (which inflates bowel in chest), placing an NGT for bowel decompression, and hemodynamic stabilization. Surgery is delayed for 24–72 hours until pulmonary hypertension is controlled and oxygenation optimized. Emergency surgery in the unstable neonate worsens outcomes due to hemodynamic decompensation. ECMO is reserved for refractory hypoxia failing conventional ventilation before surgery.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.