Congenital Diaphragmatic Hernia with Dr. Yigit Guner & Dr. Amir Ashrafi -- Part 2 of 3
Mar 18, 2024
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Exploring delivery room procedures, ECMO transition decisions for neonates with congenital diaphragmatic hernia. Optimizing care in the NICU with blood gas analysis, ventilation strategies, and hemodynamic resuscitation. Managing pulmonary vascular resistance with pulmonary vasodilators. Navigating ECMO cannulation decision and surgical repair. Team approach and ECMO considerations for CDH patients.
Swift intervention with intubation post-delivery optimizes breathing support for CDH babies.
Gas exchange goals in NICUs prioritize parameters like PCO2 levels and employ tidal volume ventilation techniques.
Balancing factors like high PVR and low SVR in CDH shock management requires tailored hemodynamic support strategies.
Deep dives
Approaching High-Risk Deliveries for CDH Patients
In managing deliveries of babies with congenital diaphragmatic hernia (CDH), the focus is on swift intervention post-delivery. A key immediate step involves intubating the baby to prevent air ingestion, which can further impede lung function. It's crucial to establish functional residual capacity (FRC) and relieve any stomach pressure by inserting an NG tube. This meticulous approach aims to optimize breathing support during the critical early moments in the delivery room.
Setting Gas Exchange Goals and Ventilator Management
In neonatal intensive care units (NICUs), setting gas exchange goals involves prioritizing parameters like PCO2 levels, oxygen saturation, and CO2 tolerances. Techniques such as tidal volume ventilation, ideally with synchronized intermittent mandatory ventilation (SIMV), are employed to enhance alveoli growth. Permissive hypercapnia is a standard care practice, prioritizing adequate gas exchange over stringent CO2 targets. Ventilator adjustments may include transitioning to oscillators if peak pressures exceed manageable levels.
Managing Hemodynamic Resuscitation for Shock Patients
Addressing shock in CDH patients requires a nuanced approach due to the interplay of factors like high pulmonary vascular resistance (PVR) and low systemic vascular resistance (SVR). Maintaining a delicate balance involves cautious fluid management, choosing vasoactive medications like vasopressin to mitigate potential pulmonary hypertension. Individualizing treatment based on whether the shock stems from cardiac output or SVR issues ensures tailored hemodynamic support. Echocardiography plays a pivotal role in guiding optimal hemodynamic strategies.
Deciding on ECMO Cannulation in Critical Situations
The decision-making process for initiating extracorporeal membrane oxygenation (ECMO) in CDH patients involves a multidisciplinary team approach and keen understanding of patient requirements. While traditional guidelines outline specific thresholds like oxygenation indices for ECMO consideration, individual patient phenotypes dictate the course of action. Collaborative decision-making, early involvement of experts, and constant patient monitoring aid in determining the appropriate timing for ECMO initiation, emphasizing proactive rather than reactive care.
Exploring VV ECMO for CDH Patients
The potential role of veno-venous (VV) ECMO in CDH patients, especially those with gas exchange challenges, presents an alternative to veno-arterial (VA) ECMO support. While VA ECMO is often favored for its simplicity and versatility, transitioning to VV ECMO poses challenges due to cannula size limitations and procedural complexities. Evaluating patient-specific factors like run duration, respiratory requirements, and potential complications guides the selection between VA and VV ECMO, ensuring tailored support for optimal patient outcomes.
Dr. Yigit Guner earned his Doctor of Medicine degree from the Rosalind Franklin University of Medicine and Science at the Chicago Medical School. He completed his internship and residency in general surgery at UC Davis Medical Center, where he served as chief resident. Dr. Guner’s training continued with a fellowship in pediatric surgery at the University of Texas, Houston. In addition, he finished a post-doctoral research fellowship at the USC-CHLA Department of Pediatric Surgery. Dr. Guner continues to publish articles in peer-reviewed journals, presents lectures at nationally recognized conferences, has collaborated on book chapters, and is a member of several professional associations and hospital leadership committees. He also serves as an assistant professor of surgery at UC Irvine.
Dr. Amir Ashrafi is an expert in neonatology and neonatal-cardiac physiology. His primary focus is treating newborns with congenital heart disease. He holds the national distinction of being one of the few physicians to receive formal training in both neonatal intensive care and cardiac intensive care. Dr. Ashrafi is the co-founder of the conference NeoHeart: Cardiovascular Management of the Neonate which is an international collaboration dedicated to advancing the care of newborns with complex heart disease. He attended medical school at the University of Utah and completed pediatric residency training at Emory University in Atlanta. He spent time in the Emergency Dept at Children’s Hospital of Los Angeles prior to completing his neonatal intensive care fellowship at UCLA, where he was recognized as the chief fellow. Dr. Ashrafi then completed a second fellowship in cardiac intensive care in Boston Children’s Hospital at Harvard University. His research focus includes Neonatal-cardiac physiology, non-invasive tissue perfusion monitoring, neurodevelopment outcomes in infants with congenital heart disease, and targeted neonatal echocardiography.
By the end of this podcast, listeners should be able to discuss:
The clinically relevant anatomic and physiologic consequences of CDH.
The relevant prenatal evaluation and interventions for unborn babies with CDH.
The core aspects of neonatal resuscitation and cardiopulmonary support for neonates with CDH.
The role of ECMO in neonates with CDH.
The timing, general approach and relevant complications of CDH surgical repair.
The expected long-term outcomes of neonates with CDH.
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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
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