Emergency Corrective Surgery of Congenital Diaphragmatic Hernia With Pulmonary Hypertension: Prolonged Use of Dexmedetomidine as a Pharmacologic Adjunct

Abstract

Introduction:Underdevelopment of the lung parenchyma associated with abnormal growth of pulmonary vasculature in neonates with congenital diaphragmatic hernia results in pulmonary hypertension which mandates smooth elective mechanical ventilation in postoperative period, for proper alveolar recruitment and oxygenation, allowing lungs to mature enough for its functional anatomy and physiology. Dexmedetomidine is sympatholytic, reduces pulmonary vascular resistance and exerts sedative and analgesic property to achieve stable hemodynamics during elective ventilation. Neonatal experience with dexmedetomidine has been predominately in the form of short term or procedural use as a sedative.Case Presentation:The preliminary clinical experience with pre-induction to 48 hours postoperative use of dexmedetomidine infusion as a pharmacologic adjunct in the emergency corrective surgery of three such neonates are presented.Conclusions:Hemodynamics remained virtually stable during the whole procedure and post-operative pain relief and recovery profile were satisfactory. The prolonged infusion was well tolerated with a gradual trend towards improved oxygen saturation. Careful planning of the anesthetic management and the ability to titrate the adjunct utilized for smooth postoperative ventilation are the keys to ameliorate the complications encountered and favorable outcomes achieved in such patients.

Analgesia, Sedation, and Neuromuscular Blockade in Infants with Congenital Diaphragmatic Hernia

“…Dexmedetomidine is an α-2 adrenergic agonist that has sedative and analgesic effects without suppressing respiratory drive. 28 29 30 A recent pediatric study found that using dexmedetomidine reduced the use of both benzodiazepines and opioids and was associated with less delirium, lower pain scores, and lower withdrawal scores. 28 When used in children on treatment for reactive pulmonary hypertension, dexmedetomidine led to an increase in systemic vascular resistance without affecting the pulmonary vasculature.…”

“…31 A very small case series of prolonged perioperative dexmedetomidine in infants with CDH suggests the medication was tolerated well during the first 48 hours after hernia repair. 29 These early reports suggest it may provide adequate sedation without the known risks associated with benzodiazepines; however, much more research is needed to understand the safety and efficacy of dexmedetomidine in neonates, especially in the setting of prolonged use.…”