[Diagnosis and preoperative intensive therapy of congenital diaphragmatic hernias]

For newborn infants hospitalised after the 24 th hour, preparation is simple and poses no more problems than a standard thoracic surgical procedure. Children hospitalised during the first 24 hours may be divided into two groups: those without marked signs of respiratory distress and those with severe respiratory insufficiency. It is essential to reequilibrate these children before surgery, since the latter will not be associated with any immediate spectacular improvement. The first gesture should be the insertion of a gastric tube, if possible before any ventilation by mask. Intubation and artificial ventilation are often essential but it must be born in mind that the risk of contralateral pneumothorax is high, because of the commonly present pulmonary hypoplasia, which usually leads to the use of high respiratory rates, low tidal volumes and requires perfect adaptation of the child ventilation. Acidosis is as a rule corrected by artificial ventilation only and the excessive use of buffer substances should be avoided. An adequate and effective venous line is essential and the insertion of a central catheter via the external or internal jugular is usually possible. It is essential in severe forms to have access to open measurement of blood pressure from the right radial, either by puncture or cutdown. We do not feel that the insertion of an aortic catheter via the umbilical artery is absolutely essential. By contrast, permanent record of pulmonary artery pressure would be of value but comes up against technical problems which are difficult to resolve. It is essential that the child taken to the operating room should be normothermic, normocapnic, have a satisfactory blood pressure and a good peripheral circulation. These conditions are essential but do not suffice to guarantee success in a child with pulmonary hypoplasia incompatible with survival.