Management of neonatal posterolateral diaphragmatic hernia

From March 1978 to April 1982 13 neonates with a left posterolateral diaphragmatic hernia were seen in respiratory distress within 12 hours of birth. Each had severe acidosis and hypoxia. They were immediately intubated and ventilated. Arterial and central venous lines were inserted, the acidosis was partially corrected, and a dopamine infusion of 4-8 micrograms/kg/min was begun immediately. Continuous monitoring of arterial and venous pressures, core and skin temperatures, blood gases, and pH was instituted. Diaphragmatic defects were repaired by direct suture in nine neonates and by Gore-Tex patches in four. The left lung in all patients was hypoplastic. Ventilation and inotropic support were continued for four to five days after operation and close control of acid-base balance was maintained. All but one survive and are doing well. We consider the key to survival to be management of the dangerous combination of acidosis (by enhancing peripheral and renal perfusion with dopamine) and hypoxia (by prolonged assisted ventilation).