Pediatric Congenital Diaphragmatic Hernia Medication

  • Author: Robin H Steinhorn, MD; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Oct 13, 2010
 

Medication Summary

Medical therapy in congenital diaphragmatic hernia (CDH) is directed toward stabilizing blood pressure and circulating volume, pulmonary distress, and hypoxemia.

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Vasoactive agents

Class Summary

Judicious use of vasoactive agents may increase cardiac output without affecting systemic or pulmonary vascular resistance.

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Dopamine (Intropin)

 

Dopamine increases blood pressure primarily via stimulation of alpha-adrenergic receptors; however, its mechanism of action in newborn infants remains controversial because of developmental differences in endogenous norepinephrine stores and expression and function of alpha-adrenergic receptors. Dosage must be individualized.

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Dobutamine (Dobutrex)

 

Increases blood pressure primarily via stimulation of beta1-adrenergic receptors. It appears to have a more prominent effect on cardiac output than on blood pressure.

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Milrinone (Primacor)

 

Bipyridine-positive inotrope and vasodilator with little chronotropic activity. Mode of action differs from that of digitalis glycosides and catecholamines. Selectively inhibits PDE III in cardiac and smooth vascular muscle, resulting in reduced afterload, reduced preload, and increased inotropy.

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Opioid analgesics

Class Summary

These agents are used for deep sedation to allow adequate mechanical ventilation. They may be particularly useful in decreasing sympathetic pulmonary vasoconstriction in response to noxious stimuli, such as suctioning.

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Fentanyl (Duragesic, Sublimaze)

 

Synthetic opioid that is 75-200 times more potent than morphine. It is highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays the weaning process. Used alone, fentanyl causes minor cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.

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Neuromuscular relaxing agents

Class Summary

Paralysis is sometimes necessary in an infant who is unstable despite adequate sedation; however, the use of paralysis is controversial and should be reserved for unusual cases in which the infant cannot be treated with appropriate sedation.

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Pancuronium (Pavulon)

 

Relatively long-acting nondepolarizing muscle relaxant. Onset of action is 1-2 min, and duration of action is 45-90 min. Excretion is renal (80%) and hepatic (20%), and duration of action may be longer if renal or hepatic failure is present.

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Vecuronium (Norcuron)

 

Has few to no adverse hemodynamic adverse effects and may be preferred over pancuronium as a muscle relaxant in the infant with PPHN; however, it is more expensive than pancuronium.

Intermediate-acting nondepolarizing muscle relaxant. Onset of action is 1-2 min, and duration of action is 45-90 min. Primary route of excretion is hepatic.

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Pulmonary vasodilating agents

Class Summary

Nitric oxide is an important mediator of vascular tone that was recently approved as a therapeutic modality for infants with PPHN. It is delivered as an inhaled gas. At least 2 multicenter studies did not show that inhaled nitric oxide decreases mortality or the need for extracorporeal support in infants with CDH; however, it may be useful in stabilizing an infant while evaluating or transferring for ECMO.

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Nitric oxide (INOmax)

 

The FDA approved nitric oxide for the treatment of PPHN in December 1999. Produced endogenously from action of enzyme NO synthetase on arginine. Relaxes vascular smooth muscle by binding to heme moiety of cytosolic guanylate cyclase, activating guanylate cyclase and increasing intracellular levels of cGMP, which then leads to vasodilation. When inhaled, NO decreases pulmonary vascular resistance and improves lung blood flow.

Optimal dose is unknown, although most investigators agree that doses >20 ppm are not beneficial and may be harmful. Administration should occur under controlled conditions, with access to ECMO if needed. NO2 and methemoglobin levels should be frequently monitored, and weaning should gradually occur. Abrupt discontinuation may be associated with severe rebound pulmonary hypertension.

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Contributor Information and Disclosures
Author

Robin H Steinhorn, MD  Raymond and Hazel Speck Berry Professor of Pediatrics, Division Head of Neonatology, Associate Chair of Pediatrics, Northwestern University School of Medicine

Robin H Steinhorn, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Heart Association, American Pediatric Society, American Thoracic Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Nicolas FM Porta, MD, FAAP  Assistant Professor, Department of Pediatrics, Northwestern University, The Feinberg School of Medicine

Nicolas FM Porta, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: United Therapeutics Consulting fee Consulting

Specialty Editor Board

David N Sheftel, MD  Director, Division of Neonatology, Clinical Associate Professor, Department of Pediatrics, Lutheran General Children's Hospital of Park Ridge, Chicago Medical School

David N Sheftel, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Arun K Pramanik, MD, MBBS  Professor of Pediatrics, Director of Neonatal Fellowship, Louisiana State University Health Sciences Center

Arun K Pramanik, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, National Perinatal Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Carol L Wagner, MD  Professor of Pediatrics, Medical University of South Carolina

Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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Radiograph of a 1-day-old infant with a moderate-sized congenital diaphragmatic hernia (CDH). Note the air- and fluid-filled bowel loops in the left chest, the moderate shift of the mediastinum into the right chest, and the position of the orogastric tube.
 
 
 
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