28 weeker (1300 gm) from NNICU in for congenital diaphragmatic hernia repair. No other significant comorbidities at present. Labs/I&Os WNL at time of surgery, fluids and lytes being controlled as expected. D10 MIVF. Nasogastric tube. Pt arrived intubated: uncuffed 3.0 at 7.5 cm. Transferred to table from isolette and surgery performed without incident with the exception that the surgeon found the absence of an intrapleural space on affected side (right). 2.5 mcg Fentanyl total. Surgeon closes and respiratory is called for transfer.

Upon transfer of patient back to isolette on vent, SaO2 begins to plummet. Respiratory suctions and gets no return. Patient returned to table and manual ventilations performed. Auscultation reveals no air movement bilaterally and CO2 return disappears. However, PIPs are < 30 and remain so. There has been no change in resistance on the bag. Repeat suctioning has no return. DVL performed to check placement…ETT confirmed between cords and NGT in esophagus. Tube remains at 7.5 cm. SaO2 bottoming out.

What is going on and what do you do?
Newbies first please…

What is a congenital diaphragmatic hernia and what are its implications for anesthesia?
What side is usually involved? Why?
What pulmonary/systemic issues can be found with these patients?
What is important when mask ventilating this patient prior to intubation?