Multisystem challenges in neonatal critical care: a CDH survivor with PPHN and septic embolism

Abstract

Congenital diaphragmatic hernia (CDH) causes pulmonary hypoplasia and maladaptive pulmonary vascular
remodeling, predisposing to persistent pulmonary hypertension of the newborn (PPHN) and, in severe cases, acute cor pulmonale (ACP). The resultant cardiopulmonary failure often necessitates prolonged ventilation, vasoactive support, and central venous access, which—together with systemic inflammation—increase vulnerability to nosocomial sepsis. In septic neonates, endothelial injury and a prothrombotic state can convert catheter-related thrombophlebitis into septic emboli that occlude peripheral arteries and threaten limb viability. Although sepsis is recognized in CDH, the specific sequence from CDH/PPHN to intensive support and catheterization, progressing to catheter-associated septic embolism with irreversible lower-limb ischemia, is rarely documented, and evidence to guide anticoagulation in this setting remains scarce. We describe a neonate with CDH complicated by PPHN, ACP, and septic embolism culminating in limb loss, illustrating this pathophysiologic linkage and the therapeutic dilemma of balancing anticoagulation against bleeding risk.

Keywords: Congenital diaphragmatic hernia; Persistent pulmonary hypertension of the newborn; Acute cor
pulmonale; Neonatal limb ischemia; Neonatal critical care

Citation: Wicaksana ZL, Semedi BP, Budi MW, Angelika D. Multisystem challenges in neonatal critical care: a CDH
survivor with PPHN and septic embolism. Anaesth. pain intensive care 2025;29(9):1333-38. DOI:
10.35975/apic.v29i9.3076

Received: October 02, 2025; Revised: October 18, 2024; Accepted: October 27, 2025