Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 0 0 2026 07 03 1584 1584 Sonal Khatavkar Department of Anesthesiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune 18, Maharashtra, India. Mandava Kumar Department of Anesthesiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune 18, Maharashtra, India. 2026 02 25 2026 03 28 Congenital diaphragmatic hernia (CDH) is a neonatal surgical emergency associated with pulmonary hypoplasia, pulmonary hypertension, and significant perioperative anesthetic risk. Right-sided CDH is relatively uncommon and may present additional challenges due to liver herniation and cardiorespiratory compromise. We report the anesthetic management of a 3-day-old, 2.7 kg male neonate with antenatally diagnosed right-sided CDH who presented with respiratory distress and significant metabolic acidosis. Preoperative workup revealed severe metabolic acidosis on arterial blood gas analysis, necessitating ventilatory support and NICU stabilization before definitive surgery. Once adequately optimized, the neonate underwent diaphragmatic repair via an abdominal approach under general anesthesia. Intraoperative priorities included lung-protective ventilation, prevention of barotrauma, maintaining satisfactory oxygenation and perfusion, and vigilant hemodynamic monitoring with continuous pre- and post-ductal saturation assessment. The herniated bowel and liver were reduced intraoperatively, and the diaphragmatic defect was closed. Throughout the perioperative course, hemodynamic stability was maintained with careful ventilatory and inotropic support. Following surgery, the neonate was kept intubated and electively ventilated in the NICU, with uneventful extubation on postoperative day 5. This case underscores the value of thorough preoperative stabilization, gentle ventilation, careful monitoring, and a coordinated multidisciplinary approach in achieving favourable perioperative outcomes in neonates with right-sided CDH and metabolic acidosis. https://aacc.tums.ac.ir/index.php/aacc/article/view/1584