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Severe congenital diaphragmatic hernia (CDH): a critical analysis of eight years' experience
P Bagolan1, G Casaccia, A Nahom
1Neonatal Surgery Unit, Bambino Gesù Paediatric Hospital IRCCS, Rome, Italy. bagolan@opbg.net
Insights
Severe Congenital Diaphragmatic Hernia (CDH) outcomes can be predicted. Some severe CDH cases with pulmonary hypoplasia may not benefit from ECMO, while others could.
Area of Science:
- Pediatric Surgery
- Neonatology
- Critical Care Medicine
Background:
- Congenital Diaphragmatic Hernia (CDH) is a severe condition requiring intensive care.
- Extracorporeal Membrane Oxygenation (ECMO) is a life-support treatment for neonates with severe respiratory failure.
Purpose of the Study:
- To define optimal outcomes for severe CDH.
- To identify criteria for excluding patients from ECMO.
- To determine which CDH patients may benefit from ECMO.
Main Methods:
- Analysis of 63 severe CDH cases (35 survivors, 28 non-survivors).
- Patients were grouped by age at death (<=24 hours vs. >24 hours).
- Comparison based on prenatal factors, birth parameters, respiratory/hemodynamic data, and pulmonary hypoplasia severity.
Main Results:
- Pulmonary hypoplasia, PaCO2, and PaO2 were significantly worse in early non-survivors (Group I).
- Late non-survivors (Group II) had similar respiratory parameters to survivors.
- A 56% survival rate was achieved without ECMO.
Conclusions:
- Severe pulmonary hypoplasia may indicate a poor prognosis despite ECMO.
- ECMO may benefit selected severe CDH patients (17%) with less severe pulmonary hypoplasia.
- Early identification of non-beneficial ECMO candidates is possible.
Unlabelled:
OBJECTIVES. 1) To define the best outcome of severe Congenital Diaphragmatic Hernia (CDH); 2) to critically evaluate deaths in order to identify possible criteria of exclusion from ECMO; and 3) to identify CDHs which could benefit from ECMO.
Materials And Methods:
63 severe CDHs, 35 (55.6 %) survivors and 28 (44.4 %) nonsurvivors, subdivided into 2 groups according to age at death: Group I dying at 12 < or = 24 hours, and Group II dying at > 24 hours after birth. The three groups were compared on the basis of prenatal diagnosis, polyhydramnios, gestational age, birth weight, pneumothorax, best values of postductal PaCO 2 and PaO 2, clinical and echocardiographic signs of persistent pulmonary hypertension, and severity of pulmonary hypoplasia (i.e., body weight to bilateral lung weight ratio at autopsy).
Results:
PaCO 2, PaO 2 and degree of pulmonary hypoplasia were significantly worse in Group I compared to Group II and to survivors. PaCO 2 and PaO 2 in Group II did not differ significantly from those of survivors.
Conclusions:
In severe CDH it is possible: 1) to achieve a survival rate of 56 % without ECMO; 2) to identify a group of patients (Group I = 27 %) with severe pulmonary hypoplasia who would probably die even with ECMO; and 3) to identify a group of patients (Group II = 17 %) who might benefit from ECMO treatment.