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Extracorporeal membrane oxygenation and congenital diaphragmatic hernia: should any infant be excluded?
K D Newman1, K D Anderson, K Van Meurs
1Department of Surgery, Children's National Medical Center, Washington, DC 20010.
Insights
Extracorporeal membrane oxygenation (ECMO) offers a 60% survival rate for infants with persistent pulmonary hypertension of the newborn (PPHN) after congenital diaphragmatic hernia (CDH) repair. Current mortality predictors are unreliable, suggesting ECMO should be considered for all CDH infants.
Area of Science:
- Pediatric Surgery
- Neonatology
- Critical Care Medicine
Background:
- Congenital diaphragmatic hernia (CDH) repair is associated with high mortality due to persistent pulmonary hypertension of the newborn (PPHN).
- Extracorporeal membrane oxygenation (ECMO) has been utilized as a rescue therapy for PPHN post-CDH repair when conventional methods fail.
Purpose of the Study:
- To evaluate the efficacy of ECMO in infants with PPHN following CDH repair.
- To assess the reliability of current predictors of high mortality in CDH patients undergoing ECMO therapy.
Main Methods:
- Retrospective analysis of 25 infants with PPHN post-CDH repair treated with ECMO.
- Comparison of outcomes between infants repaired at the institution versus those transferred for ECMO.
- Evaluation of established mortality predictors against actual outcomes in ECMO-treated infants.
Main Results:
- Overall survival rate for infants treated with ECMO was 60%.
- Mortality rates were similar for infants repaired locally and those transferred for ECMO.
- Established predictors of high mortality were found to be unreliable, with seven survivors potentially excluded by selective criteria.
Conclusions:
- Current predictors of high mortality in CDH patients are unreliable when ECMO is employed.
- Surgeons should consider ECMO for all infants with CDH, regardless of predicted mortality.
- ECMO can be a life-saving intervention for PPHN in CDH, with complications being manageable.
Abstract:
Mortality in infants with congenital diaphragmatic hernia (CDH) remains high despite improvements in neonatal and surgical care because many infants develop persistent pulmonary hypertension of the newborn (PPHN) following repair. Since 1984, extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy in all infants (n = 25) with PPHN following CDH repair when conventional management failed, with an overall survival of 60%. Repair was performed in this hospital on 12 infants and in other hospitals in 13 infants transferred for consideration of ECMO after repair. Mortality was the same in the group repaired here and those transferred for ECMO. Although complications were frequent in the surviving group, they were successfully managed with nonoperative or operative therapy. Selective use of ECMO has been advocated in CDH patients based on various predictors of high mortality such as "best" PO2 postrepair less than 100 mm Hg, oxygenation index greater than 40, and ventilation index greater than 1,000 with PCO2 greater than 40. Seven surviving infants following ECMO would have been classified as unsalvageable by at least one parameter if selection criteria based on these parameters had been used. We conclude from this series that current predictors of high mortality in CDH patients are unreliable when ECMO is used. Surgeons caring for infants with CDH should consider the use of ECMO in all infants.