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Pre-operative stabilisation with delayed repair in congenital diaphragmatic hernia
D Tibboel1, A P Bos, J W Pattenier
1Department of Paediatric Surgery, Sophia Children's Hospital, Rotterdam, The Netherlands.
Insights
Pre-operative stabilization for congenital diaphragmatic hernia (CDH) may improve outcomes. Delayed surgery following stabilization, with continuous nasogastric suction, showed promising results in high-risk infants, aiding patient selection for treatment.
Area of Science:
- Pediatric Surgery
- Neonatal Intensive Care
- Respiratory Physiology
Background:
- Congenital diaphragmatic hernia (CDH) presents significant mortality risks (30-60%) due to pulmonary hypoplasia and persistent pulmonary hypertension.
- Pre-operative stabilization is crucial for managing complications like hypoxia, acidosis, and myocardial insufficiency in neonates with CDH.
Purpose of the Study:
- To evaluate the efficacy of pre-operative stabilization in high-risk congenital diaphragmatic hernia patients.
- To assess the role of continuous nasogastric suction and ventilation parameters in patient management and outcome prediction.
Main Methods:
- A two-year study involving 16 high-risk CDH infants (respiratory insufficiency <6 hours post-birth) who underwent delayed surgery after a mean 14-hour stabilization period.
- Continuous nasogastric tube suction was employed, with chest X-rays monitoring mediastinal shift.
- Ventilation parameters including arterial alveolar oxygen gradient (A-aDO2), oxygenation index (OI), and mean airway pressure (MAP) were used for patient stratification.
Main Results:
- Continuous nasogastric suction led to complete resolution of mediastinal shift in repeat X-rays.
- Patients were categorized into three groups based on ventilation parameters: Group I (6 survivors), Group II (2 preventable deaths), and Group III (8 non-survivors).
- This stratification facilitated patient selection for appropriate treatment strategies.
Conclusions:
- Pre-operative stabilization, including nasogastric suction, can be beneficial for high-risk CDH infants.
- Ventilation parameters (A-aDO2, OI, MAP) aid in identifying patient groups and predicting outcomes.
- For non-improving patients during stabilization, alternative treatments like ECMO, HFO, or HFJV should be considered, necessitating prospective trials for comparative analysis.
Abstract:
Congenital diaphragmatic hernia (CDH) remains one of the major challenges for paediatric surgeons and paediatric intensive care specialists. Death in patients with CDH is 30-60% worldwide due to severe pulmonary hypoplasia or pulmonary hypoplasia associated with persistent pulmonary hypertension, secondary to hypoxia, metabolic acidosis or myocardial insufficiency. Pre-operative stabilisation of CDH patients might reduce the risks of these complications. In a two-year period 16 high-risk patients with CDH (respiratory insufficiency less than 6 hrs after birth) underwent delayed surgery following a stabilisation period (mean 14 hrs). Continuous suctioning on a nasogastric tube resulted in total resolution of the mediastinal shift on repeat x-rays. The use of the ventilation parameters arterial alveolar oxygen gradient (A-aDO2), oxygenation index (OI) and mean airway pressure (MAP) revealed three different groups of patients: I consisting of 6 survivors, II two preventable deaths and III eight non-survivors. In this way selection of patients with CDH is possible. In patients who do not improve during the stabilisation period alternative ways of treatment have to be evaluated such as extracorporeal membrane oxygenation (ECMO), high frequency oscillation (HFO) or high frequency jet ventilation (HFJV). Application of the ventilation parameters in prospective trials of patients with CDH enables comparison between different ways of treatment in the future.