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Toward Standardized Management of Congenital Diaphragmatic Hernia: An Analysis of Practice Guidelines
Tim Jancelewicz1, Mary E Brindle2, Yigit S Guner3
1Department of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, Tennessee.
Insights
This study analyzed congenital diaphragmatic hernia (CDH) clinical practice guidelines (CPG) in North America. Significant variability exists in CDH management, highlighting a need for standardized care protocols.
Area of Science:
- Pediatric Surgery
- Neonatology
- Critical Care Medicine
Background:
- Congenital diaphragmatic hernia (CDH) management can be improved through standardized care.
- Clinical practice guidelines (CPG) are essential for consistent patient outcomes.
- Assessing variability in current CDH CPGs is crucial for identifying areas for standardization.
Purpose of the Study:
- To assess the variability of congenital diaphragmatic hernia (CDH) clinical practice guidelines (CPG) across North American centers.
- To identify common elements and divergences in CDH management protocols.
- To provide data for the development of a consensus-based, multi-institutional approach to CDH care.
Main Methods:
- North American institutions involved in CDH care were invited to submit their CPGs.
- CPG elements were collected and categorized by therapeutic purpose.
- Descriptive analyses characterized the scope and variability of the submitted guidelines.
Main Results:
- 27 of 29 (73%) responding centers had a CDH CPG, with a primary focus on preoperative care.
- Conventional ventilation was universally the first-line strategy, with consistent peak inspiratory pressure limits.
- While targets for oxygenation and ventilation showed low variability, indications for advanced therapies like inhaled nitric oxide and extracorporeal life support varied significantly.
Conclusions:
- Synthesis of North American CDH CPGs reveals both alignment and variability in clinical practice.
- Objective data on institutional guidelines can inform the development of standardized CDH management.
- A consensus-based, multi-institutional approach is needed to optimize CDH care in North America.
Background:
Standardized care may improve outcomes in many diseases including congenital diaphragmatic hernia (CDH). Our study assesses the variability of CDH clinical practice guidelines (CPG) among North American centers.
Methods:
North American member institutions of the CDH Study Group and the Pediatric Surgical Research Collaborative were solicited to submit their CDH CPG. Elements from each CPG were collected and classified according to therapeutic purpose. Elements were assigned to umbrella topics of prenatal assessment, delivery plus initial resuscitation, ventilatory and cardiovascular management, therapeutic targets, analgesia, and criteria for transitions in care. Descriptive analyses were performed to characterize the scope and variability of CPGs.
Results:
Sixty-eight centers provided 40 responses (59%). Of these, 29 (73%) had a CDH CPG, of which 27 were obtained for review. All CPGs had a primary focus of preoperative care. Conventional ventilation was the first-line strategy in all CPGs. Ninety-three percent reported a peak inspiratory pressure limit (mean: 25.2 ± 2 cm H2O). Target oxygenation and ventilatory variables had low coefficients of variation. Two-thirds of CPGs discussed echocardiography, with indications for inhaled nitric oxide, sildenafil, and prostaglandins detailed in 81%, 30%, and 22% of CPGs, respectively. Extracorporeal life support and operative indications were specified in 93% and 59%, respectively, although specific targets for each were highly variable.
Conclusions:
This synthesis of North American CDH CPGs identifies areas of both alignment and variability and provides objective data about individual institutional guidelines in CDH care. These data may inform the development of a consensus-based, multi-institutional approach to standardized CDH management in North America.
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