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Extracorporeal membrane oxygenation following repair of congenital diaphragmatic hernias
Insights
Extracorporeal membrane oxygenation (ECMO) improved survival rates for newborns with congenital diaphragmatic hernia and severe hypoxemia. This technology offers a lifeline for infants facing high mortality risks after surgical repair.
Area of Science:
- Neonatal surgery
- Pediatric critical care
- Cardiopulmonary support
Background:
- Congenital diaphragmatic hernia (CDH) presents a significant surgical challenge in neonates.
- High mortality rates (60-80%) are reported for CDH requiring early herniorrhaphy without advanced support.
- Refractory hypoxemia post-CDH repair indicates a poor prognosis.
Purpose of the Study:
- To evaluate the efficacy of Extracorporeal Membrane Oxygenation (ECMO) in neonates with congenital diaphragmatic hernia.
- To assess survival rates and complications in CDH patients managed with ECMO.
- To compare outcomes with historical data for CDH without ECMO support.
Main Methods:
- Retrospective review of 8 newborns with CDH requiring herniorrhaphy within 8 hours of birth (1981-1986).
- Seven patients received ECMO due to criteria predicting 95% mortality (PaO2 gradient >600 mm Hg or hemodynamic instability).
- ECMO support duration ranged from 68 to 241 hours (mean 163 hours).
Main Results:
- Overall mortality was 29% (2 of 7 patients on ECMO).
- Four of seven ECMO patients experienced unremitting hypoxemia post-surgery, with 3 survivors.
- Complications included bleeding, hernia recurrence, and air embolism; 4 of 5 survivors showed normal development.
Conclusions:
- ECMO significantly improves survival for newborns with congenital diaphragmatic hernia and refractory hypoxemia.
- While complications like bleeding can occur, ECMO provides reliable oxygenation and support.
- Long-term follow-up indicates positive neurodevelopmental outcomes in a majority of ECMO survivors.
Abstract:
From 1981 through 1986, 8 newborns with congenital diaphragmatic hernia required herniorrhaphy in the first 8 hours of life. Extracorporeal membrane oxygenation (ECMO) was employed in 7 after they met local criteria predictive of 95% mortality. These criteria were an alveolar-postductal arterial oxygen gradient greater than 600 mm Hg for 12 hours or hemodynamic instability. Four of these 7 patients had unremitting hypoxemia after herniorrhaphy (no "honeymoon" period), 3 of whom survived. One additional patient died, producing a mortality of 29%. ECMO used for 68 to 241 hours (mean, 163 hours) provided reliable oxygenation in all. Deaths resulted from disseminated intravascular coagulation and bleeding, and bleeding and pulmonary failure after ligation of a patent ductus arteriosus. Complications occurred in 6 patients and included bleeding (3), hernia recurrence (3), and air embolism (1). Follow-up ranging from 1 year to 6 years after discharge of the 5 survivors shows normal growth and development in 4. The reported mortality without ECMO following congenital diaphragmatic herniorrhaphy in the first 8 hours of life ranges between 60 and 80%. While bleeding may present problems, survival of newborns with refractory hypoxemia after diaphragmatic repair has improved with ECMO.