Related Experiment Videos
Improved results in patients who have congenital diaphragmatic hernia using preoperative stabilization,
B Frenckner1, H Ehrén, T Granholm
1Department of Pediatric Surgery, St Goran's/Karolinska Hospital, Stockholm, Sweden.
Insights
This study suggests a prolonged preoperative stabilization protocol for congenital diaphragmatic hernia (CDH) significantly improves survival rates. Gentle ventilation and delayed surgical repair are key to managing this condition effectively.
Area of Science:
- Pediatric Surgery
- Neonatal Intensive Care
- Pulmonary Medicine
Background:
- Congenital diaphragmatic hernia (CDH) is linked to pulmonary hypoplasia and a highly reactive pulmonary vascular bed.
- Preventing pulmonary vasospasm is crucial in managing CDH patients.
Purpose of the Study:
- To evaluate the efficacy of a prolonged preoperative stabilization protocol for congenital diaphragmatic hernia (CDH).
- To assess the impact of gentle mechanical ventilation, controlled hypercarbia, and delayed surgical repair on CDH outcomes.
Main Methods:
- Implementation of a stabilization protocol involving gentle mechanical ventilation, low pressures (avoiding >35 cm H2O), and accepting slight hypercarbia.
- Use of extracorporeal membrane oxygenation (ECMO) based on standard criteria, supplemented with nitric oxide and high-frequency oscillation.
- Delayed surgical repair (24-96 hours post-stabilization) or repair while on ECMO for non-decannulatable patients.
Main Results:
- A survival rate of 92% (48 out of 52 patients) was achieved between 1990 and 1995.
- Among high-risk neonates with respiratory distress within 6 hours of birth, the survival rate was 91% (39 out of 43 patients).
- Only four hospital deaths occurred, all in patients with contraindications for ECMO.
Conclusions:
- The adopted preoperative stabilization protocol appears beneficial for treating CDH.
- The incidence of pulmonary hypoplasia incompatible with life in CDH patients may be lower than previously estimated.
Abstract:
Congenital diaphragmatic hernia (CDH) is associated with pulmonary hypoplasia. The pulmonary vascular bed may be extremely reactive to various stimuli, and in the treatment it is important to avoid pulmonary vasospasm. The strategy in our institution since 1990 has involved a prolonged preoperative stabilization with gentle mechanical ventilation. Pressures have been kept as low as possible, and slight hypercarbia has been accepted. Peak inspiratory pressures exceeding 35 cm H2O have been avoided. Extracorporeal membrane oxygenation (ECMO) has been used according to standard inclusion criteria. Nitric oxide and high-frequency oscillation have been added to the therapeutic modalities during the study period. When the patient was considered stabilized, surgical repair was undertaken after a delay of 24 to 96 hours. In patients on ECMO who could not be decannulated, surgical repair was undertaken while on ECMO. From 1990 through 1995, 52 patients were admitted with a diagnosis of CDH. Forty-three of these were risk group patients presenting with respiratory distress within 6 hours after birth. A total of 48 patients survived (survival rate 92%), and 39 of the risk group patients (survival rate 91%). There were only four hospital deaths, all with contraindications to ECMO. It is suggested that the adopted protocol is beneficial in the treatment of CDH and that the fraction of patients who have pulmonary hypoplasia incompatible with life is smaller than previously believed.