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Published on: February 5, 2021
Delayed repair of congenital diaphragmatic hernia with early high-frequency oscillatory ventilation during
C Reyes1, L K Chang, F Waffarn
1Department of Surgery, University of California, Irvine Medical Center, Orange 92868, USA.
Insights
This study shows an 81% survival rate for congenital diaphragmatic hernia (CDH) using delayed surgical repair, early high-frequency oscillatory ventilation (HFOV), and selective extracorporeal membrane oxygenation (ECMO) referral.
Area of Science:
- Pediatric Surgery
- Neonatology
- Critical Care Medicine
Background:
- Congenital diaphragmatic hernia (CDH) presents significant challenges in neonatal care.
- Early stabilization and appropriate ventilation strategies are crucial for improving outcomes.
Purpose of the Study:
- To evaluate the effectiveness of a management strategy involving early high-frequency oscillatory ventilation (HFOV) and delayed surgical repair for congenital diaphragmatic hernia (CDH).
- To assess the survival rates and identify factors influencing outcomes in infants with CDH.
Main Methods:
- Retrospective analysis of 24 infants with CDH treated at UCIMC between January 1993 and December 1996.
- Infants received early HFOV for preoperative stabilization, followed by delayed surgical repair.
- Selective referral for extracorporeal membrane oxygenation (ECMO) was utilized.
Main Results:
- An overall survival rate of 81% (18 of 22 infants) was achieved.
- Eighteen infants were placed on HFOV within 1 hour of life; repair was delayed to a median age of 33.5 hours.
- Factors such as pulmonary hypoplasia and congenital heart anomalies influenced mortality.
Conclusions:
- A management approach combining delayed surgical repair, early HFOV, and selective ECMO referral can lead to high survival rates in CDH patients.
- This strategy offers a viable option for improving outcomes in neonates with congenital diaphragmatic hernia.
Purpose:
The authors reviewed their experience in the management of CDH after the introduction of early high-frequency oscillatory ventilation (HFOV) during the preoperative stabilization period and delayed CDH repair.
Methods:
This is a retrospective analysis of 24 consecutive infants with CDH treated at University of California, Irvine Medical Center (UCIMC) during a 36-month period from January 1993 to December 1996.
Results:
Two patients were excluded from the study: one fetus with a prenatal diagnosis was referred for fetal surgery; one infant received CDH repair at another institution 2 weeks before transfer to UCIMC. Eight (36%) infants were inborn, and nine (41%) had a prenatal diagnosis of CDH. Median gestational age was 40 weeks (range, 29 to 42 weeks). Median birth weight was 3,019 g (range, 1,205 to 4,337 g). The defect was left sided in 18 infants (86%). Twenty-one infants were intubated within 5 hours of life, 15 had an AaDO2 greater than 610, 11 had an oxygenation index greater than 40, and 11 had a pH of less than 7.2. The median ratio of pulmonary artery pressure to systemic blood pressure was 0.93 (range, 0.51 to 1.15) in 12 infants. Eighteen infants were placed on HFOV within a median of 1 hour of life. Nitric oxide was given to six infants and surfactant to eight. Four infants were referred for extracorporeal membrane oxygenation (ECMO). Repair of CDH was performed on infants at a median age of 33.5 hours (range, 5.5 to 322). Six (30%) received a prosthetic patch. Overall 18 of 22 infants survived (81%); three survivors received ECMO. Two infants of the survivor group had congenital heart anomalies: one ventricular septal defect (VSD) and one double-outlet right ventricle with a VSD. Of the four nonsurvivors, one had lethal cardiac anomalies and bilateral CDH, two had severe bilateral pulmonary hypoplasia (one received ECMO), and one infant was a 29-week premature baby who did not qualify for ECMO.
Conclusion:
We report a survival rate of 81% (18 of 22) with the management of CDH by delayed surgical repair, early postnatal HFOV, and selective referral for ECMO.
