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Kunisaki SM, Desiraju S, Yang MJ, Lakshminrusimha S, Yoder BA. Ventilator strategies in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151439. [PMID: 38986241 DOI: 10.1016/j.sempedsurg.2024.151439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
This review focuses on contemporary mechanical ventilator practices used in the initial management of neonates born with congenital diaphragmatic hernia (CDH). Both conventional and non-conventional ventilation modes in CDH are reviewed. Special emphasis is placed on the rationale for gentle ventilation and the current evidence-based clinical practice guidelines that are recommended for supporting these fragile infants. The interplay between CDH lung hypoplasia and other key cardiopulmonary elements of the disease, namely a reduced pulmonary vascular bed, abnormal pulmonary vascular remodeling, and left ventricular hypoplasia, are discussed. Finally, we provide insights into future avenues for mechanical ventilator research in CDH.
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Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins Medicine, USA.
| | - Suneetha Desiraju
- Division of Neonatology, Johns Hopkins Children's Center, Johns Hopkins Medicine, USA
| | - Michelle J Yang
- Division of Neonatology, Primary Children's Medical Center, University of Utah Health, USA
| | - Satyan Lakshminrusimha
- Division of Neonatal-Perinatal Medicine, UC Davis Children's Hospital, University of California at Davis Health, USA
| | - Bradley A Yoder
- Division of Neonatology, Primary Children's Medical Center, University of Utah Health, USA
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Dimmer A, Baird R, Puligandla P. Role of practice standardization in outcome optimization for CDH. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000783. [PMID: 38532942 PMCID: PMC10961560 DOI: 10.1136/wjps-2024-000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
Standardization of care seeks to improve patient outcomes and healthcare delivery by reducing unwanted variations in care as well as promoting the efficient and effective use of healthcare resources. There are many types of standardization, with clinical practice guidelines (CPGs), based on a stringent assessment of evidence and expert consensus, being the hallmark of high-quality care. This article outlines the history of CPGs, their benefits and shortcomings, with a specific focus on standardization efforts as it relates to congenital diaphragmatic hernia management.
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Affiliation(s)
- Alexandra Dimmer
- Harvey E. Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Robert Baird
- Division of Pediatric General and Thoracic Surgery, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pramod Puligandla
- Harvey E. Beardmore Department of Pediatric Surgery, McGill University, Montreal, Quebec, Canada
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Martino AM, Nguyen DV, Delaplain PT, Dinh P, Jancelewicz T, Harting MT, Yu PT, Di Nardo M, Gowda S, Goodman LF, Yu Y, Guner YS. Center Volume and Survival Relationship for Neonates With Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support. Pediatr Crit Care Med 2023; 24:987-997. [PMID: 37346002 DOI: 10.1097/pcc.0000000000003313] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
OBJECTIVES Literature is emerging regarding the role of center volume as an independent variable contributing to improved outcomes. A higher volume of index procedures may be associated with decreased morbidity and mortality. This association has not been examined for the subgroup of infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS). Our study aims to examine the risk-adjusted association between center volume and outcomes in CDH-ECLS neonates, hypothesizing that higher center volume confers a survival advantage. DESIGN Multicenter, retrospective comparative study using the Extracorporeal Life Support Organization database. SETTING One hundred twenty international pediatric centers. PATIENTS Neonates with CDH managed with ECLS from 2000 to 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The cohort included 4,985 neonates with a mortality rate of 50.6%. For the 120 centers studied, mean center volume was 42.4 ± 34.6 CDH ECLS cases over the 20-year study period. In an adjusted model, higher ECLS volume was associated with lower odds of mortality: odds ratio (OR) 0.995 (95% CI, 0.992-0.999; p = 0.014). For an increase in one sd in volume, that is, 1.75 cases annually, the OR for mortality was lower by 16.7%. Volume was examined as a categorical exposure variable where low-volume centers (fewer than 2 cases/yr) were associated with 54% higher odds of mortality (OR, 1.54; 95% CI, 1.03-2.29) compared with high-volume centers. On-ECLS complications (mechanical, neurologic, cardiac, hematologic metabolic, and renal) were not associated with volume. The likelihood of infectious complications was higher for low- (OR, 1.90; 95% CI, 1.06-3.40) and medium-volume (OR, 1.87; 95% CI, 1.03-3.39) compared with high-volume centers. CONCLUSIONS In this study, a survival advantage directly proportional to center volume was observed for CDH patients managed with ECLS. There was no significant difference in most complication rates. Future studies should aim to identify factors contributing to the higher mortality and morbidity observed at low-volume centers.
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Affiliation(s)
- Alice M Martino
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Irvine, CA
| | - Patrick T Delaplain
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
| | - Peter Dinh
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Peter T Yu
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sharada Gowda
- Division of Neonatalogy, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Laura F Goodman
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
| | - Yangyang Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
| | - Yigit S Guner
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
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Hamilton M, Thornton SW, Tracy ET, Ozment C. Quality improvement strategies in pediatric ECMO. Semin Pediatr Surg 2023; 32:151337. [PMID: 37935089 DOI: 10.1016/j.sempedsurg.2023.151337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Pediatric extracorporeal membrane oxygenation is an increasingly utilized, life-saving technology with high mortality and morbidity. A complex technology employed urgently or emergently for some of the sickest children in the hospital by a large multidisciplinary team, ECMO is an ideal area for using quality improvement strategies to reduce the variability in care and improve patient outcomes. We review critical concepts from quality improvement and apply them to patient selection and management, staffing, credentialing and continuing education, and the variability of management among providers and institutions.
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Affiliation(s)
- Makenzie Hamilton
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Univeristy, Durham, NC, USA
| | - Steven W Thornton
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Elisabeth T Tracy
- Department of Surgery, Division of Pediatric Surgery, Duke University, Durham, NC, USA
| | - Caroline Ozment
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Univeristy, Durham, NC, USA.
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Holden KI, Harting MT. Recent advances in the treatment of complex congenital diaphragmatic hernia-a narrative review. Transl Pediatr 2023; 12:1403-1415. [PMID: 37575897 PMCID: PMC10416132 DOI: 10.21037/tp-23-240] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/21/2023] [Indexed: 08/15/2023] Open
Abstract
Background and Objective Congenital diaphragmatic hernia (CDH) is an anomaly of the cardiopulmonary system maturation process that results from both a global embryopathy and concomitant mechanical compression of the cardiopulmonary system from the abdominal contents during fetal maturation. This results in pulmonary hypertension, pulmonary hypoplasia, and cardiac dysfunction, requiring intense critical care management. The patients with highest risk CDH are the most challenging, resource-intensive, and bear most of the mortality. Advances at the basic, translational, and clinical research levels are leading to novel therapies and management strategies for complex, high-risk CDH. Our objective is to review novel approaches in thinking and management for the most complex and high-risk CDH patients. These include patients with prenatal and postnatal indicators of high-risk defects, those receiving extracorporeal life support (ECLS), and those with concomitant anomalies such as complex cardiac and/or chromosomal abnormalities. Methods PubMed was searched in late 2022 and early 2023 to identify relevant evidence. Search terms included congenital diaphragmatic hernia (CDH)", "extracorporeal life support (ECLS)", "pulmonary hypertension", "dual-hit hypothesis", "risk reduction", "cardiac/chromosomal anomalies", and "novel therapies". We included trials, multicenter studies (prospective and retrospective), single-center reports, and review articles/expert opinion. Key Content and Findings CDH is a congenital anomaly of the cardiopulmonary and diaphragmatic systems that represents a spectrum of disease. High-risk or complex patients are defined by prenatal/postnatal risk stratification, receipt of ECLS, and/or having concomitant anomalies, representing the severe end of that spectrum. Overall survival of high-risk CDH is about 50% and comprises the vast majority of mortality, mandating special emphasis. The development of risk-stratification processes, best practices or guidelines of management, and novel therapies is critical to optimize the care of these infants. Conclusions CDH patients with high-risk disease remain a challenging subset of CDH patients. Increasing opportunities for survival are being realized with novel, investigational approaches.
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Affiliation(s)
- Kylie I. Holden
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children’s Memorial Hermann Hospital, Houston, TX, USA
| | - Matthew T. Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children’s Memorial Hermann Hospital, Houston, TX, USA
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, TX, USA
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Romero-Lopez M, Oria M, Ferrer-Marquez F, Varela MF, Lampe K, Watanabe-Chailland M, Martinez L, Peiro JL. Fetal lung hypoxia and energetic cell failure in the nitrofen-induced congenital diaphragmatic hernia rat model. Pediatr Surg Int 2023; 39:180. [PMID: 37055635 DOI: 10.1007/s00383-023-05452-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) pathogenesis is poorly understood. We hypothesize that fetal CDH lungs are chronically hypoxic because of lung hypoplasia and tissue compression, affecting the cell bioenergetics as a possible explanation for abnormal lung development. METHODS To investigate this theory, we conducted a study using the rat nitrofen model of CDH. We evaluated the bioenergetics status using H1 Nuclear magnetic resonance and studied the expression of enzymes involved in energy production, the hypoxia-inducible factor 1α, and the glucose transporter 1. RESULTS The nitrofen-exposed lungs have increased levels of hypoxia-inducible factor 1α and the main fetal glucose transporter, more evident in the CDH lungs. We also found imbalanced AMP:ATP and ADP:ATP ratios, and a depleted energy cellular charge. Subsequent transcription levels and protein expression of the enzymes involved in bioenergetics confirm the attempt to prevent the energy collapse with the increase in lactate dehydrogenase C, pyruvate dehydrogenase kinase 1 and 2, adenosine monophosphate deaminase, AMP-activated protein kinase, calcium/calmodulin-dependent protein kinase 2, and liver kinase B1, while decreasing ATP synthase. CONCLUSION Our study suggests that changes in energy production could play a role in CDH pathogenesis. If confirmed in other animal models and humans, this could lead to the development of novel therapies targeting the mitochondria to improve outcomes.
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Affiliation(s)
- Mar Romero-Lopez
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Marc Oria
- Division of Pediatric General and Thoracic Surgery, Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, 45229, USA
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, 45267, USA
| | - Fernando Ferrer-Marquez
- Division of Pediatric General and Thoracic Surgery, Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, 45229, USA
- Division of Obstetrics and Gynecology, School of Medicine, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Maria Florencia Varela
- Division of Pediatric General and Thoracic Surgery, Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, 45229, USA
| | - Kristin Lampe
- Division of Pediatric General and Thoracic Surgery, Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, 45229, USA
| | - Miki Watanabe-Chailland
- NMR-Based Metabolomics Core, Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Leopoldo Martinez
- Servicio de Cirugía Pediátrica, Hospital la Paz, Instituto de Investigación La Paz (IdiPAZ), Madrid, Spain
| | - Jose L Peiro
- Division of Pediatric General and Thoracic Surgery, Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, 45229, USA.
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, 45267, USA.
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Lin TJ. Editorial Commentary: There Is No Standard for or Standardization of Postoperative Rehabilitation Protocols After Anterior Cruciate Ligament Reconstruction. Arthroscopy 2023; 39:590-591. [PMID: 36740283 DOI: 10.1016/j.arthro.2022.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 02/07/2023]
Abstract
The anterior cruciate ligament (ACL) is the most studied ligament in the knee and one of the most studied topics in orthopaedics, with little consensus on best options for surgical technique or graft choice. While there is little question that physical rehabilitation is one of the most important variables in the episode of care before and after ACL reconstruction (ACLR), recent research surveying orthopaedic surgeons demonstrates no consensus of how to rehab ACLR patients and how to get them to return to sport safely and quickly. Seventy-two percent of surgeons prescribe "pre-hab" prior to ACLR, and 83% of surgeons use postoperative bracing, with most (55%) bracing for 3 to 6 weeks postoperatively. Patient-reported outcome measures (35%) and assessments of psychological readiness (23%) are not commonly used to progress patients through the stages of rehab. When asked what they believe is the single most important factor in unrestricted return to sport, 52% of surgeons stated functional testing scores were most important, while 38% stated time since surgery, and 5% stated muscle strength. As for average time to return to full activity, 50% of surgeons waited until 9+ months for full return, and 42% allowed return within 6 to 8 months. Reductions in practice variability have been shown in orthopaedic surgery and other fields to reduce costs of care delivery and improve patient outcomes, and with so much variability in ACLR rehabilitation protocols, the orthopaedic community would be wise to strive for more consensus focused on evidence-based recommendations for rehabilitation and to fill in knowledge gaps with focused, high-quality research where needed.
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Han XY, Selesner LT, Butler MW. Congenital Diaphragmatic Hernia. Surg Clin North Am 2022; 102:739-757. [DOI: 10.1016/j.suc.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Rubalcava N, Norwitz GA, Kim AG, Weiner G, Matusko N, Arnold MA, Mychaliska GB, Perrone EE. Neonatal pneumothorax in congenital diaphragmatic hernia: Be wary of high ventilatory pressures. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000341. [DOI: 10.1136/wjps-2021-000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 03/01/2022] [Indexed: 11/04/2022] Open
Abstract
BackgroundPatients with congenital diaphragmatic hernia (CDH) require invasive respiratory support and higher ventilator pressures may be associated with barotrauma. We sought to evaluate the risk factors associated with pneumothorax in CDH neonates prior to repair.MethodsWe retrospectively reviewed newborns born with CDH between 2014 and 2019 who developed a pneumothorax, and we matched these cases to patients with CDH without pneumothorax.ResultsTwenty-six patients were included (n=13 per group). The pneumothorax group required extracorporeal life support (ECLS) more frequently (85% vs 54%, p=0.04), particularly among type A/B defects (31% vs 7%, p=0.01). The pneumothorax group had higher positive end-expiratory pressure (PEEP) within 1 hour of birth (p=0.02), at pneumothorax diagnosis (p=0.003), and at ECLS (p=0.02). The pneumothorax group had a higher mean airway pressure (Paw) at birth (p=0.01), within 1 hour of birth (p=0.01), and at pneumothorax diagnosis (p=0.04). Using multiple logistic regression with cluster robust SEs, higher Paw (OR 2.2, 95% CI 1.08 to 3.72, p=0.03) and PEEP (OR 1.8, 95% CI 1.15 to 3.14, p=0.007) were associated with an increased risk of developing pneumothorax. There was no difference in survival (p=0.09).ConclusionsDevelopment of a pneumothorax in CDH neonates is independently associated with higher Paw and higher PEEP. A pneumothorax increases the likelihood of treated with ECLS, even with smaller defect.
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Chock VY, Danzer E, Chung S, Noh CY, Ebanks AH, Harting MT, Lally KP, Van Meurs KP. In-Hospital Morbidities for Neonates with Congenital Diaphragmatic Hernia: The Impact of Defect Size and Laterality. J Pediatr 2022; 240:94-101.e6. [PMID: 34506854 DOI: 10.1016/j.jpeds.2021.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/07/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine in-hospital morbidities for neonates with right-sided congenital diaphragmatic hernia (R-CDH) compared with those with left-sided defects (L-CDH) and to examine the differential effect of laterality and defect size on morbidities. STUDY DESIGN This retrospective, multicenter, cohort study from the international Congenital Diaphragmatic Hernia Study Group registry collected data from neonates with CDH surviving until hospital discharge from 90 neonatal intensive care units between January 1, 2007, and July 31, 2020. Major pulmonary, cardiac, neurologic, and gastrointestinal morbidities were compared between neonates with L-CDH and R-CDH, adjusted for prenatal and postnatal factors using logistic regression. RESULTS Of 4123 survivors with CDH, those with R-CDH (n = 598 [15%]) compared with those with L-CDH (n = 3525 [85%]) had an increased odds of pulmonary (1.7; 95% CI, 1.4-2.2, P < .0001), cardiac (1.4; 95% CI, 1.1-1.8; P = .01), gastrointestinal (1.3; 95% CI, 1.1-1.6; P = .01), and multiple (1.6; 95% CI, 1.2-2.0; P < .001) in-hospital morbidities, with a greater likelihood of morbidity with increasing defect size. There was no difference in neurologic morbidities between the groups. CONCLUSIONS Neonates with R-CDH and a larger defect size are at an increased risk for in-hospital morbidities. Counseling and clinical strategies should incorporate knowledge of these risks, and approach to neonatal R-CDH should be distinct from current practices targeted to L-CDH.
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Affiliation(s)
- Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Enrico Danzer
- Division of Pediatric Surgery, Kaiser Permanente Medical Center, Santa Clara, CA
| | - Sukyung Chung
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Caroline Y Noh
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ashley H Ebanks
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Kevin P Lally
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
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Predicting treatment of pulmonary hypertension at discharge in infants with congenital diaphragmatic hernia. J Perinatol 2022; 42:45-52. [PMID: 34711937 DOI: 10.1038/s41372-021-01249-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/30/2021] [Accepted: 10/12/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To predict pulmonary hypertension (PH) therapy at discharge in a large multicenter cohort of infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN Six-year linked records from Children's Hospitals Neonatal Database and Pediatric Health Information System were used; patients whose diaphragmatic hernia was repaired before admission or referral, who were previously home before admission or referral, and non-survivors were excluded. The primary outcome was the use of PH medications at discharge and the secondary outcome was an inter-center variation of therapies during inpatient utilization. Clinical factors were used to develop a multivariable equation randomly applied to 80% cohort; validated in the remaining 20% infants. RESULTS A total of 831 infants with CDH from 23 centers were analyzed. Overall, 11.6% of survivors were discharged on PH medication. Center, duration of mechanical ventilation, and duration of inhaled nitric oxide were associated with the use of PH medication at discharge. This model performed well in the validation cohort area under the receiver operating characteristic curve of 0.9, goodness-of-fit χ2, p = 0.17. CONCLUSIONS Clinical variables can predict the need for long-term PH medication after NICU hospitalization in surviving infants with CDH. This information may be useful to educate families and guide the development of clinical guidelines.
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Joharifard S, Trudeau MO, Miyata S, Malo J, Bouchard S, Beaunoyer M, Brocks R, Lemoine C, Villeneuve A. Implementing a standardized gastroschisis protocol significantly increases the rate of primary sutureless closure without compromising closure success or early clinical outcomes. J Pediatr Surg 2022; 57:12-17. [PMID: 34654548 DOI: 10.1016/j.jpedsurg.2021.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Standardized protocols have been shown to improve outcomes in several pediatric surgical conditions. We implemented a multi-disciplinary gastroschisis practice bundle at our institution in 2013. We sought to evaluate its impact on closure type and early clinical outcomes. METHODS We performed a retrospective review of uncomplicated gastroschisis patients treated at our institution between 2008-2019. Patients were divided into two groups: pre- and post-protocol implementation. Multivariate logistic regression was used to compare closure location, method, and success. RESULTS Neonates (pre-implementation n = 53, post-implementation n = 43) were similar across baseline variables. Successful immediate closure rates were comparable (75.5% vs. 72.1%, p = 0.71). The proportion of bedside closures increased significantly after protocol implementation (35.3% vs. 95.4%, p < 0.01), as did the proportion of sutureless closures (32.5% vs. 71.0%, p < 0.01). Median postoperative mechanical ventilation decreased significantly (4 days IQR [3, 5] vs. 2 days IQR [1, 3], p < 0.01). Postoperative complications and duration of parenteral nutrition were equivalent. After controlling for potential confounding, infants in the post-implementation group had a 44.0 times higher odds of undergoing bedside closure (95% CI: 9.0, 215.2, p < 0.01) and a 7.7 times higher odds of undergoing sutureless closure (95% CI: 2.3, 25.1, p < 0.01). CONCLUSIONS Implementing a standardized gastroschisis protocol significantly increased the proportion of immediate bedside sutureless closures and decreased the duration of mechanical ventilation, without increasing postoperative complications. Level of Evidence III Type of Study Retrospective comparative study.
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Affiliation(s)
- Shahrzad Joharifard
- The University of British Columbia, Department of Surgery, Vancouver, British Columbia, Canada V6H3V4.
| | - Maeve O'Neill Trudeau
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Shin Miyata
- Division of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, MO, USA
| | - Josianne Malo
- Department of Pharmacy, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Sarah Bouchard
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Mona Beaunoyer
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Rebecca Brocks
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Caroline Lemoine
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andréanne Villeneuve
- Division of Neonatology, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
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Rideout DA, Wulkan M. Thoracoscopic Neonatal Congenital Diaphragmatic Hernia Repair: How We Do It. J Laparoendosc Adv Surg Tech A 2021; 31:1168-1174. [PMID: 34569855 DOI: 10.1089/lap.2021.0420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Congenital diaphragmatic hernia (CDH) is a relatively common congenital anomaly, typically requiring repair in the neonatal period. Approaches to surgical repair of a CDH are varied. A small defect may be repaired primarily while a large defect often requires a patch repair. Minimally invasive and open techniques have been reported to have varying benefits and outcomes. Materials and Methods: The authors describe their technique of CDH repair and present a review of the literature. Results: In a stabilized neonate with a small-to-moderate CDH defect, a thoracoscopic primary repair with biological mesh underlay (or a patch repair if needed to reduce tension) represents our approach of choice to treat this pathology. However, attention to specific technical details is required to minimize incidence of recurrence. Conclusions: The data favor a minimally invasive approach to CDH repair in the appropriate patients.
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Affiliation(s)
- Drew A Rideout
- Department of Pediatric Surgery, John Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Mark Wulkan
- Department of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio, USA
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Risk factors of early mortality after neonatal surgery in Tunisia. J Pediatr Surg 2020; 55:2233-2237. [PMID: 32654833 DOI: 10.1016/j.jpedsurg.2020.05.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 05/19/2020] [Accepted: 05/29/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Research concerning factors of death after neonatal surgery is scarce. Insight into mortality might improve perioperative care. This study aimed to identify predictive factors of mortality after neonatal surgery in a low income country (LIC). METHODS Charts of all newborn patients who underwent surgical procedures under general anesthesia during the neonatal period in our department of pediatric surgery between January 2010 and December 2017 were reviewed. We used univariate and multivariate analysis to evaluate perioperative variables potentially predictive of early postoperative mortality. RESULTS One hundred eighty-two cases were included in the study: 41 newborns (28.6%) were premature (<37 weeks of gestation) and 52 (22.5%) weighed less than 2.5 kg. The most commonly diagnosed conditions were esophageal atresia (24%) and bowel obstruction (19%). Forty-four patients (24%) died during hospitalization. The highest rate of mortality was observed for congenital diaphragmatic hernia. Univariate analysis showed that perinatal predictive variables of mortality were prematurity, low birth weight, the necessity of preoperative intubation, and duration of surgery more than 2 h. Logistic regression showed three independent risk factors, which are the duration of surgery, low birth weight and the necessity of preoperative intubation. CONCLUSION The overall mortality in infants undergoing neonatal surgery is still high in LICs. Knowledge of independent risk factors of early mortality may help clinicians to more adequately manage the high-risk population. TYPE OF THE STUDY Clinical research paper. LEVEL OF EVIDENCE III.
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15
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Standardizing congenital diaphragmatic hernia care in Canada: Implementing national clinical practice guidelines. J Pediatr Surg 2020; 55:835-843. [PMID: 32085916 DOI: 10.1016/j.jpedsurg.2020.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/25/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE We sought to identify implementation barriers and opportunities to increase utilization of the Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative's clinical practice guideline. METHODS A validated readiness assessment was sent via SurveyMonkey™ to CAPSNet site coordinators and local CDH stakeholders. The survey was open from 11/2018 to 02/2019. Data and responses were analyzed using descriptive statistics (REB 2019-4753). RESULTS Eighty-six responses were received, of which 65% (n = 56/86) were fully completed. The greatest number of responses came from neonatology (n = 27), pediatric surgery (n = 25), and respiratory therapy (n = 10). Seventy-eight percent (n = 67/86) of respondents were aware of the CDH guideline, and 63% (n = 54/86) used the entire guideline, while 23% (n = 20/86) used only certain sections. Besides recommendations pertaining to fetal intervention and ECLS, interdisciplinary long-term surveillance and prenatal diagnosis were considered most difficult to implement owing to funding limitations. Most respondents (n = 49/56; 87.5%) felt they could implement >75% of the recommendations. Establishing common team goals [i.e., minimize care variations] (n = 33/58;57%), provider buy-in [commitment of all health professionals to the guideline] (n = 28/58;48%), and regular compliance assessment (n = 23/58;40%) would increase uptake. CONCLUSION There is national awareness of the CDH guideline. Implementation strategies ensuring common team goals, provider buy-in, and regular compliance assessment should increase guideline uptake/utilization. Consolidating funding for interdisciplinary long-term surveillance and prenatal diagnosis is necessary for any site-specific implementation strategy. LEVEL OF EVIDENCE Level 4 qualitative, survey.
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16
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Attar MA, Dechert RE, Donn SM. Rescue high frequency ventilation for congenital diaphragmatic hernia. J Neonatal Perinatal Med 2020; 12:173-178. [PMID: 30829621 DOI: 10.3233/npm-1813] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION High frequency jet (HFJV) and oscillatory (HFOV) ventilation were used to rescue newborns with congenital diaphragmatic hernia (CDH), who failed conventional mechanical ventilation (CV). Changes in ventilator settings and pulmonary gas exchange were evaluated following transition to high frequency ventilation (HFV). METHODS Records of patients with CDH rescued with HFV prior to surgical intervention between 2006 and 2015 were reviewed. Mean airway pressure (Pāw) and arterial blood gases during CV and those obtained within the first hour of HFV were compared. A composite repeated measure analysis was performed to evaluate longitudinal and intergroup variances. RESULTS Twenty-seven patients were rescued from CV, 16 by HFJV and 11 by HFOV. The two groups had similar gestational ages and birth weights. Prior to HFV, both groups had similar Pāw, PaCO2, FiO2 and PaO2. HFV was associated with a significant improvement in ventilation, and the rate of decrease of PaCO2 was no different between groups. There was a significantly higher increase in Pāw increase with HFOV compared to HFJV. CONCLUSIONS In newborns with CDH rescued with HFV, ventilation improved but Pāw was significantly lower in patients supported with HFJV compared to HFOV.
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Affiliation(s)
- M A Attar
- Department of Pediatrics and Communicable Diseases, Division of Neonatal-Perinatal Medicine, Ann Arbor, Michigan, USA
| | - R E Dechert
- Department of Critical Care Support Services Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - S M Donn
- Department of Pediatrics and Communicable Diseases, Division of Neonatal-Perinatal Medicine, Ann Arbor, Michigan, USA
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17
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Tingay DG, Kinsella JP. Heart of the Matter? Early Ventricular Dysfunction in Congenital Diaphragmatic Hernia. Am J Respir Crit Care Med 2019; 200:1462-1464. [PMID: 31600453 PMCID: PMC6909840 DOI: 10.1164/rccm.201909-1737ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- David G Tingay
- Neonatal ResearchMurdoch Children's Research InstituteParkville, Australia
- NeonatologyThe Royal Children's HospitalParkville, Australia
- Department of PaediatricsUniversity of MelbourneMelbourne, Australia
| | - John P Kinsella
- Department of PediatricsUniversity of Colorado School of MedicineAurora, Coloradoand
- Children's Hospital ColoradoAurora, Colorado
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18
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Toward Standardized Management of Congenital Diaphragmatic Hernia: An Analysis of Practice Guidelines. J Surg Res 2019; 243:229-235. [DOI: 10.1016/j.jss.2019.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/10/2019] [Accepted: 05/01/2019] [Indexed: 11/20/2022]
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19
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Risk-stratification enables accurate single-center outcomes assessment in congenital diaphragmatic hernia (CDH). J Pediatr Surg 2019; 54:932-936. [PMID: 30792092 DOI: 10.1016/j.jpedsurg.2019.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 01/27/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Management of CDH is highly variable from center to center, as are patient outcomes. The purpose of this study was to examine risk-stratified survival and extracorporeal membrane oxygenation (ECMO) rates at a single center, and to determine whether adverse outcomes are related to patient characteristics or management. METHODS A retrospective single-center review of CDH patients was performed, and outcomes compared to those reported by the CDH Study Group (CDHSG) registry. Patient demographics, disparities, and clinical characteristics were examined to identify unique features of the cohort. A model derived using the registry that estimates probability of ECMO use or death in CDH newborns was used to risk-stratify patients and assess mortality rates. Observed over expected (O/E) ECMO use rates were calculated to measure whether "excess" or "appropriate" ECMO use was occurring. RESULTS There were 81 CDH patients treated between 2004-2017, and 5034 in the CDHSG registry. Mortality in ECMO-treated patients was higher than the registry. Socioeconomic variables were not significantly associated with outcomes. The strongest predictors of mortality were ECMO use and early blood gas variables. The risk model accurately predicted ECMO use with a c-statistic of 0.79. Compared with the registry, the disparity in mortality rates was greatest for moderate-risk patients. O/E ECMO use was highest in low and moderate-risk patients. CONCLUSIONS ECMO use is a more consistent predictor of mortality than CDH severity at a single center, and there is relative overuse of ECMO in lower-risk patients. Risk stratification allows for more accurate institutional assessment of mortality and ECMO use, and other centers could consider such an adjusted analysis to identify opportunities for outcomes improvement. LEVEL OF EVIDENCE III.
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20
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Dizon MLV, Rao R, Hamrick SE, Zaniletti I, DiGeronimo R, Natarajan G, Kaiser JR, Flibotte J, Lee KS, Smith D, Yanowitz T, Mathur AM, Massaro AN. Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs. BMC Pediatr 2019; 19:67. [PMID: 30813933 PMCID: PMC6391819 DOI: 10.1186/s12887-019-1441-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/20/2019] [Indexed: 12/20/2022] Open
Abstract
Background While intercenter variation (ICV) in anti-epileptic drug (AED) use in neonates with seizures has been previously reported, variation in AED practices across regional NICUs has not been specifically and systematically evaluated. This is important as these centers typically have multidisciplinary neonatal neurocritical care teams and protocolized approaches to treating conditions such as hypoxic ischemic encephalopathy (HIE), a population at high risk for neonatal seizures. To identify opportunities for quality improvement (QI), we evaluated ICV in AED utilization for neonates with HIE treated with therapeutic hypothermia (TH) across regional NICUs in the US. Methods Children’s Hospital Neonatal Database and Pediatric Health Information Systems data were linked for 1658 neonates ≥36 weeks’ gestation, > 1800 g birthweight, with HIE treated with TH, from 20 NICUs, between 2010 and 2016. ICV in AED use was evaluated using a mixed-effect regression model. Rates of AED exposure, duration, prescription at discharge and standardized AED costs per patient were calculated as different measures of utilization. Results Ninety-five percent (range: 83–100%) of patients with electrographic seizures, and 26% (0–81%) without electrographic seizures, received AEDs. Phenobarbital was most frequently used (97.6%), followed by levetiracetam (16.9%), phenytoin/fosphenytoin (15.6%) and others (2.4%; oxcarbazepine, topiramate and valproate). There was significant ICV in all measures of AED utilization. Median cost of AEDs per patient was $89.90 (IQR $24.52,$258.58). Conclusions Amongst Children’s Hospitals, there is marked ICV in AED utilization for neonatal HIE. Variation was particularly notable for HIE patients without electrographic seizures, indicating that this population may be an appropriate target for QI processes to harmonize neuromonitoring and AED practices across centers.
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Affiliation(s)
- Maria L V Dizon
- Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, 225 East Chicago Ave, Box 45, Chicago, IL, 60611, USA.
| | - Rakesh Rao
- Washington University, St. Louis, MO, USA
| | | | | | - Robert DiGeronimo
- Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | | | | | - John Flibotte
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Toby Yanowitz
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - An N Massaro
- Children's National Health Systems, Washington, DC, USA
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21
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Gibb ACN, Crosby MA, McDiarmid C, Urban D, Lam JYK, Wales PW, Brockel M, Raval M, Offringa M, Skarsgard ED, Wester T, Wong K, de Beer D, Nelson G, Brindle ME. Creation of an Enhanced Recovery After Surgery (ERAS) Guideline for neonatal intestinal surgery patients: a knowledge synthesis and consensus generation approach and protocol study. BMJ Open 2018; 8:e023651. [PMID: 30530586 PMCID: PMC6303622 DOI: 10.1136/bmjopen-2018-023651] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS) guidelines integrate evidence-based practices into multimodal care pathways designed to optimise patient recovery following surgery. The objective of this project is to create an ERAS protocol for neonatal abdominal surgery. The protocol will identify and attempt to bridge the gaps between current practices and best evidence. Our study is the first paediatric ERAS protocol endorsed by the International ERAS Society. METHODS A research team consisting of international clinical and family stakeholders as well as methodological experts have iteratively defined the scope of the protocol in addition to individual topic areas. A modified Delphi method was used to reach consensus. The second phase will include a series of knowledge syntheses involving a rapid review coupled with expert opinion. Potential protocol elements supported by synthesised evidence will be identified. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system will be used to determine strength of recommendations and the quality of evidence. The third phase will involve creation of the protocol using a modified RAND/UCLA Appropriateness Method. Group consensus will be used to rate each element in relation to the quality of evidence supporting the recommendation and the appropriateness for guideline inclusion. This protocol will form the basis of a future implementation study. ETHICS AND DISSEMINATION This study has been registered with the ERAS Society. Human ethics approval (REB 18-0579) is in place to engage patient families within protocol development. This research is to be published in peer-reviewed journals and will form the care standard for neonatal intestinal surgery.
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Affiliation(s)
- Ashleigh C N Gibb
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Megan A Crosby
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Caraline McDiarmid
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Denisa Urban
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Y K Lam
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul W Wales
- Department of Pediatric Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Megan Brockel
- Department of Pediatric Anesthesia, University of Colorado, Aurora, Colorado, USA
| | - Mehul Raval
- Department of Pediatric Anesthesia, University of Colorado, Aurora, Colorado, USA
- Department of Pediatric Surgery, Northwestern University, Chicago, Illinois, USA
| | - Martin Offringa
- Department of Neonatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Erik D Skarsgard
- Department of Pediatric Surgery, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University, Stockholm, Sweden
| | - Kenneth Wong
- Department of Surgery, University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - David de Beer
- Department of Pediatric Anesthesia, Great Ormond Street Hospital, London, UK
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary E Brindle
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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22
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Jancelewicz T, Brindle ME, Harting MT, Tolley EA, Langham MR, Lally PA, Gosain A, Storgion SA, Kays DW. Extracorporeal Membrane Oxygenation (ECMO) Risk Stratification in Newborns with Congenital Diaphragmatic Hernia (CDH). J Pediatr Surg 2018; 53:1890-1895. [PMID: 29754878 DOI: 10.1016/j.jpedsurg.2018.04.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 03/05/2018] [Accepted: 04/08/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND A means for early postnatal stratification of ECMO risk in CDH newborns could be used to comparatively assess the utilization and outcomes of ECMO use between centers. While multiple CDH mortality risk calculators are available, no validated tool exists specifically for prediction of ECMO use. The purpose of this study was to derive and validate an ECMO risk stratification model. METHODS The study population was obtained from CDH Study Group registry for the period between 2007 and 2016. Only centers offering ECMO were included. The cohort was restricted to ECMO candidates and then divided into derivation and validation sets. Using all relevant perinatal predictors in the registry, univariate analysis was performed for the composite outcome of ECMO use or death without ECMO use. The model was derived using the derivation cohort with multivariable logistic regression and automatic stepwise forward selection (P < 0.05 for qualifying variables), and a c-statistic was obtained. The model was then tested on the validation cohort. Sample reuse validation and bootstrap validation were performed. The validated model was then tested for accuracy on CDH subgroups. RESULTS There were 1992 patients in the derivation cohort. Four significant variables were identified in the final ECMO risk model: 1-min and 5-min Apgar scores and highest and lowest post-ductal partial pressure of CO2 during the first 24 h of life. The model c-statistic was 0.824 which was confirmed with cross-validation and bootstrap optimism correction. The validation cohort c-statistic was 0.823 (N = 993). The model had good discrimination for left and right CDH, inborn and outborn patients, patients born before and after 2011, and high and low volume centers. The model performed significantly better for postnatally diagnosed patients. CONCLUSIONS This study represents proof-of-concept that a risk model can accurately estimate the probability of ECMO use in CDH newborns. This stratification could assist centers as a metric for assessment of ECMO usage and outcomes. Refinement and prospective validation of this model should be carried out prior to clinical application. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Mary E Brindle
- Alberta Children's Hospital and Cumming Medical School, University of Calgary, Calgary, AB, Canada
| | - Matthew T Harting
- University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Elizabeth A Tolley
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Max R Langham
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pamela A Lally
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ankush Gosain
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stephanie A Storgion
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David W Kays
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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23
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Bent DP, Nelson J, Kent DM, Jen HC. Population-Based Validation of a Clinical Prediction Model for Congenital Diaphragmatic Hernias. J Pediatr 2018; 201:160-165.e1. [PMID: 29954609 PMCID: PMC6153029 DOI: 10.1016/j.jpeds.2018.05.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/14/2018] [Accepted: 05/16/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine the external validity of a well-known congenital diaphragmatic hernia (CDH) clinical prediction model using a population-based cohort. STUDY DESIGN Newborns with CDH born in California between 2007 and 2012 were extracted from the Vital Statistics and Patient Discharge Data Linked Files. The total CDH risk score was calculated according to the Congenital Diaphragmatic Hernia Study Group (CDHSG) model using 5 independent predictors: birth weight, 5-minute Apgar, pulmonary hypertension, major cardiac defects, and chromosomal anomalies. CDHSG model performance on our cohort was validated for discrimination and calibration. RESULTS A total of 705 newborns with CDH were extracted from 3 213 822 live births. Newborns with CDH were delivered in 150 different hospitals, whereas only 28 hospitals performed CDH repairs (1-85 repairs per hospital). The observed mortality for low-, intermediate-, and high-risk groups were 7.7%, 34.3%, and 54.7%, and predicted mortality for these groups were 4.0%, 23.2%, and 58.5%. The CDHSG model performed well within our cohort with a c-statistic of 0.741 and good calibration. CONCLUSIONS We successfully validated the CDHSG prediction model using an external population-based cohort of newborns with CDH in California. This cohort may be used to investigate hospital volume-outcome relationships and guide policy development.
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Affiliation(s)
- Daniel P Bent
- Department of Surgery, Tufts Medical Center, Boston MA
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston MA
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston MA
| | - Howard C Jen
- Division of Pediatric Surgery, Mattel Children's Hospital at UCLA, Los Angeles, CA.
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25
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Farkouh-Karoleski C, Najaf T, Wynn J, Aspelund G, Chung WK, Stolar CJ, Mychaliska GB, Warner BW, Wagner AJ, Cusick RA, Lim FY, Schindel DT, Potoka D, Azarow K, Cotten CM, Hesketh A, Soffer S, Crombleholme T, Needelman H. A definition of gentle ventilation in congenital diaphragmatic hernia: a survey of neonatologists and pediatric surgeons. J Perinat Med 2017; 45:1031-1038. [PMID: 28130958 DOI: 10.1515/jpm-2016-0271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/28/2016] [Indexed: 01/30/2023]
Abstract
Ventilation practices have changed significantly since the initial reports in the mid 1980 of successful use of permissive hypercapnia and spontaneous ventilation [often called gentle ventilation (GV)] in infants with congenital diaphragmatic hernia (CDH). However, there has been little standardization of these practices or of the physiologic limits that define GV. We sought to ascertain among Diaphragmatic Hernia Research and Exploration; Advancing Molecular Science (DHREAMS) centers' GV practices in the neonatal management of CDH. Pediatric surgeons and neonatologists from DHREAMS centers completed an online survey on GV practices in infants with CDH. The survey gathered data on how individuals defined GV including ventilator settings, blood gas parameters and other factors of respiratory management. A total of 87 respondents, from 12 DHREAMS centers completed the survey for an individual response rate of 53% and a 92% center response rate. Approximately 99% of the respondents defined GV as accepting higher carbon dioxide (PCO2) and 60% of the respondents also defined GV as accepting a lower pH. There was less consensus about the use of sedation and neuromuscular blocking agents in GV, both within and across the centers. Acceptable pH and PCO2 levels are broader than the goal ranges. Despite a lack of formal standardization, the results suggest that GV practice is consistently defined as the use of permissive hypercapnia with mild respiratory acidosis and less consistently with the use of sedation and neuromuscular blocking agents. GV is the reported practice of surveyed neonatologists and pediatric surgeons in the respiratory management of infants with CDH.
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26
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Abstract
Congenital diaphragmatic hernia can be approached successfully using minimally invasive techniques. Although there are may be a suggestion of higher recurrence rates with thoracoscopic repair, this may be due to the learning curve. However, open repair is associated with additional morbidity, most notably an increased rate of small bowel obstruction. Appropriate patients who have congenital diaphragmatic hernia should be offered the benefits of minimally invasive repair.
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Affiliation(s)
- Matthew S Clifton
- Department of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA 30322, USA
| | - Mark L Wulkan
- Department of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA 30322, USA.
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27
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Abstract
Although only a small proportion of full term and late preterm infants require invasive respiratory support, they are not immune from ventilator-associated lung injury. The process of lung damage from mechanical ventilation is multifactorial and cannot be linked to any single variable. Atelectrauma and volutrauma have been identified as the most important and potentially preventable elements of lung injury. Respiratory support strategies for full term and late preterm infants have not been as thoroughly studied as those for preterm infants; consequently, a strong evidence base on which to make recommendations is lacking. The choice of modalities of support and ventilation strategies should be guided by the specific underlying pathophysiologic considerations and the ventilatory approach must be individualized for each patient based on the predominant pathophysiology at the time.
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Affiliation(s)
- Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905, USA.
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28
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Öst E, Nisell M, Frenckner B, Mesas Burgos C, Öjmyr-Joelsson M. Parenting stress among parents of children with congenital diaphragmatic hernia. Pediatr Surg Int 2017; 33:761-769. [PMID: 28527042 PMCID: PMC5486636 DOI: 10.1007/s00383-017-4093-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2017] [Indexed: 01/14/2023]
Abstract
PURPOSE The aim of this study was to examine parental stress among parents of children with congenital diaphragmatic hernia (CDH). METHODS Between 2005 and 2009, a total of 51 children with CDH were treated at Astrid Lindgren Children's Hospital. The survival rate at discharge was 86% and long-term survival rate 80%. One parent each of the long-term survivors (41 children) was included in the present study, and 34 parents (83%) agreed to participate. Participants received the Swedish Parenthood Stress Questionnaire (SPSQ). The questionnaire was supplemented by data from case records. RESULTS Parents of children with CDH, who had been supported by ECMO or had a long hospital stay, showed significantly higher overall parental stress. Mothers scored an overall higher parental stress compared with fathers. A prenatal diagnosis of CDH or lower parental educational level resulted in significantly higher parental stress in some of the factors. CONCLUSIONS Parental stress in parents of children with CDH seems to increase with the severity of the child's malformation. Mothers tend to score higher parental stress than fathers.
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Affiliation(s)
- Elin Öst
- Karolinska Institutet, Department of Women’s and Children’s Health, 171 76 Stockholm, Sweden ,Pediatric Surgery Unit, Karolinska University Hospital, Astrid Lindgren Children’s Hospital, 171 76 Stockholm, Sweden
| | | | - Björn Frenckner
- Karolinska Institutet, Department of Women’s and Children’s Health, 171 76 Stockholm, Sweden ,Pediatric Surgery Unit, Karolinska University Hospital, Astrid Lindgren Children’s Hospital, 171 76 Stockholm, Sweden
| | - Carmen Mesas Burgos
- Karolinska Institutet, Department of Women’s and Children’s Health, 171 76 Stockholm, Sweden ,Pediatric Surgery Unit, Karolinska University Hospital, Astrid Lindgren Children’s Hospital, 171 76 Stockholm, Sweden
| | - Maria Öjmyr-Joelsson
- Karolinska Institutet, Department of Women’s and Children’s Health, 171 76 Stockholm, Sweden ,Pediatric Surgery Unit, Karolinska University Hospital, Astrid Lindgren Children’s Hospital, 171 76 Stockholm, Sweden
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29
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Morini F, Capolupo I, van Weteringen W, Reiss I. Ventilation modalities in infants with congenital diaphragmatic hernia. Semin Pediatr Surg 2017. [PMID: 28641754 DOI: 10.1053/j.sempedsurg.2017.04.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Neonates with congenital diaphragmatic hernia are among the more complex patients to support with mechanical ventilation. They have particular features that add to the difficulties already present in the neonatal patient. A ventilation strategy tailored to the patient's underlying physiology rather than mode of ventilation is a crucial issue for clinicians treating these delicate patients.
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Affiliation(s)
- Francesco Morini
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Willem van Weteringen
- Department of Pediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irwin Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
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Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2017; 42:E547-E554. [PMID: 28441684 DOI: 10.1097/brs.0000000000001865] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Delphi process with multiple iterative rounds using a nominal group technique. OBJECTIVE The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols. METHODS An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. RESULTS Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge. CONCLUSION We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research. LEVEL OF EVIDENCE 5.
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Kadir D, Lilja HE. Risk factors for postoperative mortality in congenital diaphragmatic hernia: a single-centre observational study. Pediatr Surg Int 2017; 33:317-323. [PMID: 27986977 PMCID: PMC5310566 DOI: 10.1007/s00383-016-4032-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND The management of congenital diaphragmatic hernia (CDH) is a major challenge. The mortality is dependent on associated malformations, the severity of pulmonary hypoplasia, pulmonary hypertension and iatrogenic lung injury associated with aggressive mechanical ventilation. The aims of the study were to investigate the mortality over time in a single paediatric surgical centre, to compare the results with recent reports and to define the risk factors for mortality. METHODS The medical records of infants with CDH from two time periods: 1995-2005 and 2006-2016 were reviewed. Cox regression was used for statistical analysis. RESULTS The study included 113 infants. The mortality rate was significantly decreased in the later time period, compared to the earlier, 4.4 and 17.9%, respectively. At the early time period five patients (7.5%) were treated with ECMO and in the later time period ECMO was used in three patients (6.5%). The mortality in ECMO-treated patients was 50% in both time periods. Prenatal diagnosis, intrathoracic liver, low Apgar score and low birth weight were defined as independent risk factors for mortality. CONCLUSION Despite no significant differences in the incidence of independent risk factors and the use of ECMO between the two time periods, mortality decreased over time. The mortality was lower than previously reported. The results indicate that there are many important factors involved in a successful outcome after CDH repair. Large multicentre studies are necessary to define those critical factors and to determine optimal treatment strategies.
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Affiliation(s)
- Darya Kadir
- Department of Women's and Children's Health, Section of Pediatric Surgery, Uppsala University, 751 85, Uppsala, Sweden
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | - Helene Engstrand Lilja
- Department of Women's and Children's Health, Section of Pediatric Surgery, Uppsala University, 751 85, Uppsala, Sweden.
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden.
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Rudra S, Adibe OO, Malcolm WF, Smith PB, Cotten CM, Greenberg RG. Gastrostomy tube placement in infants with congenital diaphragmatic hernia: Frequency, predictors, and growth outcomes. Early Hum Dev 2016; 103:97-100. [PMID: 27559682 PMCID: PMC5154903 DOI: 10.1016/j.earlhumdev.2016.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/08/2016] [Accepted: 08/09/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Gastrostomy tube (G-tube) placement is a common intervention for newborns with severe feeding difficulties. Infants with congenital diaphragmatic hernia (CDH) are at high risk for feeding problems. Prevalence of G-tube placement and consequent nutritional outcomes of infants with CDH and G-tubes has not been described. AIMS Determine factors associated with G-tube placement and growth in infants with congenital diaphragmatic hernia. STUDY DESIGN Retrospective cohort study of infants with CDH to evaluate the association of G-tube placement with risk factors using logistic regression. We also assessed the association between growth velocity and G-tube placement and other risk factors using linear regression. SUBJECTS The subjects of the study were infants with CDH treated at Duke University Medical Center from 1997 to 2013. OUTCOME MEASURES Weight gain in infants with CDH that had G-tube placement compared to those infants with CDH that did not. RESULT Of the 123 infants with CDH, 85 (69%) survived and G-tubes were placed in 25/85 (29%) survivors. On adjusted analysis, extracorporeal membrane oxygenation (OR=11.26 [95% CI: 1.92-65.89]; P=0.01) and proton pump inhibitor use (OR=17.29 [3.98-75.14], P≤0.001) were associated with G-tube placement. Infants without G-tubes had a growth velocity of 6.5g/day (95% CI: 2.5-10.4) more than infants with G-tubes. CONCLUSION Survivors with more complex inpatient courses were more likely to receive G-tubes. Further investigation is needed to identify optimal feeding practices for infants with CDH.
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Affiliation(s)
- Sharmistha Rudra
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Obinna O Adibe
- Department of Surgery, Duke University Medical Center, Durham, NC, United States.
| | - William F Malcolm
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States.
| | - P Brian Smith
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States; Duke Clinical Research Institute, Durham, NC, United States.
| | - C Michael Cotten
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States.
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States; Duke Clinical Research Institute, Durham, NC, United States.
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Kalanj J, Salevic P, Rsovac S, Medjo B, Antunovic SS, Simic D. Congenital diaphragmatic hernia - a Belgrade single center experience. J Perinat Med 2016; 44:913-918. [PMID: 26985684 DOI: 10.1515/jpm-2015-0333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 02/17/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Though the outcome for children with congenital diaphragmal hernia (CDH) is improving, management of seriously compromised respiratory and cardiovascular function remains a great challenge. The aim of this study was to review a tertiary center experience in treating children with CDH. DESIGN Retrospective observational study from January 2005 to December 2014. SETTING Neonatal Intensive Care Unit (NICU) of University Children Hospital (UCH), Belgrade, Serbia. PATIENTS Children with CDH. RESULTS The CDH was diagnosed prenatally in 23% patients. An overall survival rate was 62%. Among those patients who underwent surgical repair 29 (90%) survived. There was statistically significant difference in survival rate between operated patients and total examined population (P=0.020). Prenatally diagnosed neonates with CDH had significantly lower survival rate comparing to those who were postnatally diagnosed (20% vs. 75%; P=0.002). Fatal outcome was more frequent in patients with small birth weight comparing to those with normal birth weight (67% vs. 30%; P=0.046). CONCLUSIONS Our center survival rate for CDH is in accordance with other reported studies. Based on our experience there are potential points for further improvement. First, further increase of prenatal detection, planning for delivery, and coordinated transfer to tertiary institution, in order to avoid transfer of near death patients. Second, preoperative management in the NICU. This could be done by more uniform implementation of current consensual guidelines in monitoring, mechanical ventilation and circulatory support of these delicate patients, together with rationale use of newer therapeutic resources.
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Self-assessed physical health among children with congenital diaphragmatic hernia. Pediatr Surg Int 2016; 32:493-503. [PMID: 26909750 DOI: 10.1007/s00383-016-3879-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE The aim of this long-term follow-up study was to investigate the current self assessed physical health in a CDH birth cohort at a single center. METHODS Between 1990 and 2009, 195 children born with CDH were treated at Astrid Lindgren Children's Hospital. The primary survival rate was 85 %, and in 2010, 78 % were still alive. Data from medical records were supplemented by a questionnaire consisting of questions about perceived physical function. Patients were divided into groups according to time for intubation and need for extracorporeal membrane oxygenation. RESULTS Children born with CDH reported themselves to be having greater problems with asthma, developmental delay, seizure disorder, poor vision, and scoliosis in comparison with normal Swedish children. They also described a sense of having less strength and becoming breathless more often than healthy friends. Symptoms of gastroesophageal reflux and abdominal pain were also reported. CONCLUSIONS The majority of the children perceived their physical health as being overall good, but there was an increase of reported symptoms correlating with the severity of the malformation.
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Malowitz JR, Hornik CP, Laughon MM, Testoni D, Cotten CM, Clark RH, Smith PB. Management Practice and Mortality for Infants with Congenital Diaphragmatic Hernia. Am J Perinatol 2015; 32:887-94. [PMID: 25715314 PMCID: PMC4516623 DOI: 10.1055/s-0035-1544949] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Congenital diaphragmatic hernia (CDH) is fatal in 20 to 40% of cases, largely due to pulmonary dysmaturity, lung hypoplasia, and persistent pulmonary hypertension. Evidence for survival benefit of inhaled nitric oxide (iNO), extracorporeal membrane oxygenation (ECMO), and other medical interventions targeting pulmonary hypertension is lacking. We assessed medical interventions and mortality over time in a large multicenter cohort of infants with CDH. STUDY DESIGN We identified all infants ≥ 34 weeks' gestation with CDH discharged from 29 neonatal intensive care units between 1999 and 2012 with an average of ≥ 2 CDH admissions per year. We examined mortality and the proportion of infants exposed to medical interventions, comparing four periods of time: 1999-2001, 2002-2004, 2005-2007, and 2008-2012. RESULTS We identified 760 infants with CDH. From 1999-2001 to 2008-2012, use of iNO increased from 20% of infants to 50%, sildenafil use increased from 0 to 14%, and milrinone use increased from 0 to 22% (p < 0.001). Overall mortality (28%) did not significantly change over time compared with the earliest time period. CONCLUSION Despite changing use of iNO, sildenafil, and milrinone, CDH mortality has not significantly decreased in this population of infants.
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Affiliation(s)
- Jonathan R. Malowitz
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Matthew M. Laughon
- Department of Pediatrics, North Carolina Children’s Hospital, Chapel Hill, North Carolina
| | - Daniela Testoni
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- Division of Neonatal Medicine, Escola Paulista de Medicina – Universidade Federal de São Paulo, São Paulo, Brazil
| | - C. Michael Cotten
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | | | - P. Brian Smith
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Zalla JM, Stoddard GJ, Yoder BA. Improved mortality rate for congenital diaphragmatic hernia in the modern era of management: 15 year experience in a single institution. J Pediatr Surg 2015; 50:524-7. [PMID: 25840055 PMCID: PMC4386064 DOI: 10.1016/j.jpedsurg.2014.11.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 09/19/2014] [Accepted: 11/03/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND/PURPOSE Mortality rates with congenital diaphragmatic hernia (CDH) have remained at approximately 30% for the last 2 decades. Therapies targeting pulmonary hypertension (PHTN) have not been systematically studied in this population, but are increasingly used. We hypothesized that incremental changes in treatments for PHTN have improved mortality for CDH infants. METHODS Prospective data from 1998 to 2013 on all liveborn CDH patients treated at our institution were retrospectively analyzed. Based on management of PHTN, 4 eras were identified for comparison. Logistic and linear regression were used to compare characteristics. The primary outcome of death prior to discharge was analyzed by multivariable Cox regression modeling. RESULTS The study included 192 infants who met inclusion criteria. Length of stay increased, whereas rates of primary repair decreased, suggesting a sicker cohort in the most recent eras. Analysis of mortality across 4 eras showed no difference. By post-hoc analysis, ECMO availability was associated with mortality reduction for eras 3-4 versus 1-2 (HR=0.27, p<0.001). CONCLUSIONS Improved survival at our institution may be related to recent introduction of ECMO and more aggressive approaches to pulmonary hypertension. Further systematic studies of these PHTN therapies in this specific population are warranted.
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Affiliation(s)
- Jennifer M Zalla
- Division of Neonatology, University of Utah, Salt Lake City, UT, 84132, USA.
| | - Gregory J Stoddard
- Division of Epidemiology, Study Design and Biostatistics Center, Center for Clinical and Translational Science, University of Utah, Salt Lake City, UT, 84132, USA
| | - Bradley A Yoder
- Division of Neonatology, University of Utah, Salt Lake City, UT, 84132, USA
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The soluble guanylyl cyclase activator BAY 60-2770 potently relaxes the pulmonary artery on congenital diaphragmatic hernia rabbit model. Pediatr Surg Int 2014; 30:1031-6. [PMID: 25062768 DOI: 10.1007/s00383-014-3561-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) is associated with pulmonary hypertension which is often difficult to manage, and a significant cause of morbidity and mortality. In this study, we have used a rabbit model of CDH to evaluate the effects of BAY 60-2770 on the in vitro reactivity of left pulmonary artery. METHODS CDH was performed in New Zealand rabbit fetuses (n = 10 per group) and compared to controls. Measurements of body, total and left lung weights (BW, TLW, LLW) were done. Pulmonary artery rings were pre-contracted with phenylephrine (10 μM), after which cumulative concentration-response curves to glyceryl trinitrate (GTN; NO donor), tadalafil (PDE5 inhibitor) and BAY 60-2770 (sGC activator) were obtained as well as the levels of NO (NO3/NO2). RESULTS LLW, TLW and LBR were decreased in CDH (p < 0.05). In left pulmonary artery, the potency (pEC50) for GTN was markedly lower in CDH (8.25 ± 0.02 versus 9.27 ± 0.03; p < 0.01). In contrast, the potency for BAY 60-2770 was markedly greater in CDH (11.7 ± 0.03 versus 10.5 ± 0.06; p < 0.01). The NO2/NO3 levels were 62 % higher in CDH (p < 0.05). CONCLUSION BAY 60-2770 exhibits a greater potency to relax the pulmonary artery in CDH, indicating a potential use for pulmonary hypertension in this disease.
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Murthy K, Dykes FD, Padula MA, Pallotto EK, Reber KM, Durand DJ, Short BL, Asselin JM, Zaniletti I, Evans JR. The Children's Hospitals Neonatal Database: an overview of patient complexity, outcomes and variation in care. J Perinatol 2014; 34:582-6. [PMID: 24603454 DOI: 10.1038/jp.2014.26] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 12/10/2013] [Accepted: 01/13/2014] [Indexed: 02/03/2023]
Abstract
The Children's Hospitals Neonatal Consortium is a multicenter collaboration of leaders from 27 regional neonatal intensive care units (NICUs) who partnered with the Children's Hospital Association to develop the Children's Hospitals Neonatal Database (CHND), launched in 2010. The purpose of this report is to provide a first summary of the population of infants cared for in these NICUs, including representative diagnoses and short-term outcomes, as well as to characterize the participating NICUs and institutions. During the first 2 1/2 years of data collection, 40910 infants were eligible. Few were born inside these hospitals (2.8%) and the median gestational age at birth was 36 weeks. Surgical intervention (32%) was common; however, mortality (5.6%) was infrequent. Initial queries into diagnosis-specific inter-center variation in care practices and short-term outcomes, including length of stay, showed striking differences. The CHND provides a contemporary, national benchmark of short-term outcomes for infants with uncommon neonatal illnesses. These data will be valuable in counseling families and for conducting observational studies, clinical trials and collaborative quality improvement initiatives.
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Affiliation(s)
- K Murthy
- Ann & Robert H Lurie Children's Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University Chicago, Chicago, IL, USA
| | - F D Dykes
- Children's Healthcare of Atlanta at Egleston and the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - M A Padula
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - E K Pallotto
- Children's Mercy Hospital and Clinics and the Department of Pediatrics, University of Missouri School of Medicine, Kansas City, MO, USA
| | - K M Reber
- Nationwide Children's Hospital and the Department of Pediatrics, Ohio State University School of Medicine, Columbus, OH, USA
| | - D J Durand
- Department of Pediatrics, Children's Hospital Oakland & Research Center, Oakland, CA, USA
| | - B L Short
- Children's National Medical Center and the Department of Pediatrics, George Washington University School of Medicine, Washington DC, USA
| | - J M Asselin
- Department of Pediatrics, Children's Hospital Oakland & Research Center, Oakland, CA, USA
| | - I Zaniletti
- Children's Hospital Association, Overland Park, KS, USA
| | - J R Evans
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Congenital diaphragmatic hernia (CDH) is a congenital defect in the diaphragm that allows herniation of abdominal contents into the fetal chest and leads to varying degrees of pulmonary hypoplasia and pulmonary hypertension. Advances in prenatal diagnosis and the institution of standardized delivery and postnatal care protocols have led to improved survival. Fetal endoscopic tracheal occlusion shows early promise for patients with the most severe CDH, but prospective randomized data is still required. CDH survivors have a variety of associated morbidities that require long-term follow-up and early intervention strategies for optimal care.
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Affiliation(s)
- Andrea Badillo
- Children's National Medical Center, 111 Michigan Avenue NW, Suite W4-200, Washington, DC 20008.
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Periodic MRI lung volume assessment in fetuses with congenital diaphragmatic hernia: prediction of survival, need for ECMO, and development of chronic lung disease. AJR Am J Roentgenol 2013; 201:419-26. [PMID: 23883224 DOI: 10.2214/ajr.12.8655] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of the study was to investigate the ability to predict survival, need for extracorporeal membrane oxygenation (ECMO), and incidence of chronic lung disease in patients with congenital diaphragmatic hernia in the context of a classification into three different times of gestation (< 28, 28-32, and > 32 weeks) by assessing the ratio between observed and expected MRI fetal lung volume. MATERIALS AND METHODS The data analysis included 226 fetuses with congenital diaphragmatic hernia. MRI was performed at different times of gestation with a T2-weighted HASTE sequence. Receiver operating characteristic curve analysis was performed to investigate the prognostic value of assessment of the ratio between observed and expected MRI fetal lung volumes at different stages of fetal growth. RESULTS For all reviewed times of gestation, the ratio between observed and expected MRI fetal lung volumes had almost equivalent statistically significant differences for neonatal survival (p ≤ 0.0029), need for ECMO therapy (p ≤ 0.0195), and development of chronic lung disease (p ≤ 0.0064). Results with high prognostic accuracy for early and for medium and late times in gestation also were obtained. Receiver operating characteristic analysis showed the highest area under the curve (≥ 0.819) for neonatal survival. CONCLUSION In patients with congenital diaphragmatic hernia, the relation between observed and expected MRI fetal lung volume is a valuable prognostic parameter for predicting neonatal mortality, morbidity represented by the development of chronic lung disease, and the need for ECMO therapy in early gestation (< 28 weeks) as well as later gestation with no statistically significant differences.
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Takahashi S, Sago H, Kanamori Y, Hayakawa M, Okuyama H, Inamura N, Fujino Y, Usui N, Taguchi T. Prognostic factors of congenital diaphragmatic hernia accompanied by cardiovascular malformation. Pediatr Int 2013; 55:492-7. [PMID: 23565971 DOI: 10.1111/ped.12104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/06/2013] [Accepted: 03/12/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia is associated with cardiovascular malformation. Many prognostic factors have been identified for isolated congenital diaphragmatic hernia; however, reports of concurrent congenital diaphragmatic hernia and cardiovascular malformation in infants are limited. This study evaluated congenital diaphragmatic hernia associated with cardiovascular malformation in infants. Factors associated with prognosis for patients were also identified. METHODS This retrospective cohort study was based on a Japanese survey of congenital diaphragmatic hernia patients between 2006 and 2010. Frequency and outcome of cardiovascular malformation among infants with congenital diaphragmatic hernia were examined. Severity of congenital diaphragmatic hernia and cardiovascular malformation were compared as predictors of mortality and morbidity. RESULTS Cardiovascular malformation was identified in 76 (12.3%) of 614 infants with congenital diaphragmatic hernia. Mild cardiovascular malformation was detected in 19 (33.9%) and severe cardiovascular malformation in 37 (66.1%). Their overall survival rate at discharge was 46.4%, and the survival rate without morbidity was 23.2%. Mortality and morbidity at discharge were more strongly associated with severity of cardiovascular malformation (adjusted OR 7.69, 95%CI 1.96-30.27; adjusted OR 7.93, 95%CI 1.76-35.79, respectively) than with severity of congenital diaphragmatic hernia. CONCLUSIONS The prognosis for infants with both congenital diaphragmatic hernia and cardiovascular malformation remains poor. Severity of cardiovascular malformation is a more important predictive factor for mortality and morbidity than severity of congenital diaphragmatic hernia.
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Affiliation(s)
- Shigehiro Takahashi
- Division of Neonatology, Center for Maternal-Fetal and Neonatal Medicine, National Center for Child Health and Development, Tokyo, Japan.
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Beres AL, Puligandla PS, Brindle ME. Stability prior to surgery in Congenital Diaphragmatic Hernia: is it necessary? J Pediatr Surg 2013; 48:919-23. [PMID: 23701760 DOI: 10.1016/j.jpedsurg.2013.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 02/03/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delaying surgery for infants with CDH until they achieve clinical stability is common practice. Stability, however, is inconsistently defined, and many infants fail to reach pre-established criteria. We sought to determine if infants undergoing surgery without meeting pre-established criteria could achieve meaningful survival. METHODS All infants in the CAPSNet database were analyzed (2005-2010). Patients undergoing operative repair were divided into two groups based on whether they met strict (FiO2<0.40, conventional ventilation, preductal saturation >92%, no inotropes or vasodilators), or lenient (FiO2 <0.60, conventional ventilation, preductal saturation >88%, no vasodilators) criteria. Univariate analyses were performed comparing characteristics of those who survived after surgery (N=273) with those who did not (N=21). RESULTS 294 patients (85%) survived to surgery. Predictors of post-operative survival included prenatal liver position (p=0.003), preoperative oxygen requirements (p=0.008), preoperative inotropes (p<0.0001), and non-conventional ventilation (p=0.004). Infants meeting strict criteria had increased survival (99%; p<0.0001). Infants meeting lenient criteria constituted 70% of survivors. Nearly one-third of survivors met neither strict nor lenient criteria. CONCLUSIONS Infants with CDH can achieve good survival even when criteria for pre-operative stability are not met. We suggest that all infants should be repaired even if lenient criteria for ventilatory, inotrope, or vasodilator requirements are not achieved.
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Affiliation(s)
- Alana L Beres
- The Montreal Children's Hospital, Division of Pediatric General and Thoracic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Hayakawa M, Ito M, Hattori T, Kanamori Y, Okuyama H, Inamura N, Takahashi S, Nagata K, Taguchi T, Usui N. Effect of hospital volume on the mortality of congenital diaphragmatic hernia in Japan. Pediatr Int 2013; 55:190-6. [PMID: 23360371 DOI: 10.1111/ped.12059] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 11/25/2012] [Accepted: 01/07/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND During the last decade, new supportive modalities and new therapeutic strategies to treat congenital diaphragmatic hernia (CDH) have been introduced. In Japan, the large number of hospitals prevents centralizing infants with CDH in tertiary centers. The aim of this study was to evaluate the correlations between the number of CDH patients, survival rates, and the current strategies employed to treat CDH at the individual hospitals. METHODS Eighty-three hospitals with 674 CDH cases were analyzed using questionnaires. We classified the hospitals into three groups according to the number of CDH patients treated: Group 1 (G1; more than 21 patients), Group 2 (G2; 11-20 patients), and Group 3 (G3; fewer than 10 patients). RESULTS The median number of CDH patients in G1, G2, and G3 were 28, 14, and 4, respectively. The overall survival rate was 74.5%. When only the isolated CDH cases with a prenatal diagnosis were included, the overall survival rate was 79.3%. The survival rate of isolated CDH cases with a prenatal diagnosis was significantly higher in G1 than that in G2 or G3 (87.2% vs 75.2% vs 74.3%; P < 0.001). There were no differences in perinatal therapeutic strategies among the three groups. CONCLUSIONS We concluded that it might therefore be important to centralize infants with CDH, especially those with isolated CDH with a prenatal diagnosis, to tertiary centers in Japan in order to improve the survival rates.
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Affiliation(s)
- Masahiro Hayakawa
- Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan.
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Benjamin JR, Gustafson KE, Smith PB, Ellingsen KM, Tompkins KB, Goldberg RN, Cotten CM, Goldstein RF. Perinatal factors associated with poor neurocognitive outcome in early school age congenital diaphragmatic hernia survivors. J Pediatr Surg 2013; 48:730-7. [PMID: 23583126 PMCID: PMC3734202 DOI: 10.1016/j.jpedsurg.2012.09.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 08/29/2012] [Accepted: 09/02/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine predictors of neurocognitive outcome in early school age congenital diaphragmatic hernia (CDH) survivors. STUDY DESIGN Prospective study of infants with CDH at Duke University Medical Center. Neurocognitive delay (NCD) at school age (4 to 7years) was defined as a score<80 in any of the following areas: Verbal Scale IQ, Performance Scale IQ, Expressive Language, or Receptive Language. Logistic regression, Fisher's exact, and the Wilcoxon rank sum test were used to examine the relationship between NCD at early school age and 6 demographic and 18 medical variables. RESULTS Of 43 infants with CDH, twenty seven (63%) survived to hospital discharge, and 16 (59%) returned for school age testing at a median age of 4.9years. Seven (44%) of the children evaluated had NCD. Patch repair (p=0.01), extracorporeal membrane oxygenation (ECMO; p=0.02), days on ECMO (p=0.01), days of mechanical ventilation (p=0.049), and post-operative use of inhaled nitric oxide (p=0.02) were found to be associated with NCD at early school age. CONCLUSIONS CDH survivors are at risk for neurocognitive delay persisting into school age. Perinatal factors such as patch repair and ECMO treatment may aid in identifying CDH survivors at high risk for continued learning difficulties throughout childhood.
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Affiliation(s)
- Jennifer R. Benjamin
- Division of Newborn Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts, US
| | - Kathryn E. Gustafson
- Pediatric Neurocognitive Outcomes Research Program, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, US
| | - P. Brian Smith
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, US
,Division of Neonatal-Perinatal Medicine, Jean and George Brumley, Jr. Neonatal Perinatal Research Institute, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, US
| | - Kirsten M. Ellingsen
- Pediatric Neurocognitive Outcomes Research Program, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, US
| | - K. Brooke Tompkins
- Pediatric Neurocognitive Outcomes Research Program, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, US
| | - Ronald N. Goldberg
- Division of Neonatal-Perinatal Medicine, Jean and George Brumley, Jr. Neonatal Perinatal Research Institute, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, US
| | - C. Michael Cotten
- Division of Neonatal-Perinatal Medicine, Jean and George Brumley, Jr. Neonatal Perinatal Research Institute, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, US
| | - Ricki F. Goldstein
- Pediatric Neurocognitive Outcomes Research Program, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, US
,Division of Neonatal-Perinatal Medicine, Jean and George Brumley, Jr. Neonatal Perinatal Research Institute, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, US
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Haroon J, Chamberlain RS. An evidence-based review of the current treatment of congenital diaphragmatic hernia. Clin Pediatr (Phila) 2013; 52:115-24. [PMID: 23378478 DOI: 10.1177/0009922812472249] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Congenital diaphragmatic hernia is a rare but severe condition affecting 1 in 2000 to 3000 newborns with a survival rate of 67%. Although regular antenatal screening allows prenatal diagnosis in many cases, traditionally treatment has been based on postnatal surgical repair. Recent literature has pointed out the survival benefits of initial stabilization and the use of gentle ventilation strategies prior to definitive treatment, shifting the trend from immediate to delayed surgical repair. Advances in fetal intervention have allowed the introduction of fetal endoscopic tracheal occlusion as a method to hasten lung development before birth in order to minimize postnatal morbidity. Despite appropriate treatment, the long-term outcomes of these patients are plagued with numerous complications, associated with the primary pathology and also aggressive therapeutic measures. International centers of excellence have recently come together in an effort to standardize the care of such patients in hopes of maximizing their outcomes.
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Affiliation(s)
- Junaid Haroon
- Saint Barnabas Medical Center, Livingston, NJ 07039, USA
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High Frequency Jet Ventilation during Initial Management, Stabilization, and Transport of Newborn Infants with Congenital Diaphragmatic Hernia: A Case Series. Crit Care Res Pract 2013; 2013:937871. [PMID: 23346391 PMCID: PMC3549376 DOI: 10.1155/2013/937871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Accepted: 12/19/2012] [Indexed: 12/15/2022] Open
Abstract
Objective. To review experience of the transport and stabilization of infants with CDH who were treated with high frequency jet ventilation (HFJV).
Study Design. Retrospective chart review was performed of infants with antenatal diagnosis of CDH born between 2004 and 2009, at Mount Sinai Hospital Toronto, Ontario, Canada. Detailed information was abstracted from the charts of all infants who received HFJV.
Results. Of the 55 infants, 25 were managed with HFJV at some point during resuscitation and stabilization prior to transport. HFJV was the initial ventilation mode in six cases and nineteen infants were placed on HFJV as rescue therapy. Blood gases procured from the umbilical artery before and/or after the initiation of HFJV. There was a significant difference detected for both PaCO2 (P = 0.0002) and pH (P < 0.0001). The pre- and posttransport vital signs remained stable and no transport related deaths or significant complications occurred.
Conclusion. HFJV appears to be safe and effective providing high frequency rescue therapy for infants with CDH failing conventional mechanical ventilation. This paper supports the decision to utilize HFJV as it likely contributed to safe transport of many infants that would not otherwise have tolerated transport to a surgical centre.
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Wong JM, Bader AM, Laws ER, Popp AJ, Gawande AA. Patterns in neurosurgical adverse events and proposed strategies for reduction. Neurosurg Focus 2012; 33:E1. [DOI: 10.3171/2012.9.focus12184] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to reducing risk and to measuring and improving outcomes. The authors performed a review of patterns and frequencies of adverse events in neurosurgery as background for future efforts directed at the improvement of quality and safety in neurosurgery.
They found 6 categories of contributory factors in neurosurgical adverse events, categorizing the events as influenced by issues in surgical technique, perioperative medical management, use of and adherence to protocols, preoperative optimization, technology, and communication. There was a wide distribution of reported occurrence rates for many of the adverse events, in part due to the absence of definitive literature in this area and to the lack of standardized reporting systems.
On the basis of their analysis, the authors identified 5 priority recommendations for improving outcomes for neurosurgical patients at a population level: 1) development and implementation of a national registry for outcome data and monitoring; 2) full integration of the WHO Surgical Safety Checklist into the operating room workflow, which improves fundamental aspects of surgical care such as adherence to antibiotic protocols and communication within surgical teams; and 3–5) activity by neurosurgical societies to drive increased standardization for the safety of specialized equipment used by neurosurgeons (3), more widespread regionalization and/or subspecialization (4), and establishment of data-driven guidelines and protocols (5). The fraction of adverse events that might be avoided if proposed strategies to improve practice and decrease variability are fully adopted remains to be determined. The authors hope that this consolidation of what is currently known and practiced in neurosurgery, the application of relevant advances in other fields, and attention to proposed strategies will serve as a basis for informed and concerted efforts to improve outcomes and patient safety in neurosurgery.
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Affiliation(s)
- Judith M. Wong
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 3Departments of Neurosurgery,
| | - Angela M. Bader
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 4Anesthesiology, Perioperative and Pain Medicine, and
| | | | | | - Atul A. Gawande
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 5Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Association of high ventilator pressures with the development of chronic pulmonary hypertension in congenital diaphragmatic hernia patients requiring ECMO. Pediatr Surg Int 2012; 28:977-82. [PMID: 22806605 DOI: 10.1007/s00383-012-3132-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) patients requiring extracorporeal membrane oxygenation (ECMO) were examined to determine, if aspects of their complex ventilatory management were associated with the development of chronic pulmonary hypertension (cPH). METHODS CDH patients requiring ECMO from 1992 to 2007 were retrospectively reviewed. cPH was defined as pulmonary hypertension at 3 months of age. Demographic and clinical variables including peak ventilatory pressures (PVP) and mean airway pressures (MAP) were tabulated. RESULTS 10/31 (32 %) patients developed cPH. Gestational age, birth weight, inborn status, CDH side and liver position were not different between cPH and non-cPH patients. Pre-ECMO, both groups required statistically similar ventilatory support, though there was a trend toward higher oxygenation index and higher PVP for cPH patients. While ECMO duration was similar between groups, cPH patients required significantly higher PVP (30.0 vs. 25.0 cmH(2)O, p = 0.01) and MAP (11.5 vs. 9.0 cmH(2)O, p = 0.02) for ECMO decannulation. Post-ECMO, maximum PVP (50.0 vs. 26.0 cmH(2)O, p < 0.001), MAP (18.1 vs. 12.0, p = 0.001), HFV requirement (90 vs. 10 %, p < 0.001), and ventilator time (35.7 vs. 20 days, p < 0.001) increased significantly for cPH patients. CONCLUSION Not until after ECMO decannulation do we see clinical differences separating patients who ultimately develop cPH. Although the degree of pulmonary hypoplasia may ultimately dictate ECMO decannulation criteria, perhaps greater physiologic optimization before decannulation could decrease the incidence of cPH.
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Abstract
PURPOSE OF REVIEW Congenital diaphragmatic hernia (CDH) is a rare developmental defect resulting in variable degrees of lung and pulmonary vasculature hypoplasia. Whereas many high-volume centers have recently reported increased survival rates, this has not been the collective trend. One potential explanation for this is inconsistent perinatal care among centers. RECENT FINDINGS Significant efforts have been made to identify prenatally those fetuses that will be most severely affected. A number of radiologic features have shown promise for achieving this goal as well as identifying fetuses that may benefit from prenatal intervention. When CDH is antenatally diagnosed, early referral to a tertiary center is recommended. Centers that routinely use postnatal management protocols have demonstrated improved overall survival rates including increased survival in high-risk CDH patients. SUMMARY As a result of advancements in perinatal care, more severely affected newborns with CDH are now surviving. These patients may experience a number of associated morbidities which affect not only their health but overall quality of life. A multidisciplinary approach to the long-term care of these patients will allow early identification and management of these morbidities.
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Guidry CA, Hranjec T, Rodgers BM, Kane B, McGahren ED. Permissive hypercapnia in the management of congenital diaphragmatic hernia: our institutional experience. J Am Coll Surg 2012; 214:640-645, 647.e1; discussion 646-7. [PMID: 22381592 DOI: 10.1016/j.jamcollsurg.2011.12.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 12/20/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a potentially lethal anomaly associated with pulmonary hypoplasia and persistent pulmonary hypertension. Permissive hypercapnia is a strategy designed to reduce lung injury from mechanical ventilation in infants. It has been shown to be a potentially superior method of ventilator management for patients with CDH. In 2001, the Divisions of Neonatology and Pediatric Surgery at the University of Virginia Children's Hospital established permissive hypercapnia as the management strategy for treatment of CDH. We hypothesized that permissive hypercapnia would be associated with improved outcomes in this patient population. STUDY DESIGN This retrospective review compares outcomes of infants treated for CDH in the extracorporeal membrane oxygenation (ECMO) era before and after initiation of permissive hypercapnia at a single institution. Outcomes were compared using univariate statistical analysis. RESULTS Ninety-one patients were available for analysis and were divided into 2 groups: 42 (Group 1) treated before and 49 (Group 2) treated after implementation of permissive hypercapnia. Survival was higher in Group 2 (85.8% vs 54.8%; p = 0.001; relative risk [RR] 3.17). Morbidity was lower in Group 2 and approached statistical significance (65.3% vs 83.3%; p = 0.052). Patients in Group 2 were repaired later, had a lower rate of ECMO use, and were extubated earlier. There was no difference in hospital stay. CONCLUSIONS The use of permissive hypercapnia for infants with CDH was associated with decreased mortality, a longer period of ventilation before repair with a shorter period of ventilation after repair, a lower rate of ECMO use, and no lengthening of hospital stay. Permissive hypercapnia remains the standard of care for ventilation of infants with CDH at our institution.
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Affiliation(s)
- Christopher A Guidry
- Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908-0709, USA
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