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Guner YS, Hammond JD, Keene S, Gray B. The role of ECLS in the management of congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151440. [PMID: 38996506 DOI: 10.1016/j.sempedsurg.2024.151440] [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: 07/14/2024]
Abstract
In the complex arena of Congenital Diaphragmatic Hernia (CDH) management, Extracorporeal Life Support (ECLS) provides a strategic window for stabilization and surgical correction, during which time marginal gains in patient stability can tip the scales towards survival. In modern neonatal ECLS, the focus is increasingly on minimizing survivor morbidity, which calls for considerable multidisciplinary expertise to enhance patient outcomes. This review will delve into the most up-to-date literature on the management of CDH in the context of ECLS, providing a comprehensive synthesis of current insights.
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Affiliation(s)
- Yigit S Guner
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, United States; Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States.
| | - J D Hammond
- Department of Pediatrics, University of California Irvine Medical Center, Orange, CA, United States; Division of Neonatology, Children's Hospital of Orange County, Orange, CA, United States
| | - Sarah Keene
- Division of Neonatology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Brian Gray
- Department of Surgery, Section of Pediatric Surgery, Indiana University, Indianapolis, IN, United States
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2
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Alcindor ML. Benefits of targeted nutritional practices to address growth failure in neonates diagnosed with congenital diaphragmatic hernia (CDH). Evid Based Nurs 2024:ebnurs-2023-103888. [PMID: 38942467 DOI: 10.1136/ebnurs-2023-103888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 06/30/2024]
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Yang MJ, Ellsworth TS, Woodward PJ, Kennedy AM, Fenton SJ, Russell KW, Byrne JLB, Yost CC, Yoder BA. Comparison of current to past outcomes in congenital diaphragmatic hernia using mri observed-to-expected total fetal lung volume. J Perinatol 2024:10.1038/s41372-024-02008-z. [PMID: 38796522 DOI: 10.1038/s41372-024-02008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/23/2023] [Accepted: 05/14/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Fetal Centers use imaging studies to predict congenital diaphragmatic hernia (CDH) prognosis and the need for fetal therapy. Given improving CDH survival, we hypothesized that current fetal imaging severity predictions no longer reflect true outcomes and fail to justify the risks of fetal therapy. METHODS We analyzed our single-center contemporary data in a left-sided CDH cohort (n = 58) by prognostic criteria determined by MRI observed-to-expected total fetal lung volumes: severe <25%, moderate 25-35%, and mild >35%. We compared contemporary survival to prior studies and the TOTAL trials. RESULTS Contemporary survival was significantly higher than past studies for all prognostic classifications (mild 100% vs 80-94%, moderate 95% vs 59-75%, severe 79% vs 13-25%; P < 0.01), and to either control or fetal therapy arms of the TOTAL trials. CONCLUSIONS Current fetal imaging criteria are overly pessimistic and may lead to unwarranted fetal intervention. Fetal therapies remain experimental. Future studies will require updated prognostic criteria.
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Affiliation(s)
- Michelle J Yang
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA.
| | - Tanner S Ellsworth
- Divisions of General Pediatrics, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Paula J Woodward
- Divisions of Radiology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Anne M Kennedy
- Divisions of Radiology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Stephen J Fenton
- Divisions of Pediatric Surgery, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Katie W Russell
- Divisions of Pediatric Surgery, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Janice L B Byrne
- Divisions of Maternal-Fetal Medicine, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Christian C Yost
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
- Divisions of Molecular Medicine Program, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
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Lichtsinn KC, Church JT, Waltz PK, Azzuqa A, Graham J, Troutman J, Li R, Mahmood B. Early Ventilator Management for Infants With Congenital Diaphragmatic Hernia: Impact of a Standardized Clinical Practice Guideline. J Pediatr Surg 2024; 59:451-458. [PMID: 37865575 DOI: 10.1016/j.jpedsurg.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/31/2023] [Accepted: 09/15/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Infants with congenital diaphragmatic hernia (CDH) experience high morbidity and mortality due to pulmonary arterial hypertension and hypoplasia. Mechanical ventilation is a central component of CDH management. Our objective was to evaluate the impact of a standardized clinical practice guideline (implemented in January 2012) on ventilator management for infants with CDH, and associate management changes with short-term outcomes, specifically extracorporeal membrane oxygenation (ECMO) utilization and survival to discharge. METHODS We conducted a retrospective pre-post study of 103 CDH infants admitted from January 2007-July 2021, divided pre- (n = 40) and post-guideline (n = 63). Clinical outcomes, ventilator settings, and blood gas values in the first 7 days of mechanical ventilation were compared between the pre- and post-guideline cohorts. RESULTS Post-guideline, ECMO utilization decreased (11% vs 38%, p = 0.001) and survival to discharge improved (92% vs 68%, p = 0.001). More post-guideline patients remained on conventional mechanical ventilation without need for escalation to high-frequency ventilation or ECMO, and had higher pressures and PaCO2 with lower FiO2 and PaO2 (p < 0.05). CONCLUSIONS Standardized ventilator management optimizing pressures for adequate lung expansion and minimizing oxygen toxicity improves outcomes for infants with CDH. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Katrin C Lichtsinn
- University of Pittsburgh Medical Center, Division of Newborn Medicine, 4401 Penn Ave, Pittsburgh, PA, 15224, USA.
| | - Joseph T Church
- University of Pittsburgh Medical Center, Division of Pediatric General and Thoracic Surgery, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Paul K Waltz
- University of Pittsburgh Medical Center, Division of Pediatric General and Thoracic Surgery, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Abeer Azzuqa
- University of Pittsburgh Medical Center, Division of Newborn Medicine, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Jacqueline Graham
- University of Pittsburgh Medical Center, Division of Newborn Medicine, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Jennifer Troutman
- University of Pittsburgh Medical Center, Division of Newborn Medicine, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Runjia Li
- University of Pittsburgh, Department of Biostatistics, School of Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
| | - Burhan Mahmood
- University of Pittsburgh Medical Center, Division of Newborn Medicine, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
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5
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Bromiker R, Sokolover N, Ben-Hemo I, Idelson A, Gielchinsky Y, Almog A, Zeitlin Y, Herscovici T, Elron E, Klinger G. Congenital diaphragmatic hernia: quality improvement using a maximal lung protection strategy and early surgery-improved survival. Eur J Pediatr 2024; 183:697-705. [PMID: 37975943 DOI: 10.1007/s00431-023-05328-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
To evaluate the effectiveness of a novel protocol, adopted in our institution, as a quality improvement project for congenital diaphragmatic hernia (CDH). A maximal lung protection (MLP) protocol was implemented in 2019. This strategy included immediate use of high-frequency oscillatory ventilation (HFOV) after birth, during the stay at the Neonatal Intensive Care Unit (NICU), and during surgical repair. HFOV strategy included low distending pressures and higher frequencies (15 Hz) with subsequent lower tidal volumes. Surgical repair was performed early, within 24 h of birth, if possible. A retrospective study of all inborn neonates prenatally diagnosed with CDH and without major associated anomalies was performed at the NICU of Schneider Children's Medical Center of Israel between 2009 and 2022. Survival rates and pulmonary outcomes of neonates managed with MLP were compared to the historical standard care cohort. Thirty-three neonates were managed with the MLP protocol vs. 39 neonates that were not. Major adverse outcomes decreased including death rate from 46 to 18% (p = 0.012), extracorporeal membrane oxygenation from 39 to 0% (p < 0.001), and pneumothorax from 18 to 0% (p = 0.013). CONCLUSION MLP with early surgery significantly improved survival and additional adverse outcomes of neonates with CDH. Prospective randomized studies are necessary to confirm the findings of the current study. WHAT IS KNOWN • Ventilator-induced lung injury was reported as the main cause of mortality in neonates with congenital diaphragmatic hernia (CDH). • Conventional ventilation is recommended by the European CDH consortium as the first-line ventilation modality; timing of surgery is controversial. WHAT IS NEW • A maximal lung protection strategy based on 15-Hz high-frequency oscillatory ventilation with low distending pressures as initial modality and early surgery significantly reduced mortality and other outcomes.
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Affiliation(s)
- Ruben Bromiker
- Department of Neonatology, Schneider Children`s Medical Center of Israel, 14 Kaplan St., Petah Tikva, 49202, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Nir Sokolover
- Department of Neonatology, Schneider Children`s Medical Center of Israel, 14 Kaplan St., Petah Tikva, 49202, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Inbar Ben-Hemo
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ana Idelson
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Yuval Gielchinsky
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Fetal Medicine Center, Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Anastasia Almog
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Yelena Zeitlin
- Department of Pediatric Anesthesia, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Tina Herscovici
- Department of Neonatology, Schneider Children`s Medical Center of Israel, 14 Kaplan St., Petah Tikva, 49202, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Elron
- Department of Neonatology, Schneider Children`s Medical Center of Israel, 14 Kaplan St., Petah Tikva, 49202, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Klinger
- Department of Neonatology, Schneider Children`s Medical Center of Israel, 14 Kaplan St., Petah Tikva, 49202, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Gregorio-Hernández R, Ramos-Navarro C, Vigil-Vázquez S, Rodríguez-Corrales E, Pérez-Pérez A, Arriaga-Redondo M, Sánchez-Luna M. Lung ultrasound and postoperative follow-up of congenital diaphragmatic hernia. Eur J Pediatr 2023; 182:3973-3981. [PMID: 37368006 DOI: 10.1007/s00431-023-05074-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 06/28/2023]
Abstract
Lung ultrasound (LU) has emerged as a valuable tool for assessing pulmonary aeration noninvasively, rapidly, and reliably in different neonatal conditions. However, its role in the preoperative and postoperative evaluation in congenital diaphragmatic hernia (CDH) is still poorly analyzed. We present a cohort of 8 patients diagnosed with CDH who underwent lung ultrasound examinations at various time points before and after surgical correction. The lung ultrasound patterns were compared between two groups: mechanical ventilation ≤ 7 days (MV ≤ 7) and mechanical ventilation > 7 days (MV > 7). The ultrasound findings were also compared to CT scans and chest X-ray images to assess its diagnostic capacity for identifying postoperative complications: pneumothorax, pleural effusion, and pneumonia. Group MV ≤ 7 exhibited a normal pattern even at 48 h postsurgery, while group MV > 7 presented interstitial or alveolointerstitial pattern in both lungs for prolonged periods (2-3 weeks). Furthermore, contralateral LU pattern may be predictive of respiratory evolution. Conclusion: Lung ultrasound is a valuable tool for evaluating the progressive reaeration of the lung following surgical correction in CDH patients. It demonstrates the ability to diagnose common postoperative complications without the need for radiation exposure while offering the advantages of quick and serial assessments. These findings highlight the potential of lung ultrasound as an effective alternative to conventional imaging methods in the management of CDH. What is Known: • Lung ultrasound evaluates lung aeration and predicts respiratory outcomes in neonatal patients. What is New: • Lung ultrasound is useful in the postsurgical management of congenital diaphragmatic hernia patients, detecting reaeration and respiratory complications.
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Affiliation(s)
| | - C Ramos-Navarro
- Neonatology Department, Gregorio Marañón Hospital, Madrid, Spain
| | - S Vigil-Vázquez
- Neonatology Department, Gregorio Marañón Hospital, Madrid, Spain
| | | | - A Pérez-Pérez
- Neonatology Department, Gregorio Marañón Hospital, Madrid, Spain
| | | | - M Sánchez-Luna
- Neonatology Department, Gregorio Marañón Hospital, Madrid, Spain
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Liu R, Zheng Z, Tang C, Zhang K, Du Q, Gong Y, Zhu D, Xia X, Zhou W, Huang L, Liu Y, Jin Z. Thoracoscopic surgery for congenital diaphragmatic hernia in neonates: Should it be the first choice? Front Pediatr 2022; 10:1020062. [PMID: 36389344 PMCID: PMC9659751 DOI: 10.3389/fped.2022.1020062] [Citation(s) in RCA: 2] [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: 08/15/2022] [Accepted: 10/07/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Congenital diaphragmatic hernia (CDH) is an uncommon but potentially life-threatening surgical condition in neonates. Surgery can be performed by either open or thoracoscopic techniques. In this study, we compared the clinical efficacy, safety, and effectiveness of thoracoscopic and open CDH repair. METHODS A retrospective review of neonates with CDH who underwent operations at our hospital from 2013 to 2021 was performed. The various perioperative parameters were compared between neonates undergoing thoracoscopic and open surgery. RESULTS There were 50 neonates in this study (37 in the thoracoscopic group and 13 in the open group). Thoracoscopic surgery was associated with significantly shorter hospital stay (13.32 vs. 18.77 days, p < 0.001); shorter duration of postoperative mechanical ventilation (3.70 vs. 5.98 days, p < 0.001); early feeding (4.34 vs. 7.46 days, p < 0.001); and shorter time to reach optimal feeding (8.21 vs. 13.38 days, p < 0.001). There was one postoperative death in the open group and no death in the thoracoscopic group. The median follow-up time of the two groups was 23.8 months (20.5 months in open group and 25.0 months in thoracoscopic group). Thoracoscopic surgery was associated with lower recurrence rates, but the difference was not statistically significant (2.7% vs. 7.7%, p = 0.456). CONCLUSION Thoracoscopy CDH repair, a safe and effective surgical technique for neonates, has better cosmesis, faster postoperative recovery, and a lower recurrence rate than other procedures. It can be considered the first choice for CDH treatment for neonates among experienced surgeons.
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Affiliation(s)
- Rui Liu
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Zebing Zheng
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Chengyan Tang
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Kaizhi Zhang
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Qing Du
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Yuan Gong
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Daiwei Zhu
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Xingrong Xia
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Wankang Zhou
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Lu Huang
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Yuanmei Liu
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
| | - Zhu Jin
- Department of Pediatric Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Department of Pediatric Surgery, Guizhou Children's Hospital, Zunyi, China
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