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Wild KT, Mathew L, Ades AM, Rintoul NE, Soorikian L, Matthews K, Lee S, Van Hoose KT, Kesler E, Flohr S, Bostwick A, Reynolds T, Hedrick HL, Foglia EE. Association between initial ventilation mode and hospital outcomes for severe congenital diaphragmatic hernia. J Perinatol 2024; 44:1353-1358. [PMID: 38942929 PMCID: PMC11379620 DOI: 10.1038/s41372-024-02024-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/24/2024] [Accepted: 05/30/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE To determine the association between initial delivery room (DR) ventilator (conventional mechanical ventilation [CMV] versus high frequency oscillatory ventilation [HFOV] and hospital outcomes for infants with severe congenital diaphragmatic hernia (CDH). STUDY DESIGN Quasi-experimental design before/after introducing a clinical protocol promoting HFOV. The primary outcome was first blood gas parameters. Secondary outcomes included serial blood gas assessments, ECMO, survival, duration of ventilation, and length of hospitalization. RESULTS First pH and CO2 were more favorable in the HFOV group (n = 75) than CMV group (n = 85), median (interquartile range (IQR)) pH 7.18 (7.03, 7.24) vs. 7.05 (6.93, 7.17), adjusted p-value < 0.001; median CO2 62.0 (46.0, 82.0) vs 85.9 (59.0, 103.0), adjusted p-value < 0.001. ECMO, survival, duration of ventilation, and length of hospitalization did not differ between groups in adjusted analysis. CONCLUSION Among infants with severe CDH, initial DR HFOV was associated with improved early gas exchange with no adverse differences in hospital outcomes.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA.
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Leane Soorikian
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Kelle Matthews
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Sura Lee
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - K Taylor Van Hoose
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin Kesler
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabrina Flohr
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anna Bostwick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tom Reynolds
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth E Foglia
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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Gehle DB, Meyer LC, Jancelewicz T. The role of extracorporeal life support and timing of repair in infants with congenital diaphragmatic hernia. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000752. [PMID: 38645885 PMCID: PMC11029407 DOI: 10.1136/wjps-2023-000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Extracorporeal life support (ECLS) serves as a rescue therapy for patients with congenital diaphragmatic hernia (CDH) and severe cardiopulmonary failure, and only half of these patients survive to discharge. This costly intervention has a significant complication risk and is reserved for patients with the most severe disease physiology refractory to maximal cardiopulmonary support. Some contraindications to ECLS do exist such as coagulopathy, lethal chromosomal or congenital anomaly, very preterm birth, or very low birth weight, but many of these limits are being evaluated through further research. Consensus guidelines from the past decade vary in recommendations for ECLS use in patients with CDH but this therapy appears to have a survival benefit in the most severe subset of patients. Improved outcomes have been observed for patients treated at high-volume centers. This review details the evolving literature surrounding management paradigms for timing of CDH repair for patients receiving preoperative ECLS. Most recent data support early repair following cannulation to avoid non-repair which is uniformly fatal in this population. Longer ECLS runs are associated with decreased survival, and patient physiology should guide ECLS weaning and eventual decannulation rather than limiting patients to arbitrary run lengths. Standardization of care across centers is a major focus to limit unnecessary costs and improve short-term and long-term outcomes for these complex patients.
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Affiliation(s)
- Daniel B Gehle
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Logan C Meyer
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Stieren ES, Sankaran D, Lakshminrusimha S, Rottkamp CA. Comorbidities and Late Outcomes in Neonatal Pulmonary Hypertension. Clin Perinatol 2024; 51:271-289. [PMID: 38325946 PMCID: PMC10850767 DOI: 10.1016/j.clp.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Long-term outcomes of persistent pulmonary hypertension of newborn (PPHN) depend on disease severity, duration of ventilation, and associated anomalies. Congenital diaphragmatic hernia survivors may have respiratory morbidities and developmental delay. The presence of PPHN is associated with increased mortality in hypoxic-ischemic encephalopathy, though the effects on neurodevelopment are less clear. Preterm infants can develop pulmonary hypertension (PH) early in the postnatal course or later in the setting of bronchopulmonary dysplasia (BPD). BPD-PH is associated with higher mortality, particularly within the first year. Evidence suggests that both early and late PH in preterm infants are associated with neurodevelopmental impairment.
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MESH Headings
- Infant
- Infant, Newborn
- Humans
- Nitric Oxide
- Infant, Premature
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/therapy
- Bronchopulmonary Dysplasia/epidemiology
- Bronchopulmonary Dysplasia/therapy
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/epidemiology
- Hernias, Diaphragmatic, Congenital/therapy
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Affiliation(s)
- Emily S Stieren
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA.
| | - Deepika Sankaran
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA
| | | | - Catherine A Rottkamp
- Division of Neonatology, Department of Pediatrics, University of California, Davis, 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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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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Wild KT, Hedrick HL, Ades AM, Fraga MV, Avitabile CM, Gebb JS, Oliver ER, Coletti K, Kesler EM, Van Hoose KT, Panitch HB, Johng S, Ebbert RP, Herkert LM, Hoffman C, Ruble D, Flohr S, Reynolds T, Duran M, Foster A, Isserman RS, Partridge EA, Rintoul NE. Update on Management and Outcomes of Congenital Diaphragmatic Hernia. J Intensive Care Med 2023:8850666231212874. [PMID: 37933125 DOI: 10.1177/08850666231212874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Infants with congenital diaphragmatic hernia (CDH) benefit from comprehensive multidisciplinary teams that have experience in caring for the unique and complex issues associated with CDH. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies and pulmonary hypertension management, and extracorporeal membrane oxygenation, mortality and morbidity remain high. These infants have unique and complex issues that begin in fetal and infant life, but persist through adulthood. Here we will review the literature and share our clinical care pathway for neonatal care and follow up. While many advances have occurred in the past few decades, our work is just beginning to continue to improve the mortality, but also importantly the morbidity of CDH.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Maria V Fraga
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Juliana S Gebb
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Coletti
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Erin M Kesler
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - K Taylor Van Hoose
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Howard B Panitch
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Renee P Ebbert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Herkert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Hoffman
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Deanna Ruble
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabrina Flohr
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tom Reynolds
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa Duran
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Audrey Foster
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca S Isserman
- Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Emily A Partridge
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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7
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Danzer E, Harting MT, Dahlen A, Mesas Burgos C, Frenckner B, Lally KP, Ebanks AH, van Meurs KP. Impact of Repeat Extracorporeal Life Support on Mortality and Short-term In-hospital Morbidities in Neonates With Congenital Diaphragmatic Hernia. Ann Surg 2023; 278:e605-e613. [PMID: 36102187 DOI: 10.1097/sla.0000000000005706] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of repeat extracorporeal life support (ECLS) on survival and in-hospital outcomes in the congenital diaphragmatic hernia (CDH) neonates. BACKGROUND Despite the widespread use of ECLS, investigations on multiple ECLS courses for CDH neonates are limited. METHODS This is a retrospective cohort study of all ECLS-eligible CDH neonates enrolled in the Congenital Diaphragmatic Hernia Study Group registry between 1995 and 2019. CDH infants with estimated gestational age at birth <32 weeks and a birth weight <1.8 kg and/or with major cardiac or chromosomal anomalies were excluded. The primary outcomes were survival and morbidities during the index hospitalization. RESULTS Of 10,089 ECLS-eligible CDH infants, 3025 (30%) received 1 ECLS course, and 160 (1.6%) received multiple courses. The overall survival rate for patients who underwent no ECLS, 1 ECLS course, and multicourse ECLS were 86.9±0.8%, 53.8±1.8%, and 43.1±7.7%, respectively. Overall ECLS survival rate is increased by 5.1±4.6% ( P =0.03) for CDH neonates treated at centers that conduct repeat ECLS compared with those that do not offer repeat ECLS. This suggests that there would be an overall survival benefit from increased use of multiple ECLS courses. Infants who did not receive ECLS support had the lowest morbidity risk, while survivors of multicourse ECLS had the highest rates of morbidities during the index hospitalization. CONCLUSIONS Although survival is lower for repeat ECLS, the use of multiple ECLS courses has the potential to increase overall survival for CDH neonates. Increased use of repeat ECLS might be associated with improved survival. The potential survival advantage of repeat ECLS must be balanced against the increased risk of morbidities during the index hospitalization.
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Affiliation(s)
- Enrico Danzer
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
- Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY
| | - 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
| | - Alex Dahlen
- Quantitative Science Unit, Department of Medicine, Stanford University, Stanford, CA
| | - Carmen Mesas Burgos
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Björn Frenckner
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX
| | - Krisa P van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
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Mortality in Congenital Diaphragmatic Hernia: A Multicenter Registry Study of Over 5000 Patients Over 25 Years. Ann Surg 2023; 277:520-527. [PMID: 34334632 DOI: 10.1097/sla.0000000000005113] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if risk-adjusted survival of patients with CDH has improved over the last 25 years within centers that are long-term, consistent participants in the CDH Study Group (CDHSG). SUMMARY BACKGROUND DATA The CDHSG is a multicenter collaboration focused on evaluation of infants with CDH. Despite advances in pediatric surgical and intensive care, CDH mortality has appeared to plateau. Herein, we studied CDH mortality rates amongst long-term contributors to the CDHSG. METHODS We divided registry data into 5-year intervals, with Era 1 (E1) beginning in 1995, and analyzed multiple variables (operative strategy, defect size, and mortality) to assess evolution of disease characteristics and severity over time. For mortality analyses, patients were risk stratified using a validated prediction score based on 5-minute Apgar (Apgar5) and birth weight. A risk-adjusted, observed to expected (O:E) mortality model was created using E1 as a reference. RESULTS 5203 patients from 23 centers with >22years of participation were included. Birth weight, Apgar5, diaphragmatic agenesis, and repair rate were unchanged over time (all P > 0.05). In E5 compared to E1, minimally invasive and patch repair were more prevalent, and timing of diaphragmatic repair was later (all P < 0.01). Overall mortality decreased over time: E1 (30.7%), E2 (30.3%), E3 (28.7%), E4 (26.0%), E5 (25.8%) ( P = 0.03). Risk-adjusted mortality showed a significant improvement in E5 compared to E1 (OR 0.78, 95% CI 0.62-0.98; P = 0.03). O:E mortality improved over time, with the greatest improvement in E5. CONCLUSIONS Risk-adjusted and observed-to-expected CDH mortality have improved over time.
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Lichtsinn K, Waltz PK, Azzuqa A, Church J, Graham J, Troutman J, Mahmood B. Impact of a standardized management guideline for infants with CDH: A single-center experience. J Pediatr Surg 2023; 58:389-396. [PMID: 35965150 DOI: 10.1016/j.jpedsurg.2022.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/15/2022] [Accepted: 07/25/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Infants with congenital diaphragmatic hernia (CDH) are at high risk of death, even despite extracorporeal membrane oxygenation (ECMO) support. In January 2012 we implemented a standardized clinical practice guideline (CPG) to manage infants with CDH. We hypothesized that infants with CDH managed with CPG had better clinical outcomes, less ECMO utilization, and increased survival to discharge. METHODS We conducted a retrospective pre-post study of infants with CDH admitted between January 2007 and July 2021 (n = 133). Patients were divided into Cohort 1, pre-CPG (January 2007 to December 2011, n = 54), and Cohort 2, post-CPG (January 2012 to July 2021, n = 79). RESULTS More patients in Cohort 1 were small for gestational age than in Cohort 2. No other patient demographics were different between cohorts. Cohort 2 had significantly lower ECMO utilization as compared to Cohort 1 (18% vs 50%, p<0.001). Cohort 2 had significantly higher survival to discharge compared to Cohort 1 (85% vs 57%, p<0.001). Survival for ECMO-treated patients in Cohort 2 was significantly higher than in Cohort 1 (71% vs 26%, p = 0.005). In Cohort 1, 70% of the non-survivors were repaired, of which 81% were repaired on ECMO. In Cohort 2, 8% of the non-survivors were repaired, none on ECMO. Only 3% in Cohort 2 were discharged with pulmonary hypertension medication. CONCLUSIONS A standardized CPG to manage patients with CDH decreased ECMO utilization and improved clinical outcomes including survival to discharge. Refinement of management strategies, implementation of new interventions, and meticulous care can improve outcomes in patients with CDH.
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Affiliation(s)
- Katrin Lichtsinn
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224.
| | - Paul K Waltz
- University of Pittsburgh Medical Center, Division of Pediatric General and Thoracic Surgery. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Abeer Azzuqa
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Joseph Church
- University of Pittsburgh Medical Center, Division of Pediatric General and Thoracic Surgery. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Jacqueline Graham
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Jennifer Troutman
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Burhan Mahmood
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224
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Fideler F, Mustafi M, Kirschner HJ, Gerbig I, Fuchs J, Hofbeck M, Kumpf M, Kagan O, Michel J, Jost W, Neunhoeffer F. Successful on-ECLS Repair of CDH and Omphalocele in a Newborn. European J Pediatr Surg Rep 2023; 11:e15-e19. [PMID: 37051184 PMCID: PMC10085641 DOI: 10.1055/s-0043-1767734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/08/2023] [Indexed: 04/14/2023] Open
Abstract
Both congenital diaphragmatic hernias (CDHs) and omphaloceles show relevant overall mortality rates as individual findings. The combination of the two has been described only sparsely in the literature and almost always with a fatal course. Here, we describe a term neonate with a rare high-risk constellation of left-sided CDH and a large omphalocele who was successfully treated on extracorporeal life support (ECLS). Prenatally, the patient was diagnosed with a large omphalocele and a left CDH with a lung volume of ∼27% and an observed to expected lung-to-head ratio of 30%. Due to respiratory insufficiency, an ECLS device was implanted. As weaning from ECLS was not foreseeable, the female infant underwent successful surgery on ECLS on the ninth day of life. Perioperative high-frequency oscillatory ventilation and circulatory and coagulation management under point-of-care monitoring were the main anesthesiological challenges. Over the following 3 days, ECLS weaning was successful, and the patient was extubated after another 43 days. Surgical treatment on ECLS can expand the spectrum of therapy in high-risk constellations if potential risks are minimized and there is close interdisciplinary cooperation.
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Affiliation(s)
- Frank Fideler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
- Address for correspondence Frank Fideler, MD Department of Anesthesiology and Intensive Care Medicine, University Hospital,Tübingen,Germany
| | - Migdad Mustafi
- Department of Thoracic, Heart and Vascular Surgery, University Hospital, Tübingen, Germany
| | - Hans-Joachim Kirschner
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tübingen, Germany
| | - Ines Gerbig
- Department of Pediatric Cardiology, Pulmonology and Intensive Care Medicine, University Children's Hospital, Tübingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Intensive Care Medicine, University Children's Hospital, Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Intensive Care Medicine, University Children's Hospital, Tübingen, Germany
| | - Oliver Kagan
- Department of Women's Health, University Women's Hospital, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Intensive Care Medicine, University Children's Hospital, Tübingen, Germany
| | - Walter Jost
- Cardiovascular Engineering, University Hospital, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Intensive Care Medicine, University Children's Hospital, Tübingen, Germany
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11
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Gupta VS, Popp EC, Ebanks AH, Greenleaf CE, Annavajjhala V, Patel N, Robie DK, LaPar DJ, Lally KP, Harting MT. Isolated aortic arch anomalies are associated with defect severity and outcome in patients with congenital diaphragmatic hernia. Pediatr Surg Int 2022; 39:69. [PMID: 36580203 DOI: 10.1007/s00383-022-05354-1] [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] [Accepted: 12/19/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) patients often have suspected isolated aortic arch anomalies (IAAA) on imaging. The purpose of this work was to describe the incidence and outcomes of CDH + IAAA patients. METHODS Cardiovascular data were collected for infants from the CDH Study Group born between 2007 and 2019. IAAA were defined as coarctation of aorta, hypoplastic aortic arch, interrupted aortic arch, and aortic aneurysmal disease on early, postnatal echocardiography. Patients with major cardiac malformations and/or chromosomal abnormalities were excluded. Primary outcomes included the rate of aortic intervention, rates of extracorporeal life support (ECLS) utilization, and mortality. RESULTS Of 6357 CDH infants, 432 (7%) were diagnosed with a thoracic aortic anomaly. Of these, 165 were diagnosed with IAAA, most commonly coarctation of the aorta (n = 106; 64%) or hypoplastic aortic arch (n = 58; 35%). CDH + IAAA patients had lower birthweights (3 kg vs. 2.9 kg) and Apgar scores (7 vs. 6) than patients without IAAA (both χ2 p < 0.001). CDH + IAAA were less likely to undergo diaphragm repair (72 vs. 87%, p < 0.001), and overall mortality was higher for CDH + IAAA infants (58 vs. 24%, p < 0.001). When controlling for defect size, birth weight, and Apgar, IAAA were significantly associated with mortality (OR 3.3, 95% CI 2.2-5.0; p < 0.01) but not associated with ECLS (OR 0.98, 95% CI 0.65-1.50; p = 0.90). Only 17% (n = 28) of CDH + IAAA patients underwent aortic intervention. CONCLUSIONS IAAA in CDH are associated with increased mortality. This often simply reflects severity of the defect and thoracic anatomic derangement, as opposed to unique aortic pathology, given few CDH + IAAA patients undergo aortic intervention.
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Affiliation(s)
- Vikas S Gupta
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA
| | - Elizabeth C Popp
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA
| | - Christopher E Greenleaf
- Division of Pediatric and Congenital Heart Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Vidhya Annavajjhala
- Department of Pediatrics, Division of Pediatric Cardiology, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children Glasgow, Glasgow, Scotland
| | | | - Damien J LaPar
- Division of Pediatric and Congenital Heart Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, 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, 6431 Fannin St, MSB 5.233, Houston, TX, 77030, USA.
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12
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Prenatal markers in congenital diaphragmatic hernia-can we accurately predict outcomes? J Perinatol 2022; 42:1151-1152. [PMID: 35963888 DOI: 10.1038/s41372-022-01485-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/15/2022] [Accepted: 07/28/2022] [Indexed: 12/14/2022]
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13
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Friedmacher F, Rolle U, Puri P. Genetically Modified Mouse Models of Congenital Diaphragmatic Hernia: Opportunities and Limitations for Studying Altered Lung Development. Front Pediatr 2022; 10:867307. [PMID: 35633948 PMCID: PMC9136148 DOI: 10.3389/fped.2022.867307] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/18/2022] [Indexed: 11/21/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a relatively common and life-threatening birth defect, characterized by an abnormal opening in the primordial diaphragm that interferes with normal lung development. As a result, CDH is accompanied by immature and hypoplastic lungs, being the leading cause of morbidity and mortality in patients with this condition. In recent decades, various animal models have contributed novel insights into the pathogenic mechanisms underlying CDH and associated pulmonary hypoplasia. In particular, the generation of genetically modified mouse models, which show both diaphragm and lung abnormalities, has resulted in the discovery of multiple genes and signaling pathways involved in the pathogenesis of CDH. This article aims to offer an up-to-date overview on CDH-implicated transcription factors, molecules regulating cell migration and signal transduction as well as components contributing to the formation of extracellular matrix, whilst also discussing the significance of these genetic models for studying altered lung development with regard to the human situation.
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Affiliation(s)
- Florian Friedmacher
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Udo Rolle
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Prem Puri
- Beacon Hospital, University College Dublin, Dublin, Ireland
- Conway Institute of Biomolecular and Biomedical Research, School of Medicine, University College Dublin, Dublin, Ireland
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14
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Prasad R, Saha B, Kumar A. Ventricular function in congenital diaphragmatic hernia: a systematic review and meta-analysis. Eur J Pediatr 2022; 181:1071-1083. [PMID: 34725730 DOI: 10.1007/s00431-021-04303-9] [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: 08/05/2021] [Revised: 10/19/2021] [Accepted: 10/23/2021] [Indexed: 10/20/2022]
Abstract
There is emerging evidence supporting ventricular function as a prognostic factor in congenital diaphragmatic hernia (CDH). The present systematic review and meta-analysis aimed to determine the predictive value of early ventricular function for survival and extracorporeal membrane oxygenation (ECMO) requirement in newborns with CDH. PubMed, Google Scholar, Cochrane Central Register, Clinical Trial Registry, and Opengrey were accessed. Studies evaluating associations between echocardiographic ventricular function measured ≤ 48 h after birth and survival or ECMO requirement were included. Two independent authors extracted the following data: study and participant characteristics, prognostic factors, and outcome-related data. Eleven studies met the inclusion criteria. Five studies reported on survival, two on ECMO, and four on both outcomes. A moderate risk of bias was found in most of the studies, mainly because of selection, prognostic factors, and confounding biases. For survival (899 participants), pooled sensitivity and specificity were 86% (95% confidence interval [CI], 77-92%) and 44% (95% CI, 25-65%), respectively, in normal left ventricular function. For ECMO need (815 participants), pooled sensitivity and specificity were 39.8% (95% CI, 27-52%) and 88% (95% CI, 80-96%), respectively, in left ventricular dysfunction. Overall certainty of the evidence was graded very low for survival and low for ECMO. Inconsistent reporting of echocardiographic measurements and lack of adjustment for confounding factors were major limitations.Conclusion: Early ventricular dysfunction is a potential prognostic factor in CDH. Standardized echocardiographic measurement reporting and high-quality studies are needed to further elucidate its prognostic significance. What is Known: • Evidence supports the predictive value of echocardiographic measurements in CDH ≤ 24-48 h post-birth. • Ventricular dysfunction has been proposed as a prognostic risk factor. What is New: • Right and left ventricular functions were promising predictors of survival and ECMO requirement in neonates with CDH. • Test characteristics of ventricular function were determined as predictors of survival or need for ECMO. Specific echocardiographic markers of ventricular function can be valuable in determining prognosis.
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Affiliation(s)
- Rameshwar Prasad
- Department of Neonatology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India.
| | - Bijan Saha
- Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Amit Kumar
- Department of Neurology, Rajendra Institute of Medical Sciences, Ranchi Jharkhand, India
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15
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Edel GG, Schaaf G, Wijnen RMH, Tibboel D, Kardon G, Rottier RJ. Cellular Origin(s) of Congenital Diaphragmatic Hernia. Front Pediatr 2021; 9:804496. [PMID: 34917566 PMCID: PMC8669812 DOI: 10.3389/fped.2021.804496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 01/16/2023] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a structural birth defect characterized by a diaphragmatic defect, lung hypoplasia and structural vascular defects. In spite of recent developments, the pathogenesis of CDH is still poorly understood. CDH is a complex congenital disorder with multifactorial etiology consisting of genetic, cellular and mechanical factors. This review explores the cellular origin of CDH pathogenesis in the diaphragm and lungs and describes recent developments in basic and translational CDH research.
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Affiliation(s)
- Gabriëla G. Edel
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Cell Biology, Erasmus MC, Rotterdam, Netherlands
| | - Gerben Schaaf
- Department of Clinical Genetics, Erasmus MC, Rotterdam, Netherlands
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC, Rotterdam, Netherlands
| | - Rene M. H. Wijnen
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Gabrielle Kardon
- Department of Human Genetics, University of Utah, Salt Lake City, UT, United States
| | - Robbert J. Rottier
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Cell Biology, Erasmus MC, Rotterdam, Netherlands
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Fleming H, Dempsey AG, Palmer C, Dempsey J, Friedman S, Galan HL, Gien J. Primary contributors to gastrostomy tube placement in infants with Congenital Diaphragmatic Hernia. J Pediatr Surg 2021; 56:1949-1956. [PMID: 33773801 DOI: 10.1016/j.jpedsurg.2021.02.015] [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: 10/20/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To identify factors associated with gastrostomy tube (GT) placement in infants with congenital diaphragmatic hernia (CDH). METHODS Retrospective cohort study of 114 surviving infants with CDH at a single tertiary care neonatal intensive care unit from 2010-2019. Prenatal, perinatal and postnatal characteristics were compared between patients who were discharged home with and without a GT. Prenatal imaging was available for 50.9% of the cohort. Logistic regression was used to assess the association between GT placement and pertinent clinical factors. ROC curves were generated, and Youden's J statistic was used to determine optimal predictive cutoffs for continuous variables. Elastic net regularized regression was used to identify variables associated with GT placement in multivariable analysis. RESULTS GT was placed in 43.9% of surviving infants with CDH. Prenatal variables predictive of GT placement were percent predicted lung volume (PPLV) <21%, total lung volume (TLV) <30 ml, lung-head ratio (LHR) <1.2 or observed to expected LHR (O/E LHR) <55%. Infants who required a GT were diagnosed earlier prenatally (23.6 ± 3.4 vs. 26.4 ± 5.6 weeks). Patients whose stomach was above the diaphragm on prenatal ultrasound (up) had a higher odds of GT placement compared to those with stomachs below the diaphragm (down) position by a factor of 2.9 (95% CI: 1.25, 7.1); p = 0.0154. Postnatally, infants with GT had lower Apgar scores at 1 and 5 min, longer lengths of stay and higher proportion of flap closures. Infants with a type C or D defect and extracorporeal membrane oxygenation (ECMO) were associated with increased odds of needing a GT. Postnatal association included being NPO for >12 days, need for transpyloric (TP) feeds for >10 days, >14 days to transition to a 30 min bolus feed, presence of gastro-esophageal reflux (GER), chronic lung disease and pulmonary hypertension. In multivariable analysis, duration of NPO, time to TP feeds, transition to 30 min bolus feeds remained significantly associated with GT placement after adjusting for severity of pulmonary hypertension (PH), GER diagnosis and sildenafil treatment. CONCLUSION Identification of risk factors associated with need for long-term feeding access may improve timing of GT placement and prevent prolonged hospitalization related to feeding issues. LEVEL OF EVIDENCE RATING Level II (Retrospective Study).
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Affiliation(s)
- Hannah Fleming
- Department of Audiology, Speech and Learning, Children's Hospital Colorado. (Aurora, CO), Boulder, CO 80309, USA.
| | - Allison G Dempsey
- University of Colorado, Department of Psychiatry. (Aurora, CO), Boulder, CO 80309, USA
| | - Claire Palmer
- University of Colorado, Section of Neonatology (Aurora, CO), Boulder, CO 80309, USA
| | - Jack Dempsey
- University of Colorado, Section of Developmental Pediatrics (Aurora, CO), Boulder, CO 80309, USA
| | - Sandra Friedman
- University of Colorado, Section of Developmental Pediatrics (Aurora, CO), Boulder, CO 80309, USA
| | - Henry L Galan
- University of Colorado, Department of Obstetrics and Gynecology. (Aurora, CO), Boulder, CO 80309, USA
| | - Jason Gien
- University of Colorado, Section of Neonatology (Aurora, CO), Boulder, CO 80309, USA
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17
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Choi W, Cho WC, Choi ES, Yun TJ, Park CS. Outcomes after Extracorporeal Membrane Oxygenation in Neonates with Congenital Diaphragmatic Hernia: A Single-Center Experience. J Chest Surg 2021; 54:348-355. [PMID: 34611083 PMCID: PMC8548188 DOI: 10.5090/jcs.21.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background Congenital diaphragmatic hernia (CDH) is a rare disease often requiring mechanical ventilation after birth. In severe cases, extracorporeal membrane oxygenation (ECMO) may be needed. This study analyzed the outcomes of patients with CDH treated with ECMO and investigated factors related to in-hospital mortality. Methods Among 254 newborns diagnosed with CDH between 2008 and 2020, 51 patients needed ECMO support. At Asan Medical Center, a multidisciplinary team approach has been applied for managing newborns with CDH since 2018. Outcomes were compared between hospital survivors and nonsurvivors. Results ECMO was established at a median of 17 hours after birth. The mean birth weight was 3.1±0.5 kg. Twenty-three patients (23/51, 45.1%) were weaned from ECMO, and 16 patients (16/51, 31.4%) survived to discharge. The ECMO mode was veno-venous in 24 patients (47.1%) and veno-arterial in 27 patients (52.9%). Most cannulations (50/51, 98%) were accomplished through a transverse cervical incision. No significant between-group differences in baseline characteristics and prenatal indices were observed. The oxygenation index (1 hour before 90.0 vs. 51.0, p=0.005) and blood lactate level (peak 7.9 vs. 5.2 mmol/L, p=0.023) before ECMO were higher in nonsurvivors. Major bleeding during ECMO more frequently occurred in nonsurvivors (57.1% vs. 12.5%, p=0.007). In the multivariate analysis, the oxygenation index measured at 1 hour before ECMO initiation was identified as a significant risk factor for in-hospital mortality (odds ratio, 1.02; 95% confidence interval, 1.01–1.04; p=0.05). Conclusion The survival of neonates after ECMO for CDH is suboptimal. Timely application of ECMO is crucial for better survival outcomes.
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Affiliation(s)
- Wooseok Choi
- Division of Pediatric Cardiac Surgery, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Chul Cho
- Department of Thoracic and Cardiovascular Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Eun Seok Choi
- Division of Pediatric Cardiac Surgery, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Jin Yun
- Division of Pediatric Cardiac Surgery, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chun Soo Park
- Division of Pediatric Cardiac Surgery, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Amodeo I, Di Nardo M, Raffaeli G, Kamel S, Macchini F, Amodeo A, Mosca F, Cavallaro G. Neonatal respiratory and cardiac ECMO in Europe. Eur J Pediatr 2021; 180:1675-1692. [PMID: 33547504 PMCID: PMC7864623 DOI: 10.1007/s00431-020-03898-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Abstract
Neonatal extracorporeal membrane oxygenation (ECMO) is a life-saving procedure for critically ill neonates suffering from a potentially reversible disease, causing severe cardiac and/or respiratory failure and refractory to maximal conventional management. Since the 1970s, technology, management, and clinical applications of neonatal ECMO have changed. Pulmonary diseases still represent the principal neonatal diagnosis, with an overall 74% survival rate, and up to one-third of cases are due to congenital diaphragmatic hernia. The overall survival rate in cardiac ECMO is lower, with congenital heart defect representing the main indication. This review provides an overview of the available evidence in the field of neonatal ECMO. We will address the changing epidemiology, basic principles, technologic advances in circuitry, and monitoring, and deliver a current multidisciplinary management framework, focusing on ECMO applications, complications, and long-term morbidities. Lastly, areas for further research will be highlighted.Conclusions: ECMO is a life support with a potential impact on long-term patients' outcomes. In the next years, advances in knowledge, technology, and expertise may push neonatal ECMO boundaries towards more premature and increasingly complex infants, with the final aim to reduce the burden of ECMO-related complications and improve overall patients' outcomes. What is Known: • ECMO is a life-saving option in newborns with refractory respiratory and/or cardiac failure. • The multidisciplinary ECMO management is challenging and may expose neonates to complications with an impact on long-term outcomes. What is New: • Advances in technology and biomaterials will improve neonatal ECMO management and, eventually, the long-term outcome of these complex patients. • Experimental models of artificial placenta and womb technology are under investigation and may provide clinical translation and future research opportunities.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | | | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Shady Kamel
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Betamed Perfusion Service, Rome, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Amodeo
- ECMO & VAD Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
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Management of Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support: Interim Guidelines Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J 2021; 67:113-120. [PMID: 33512912 DOI: 10.1097/mat.0000000000001338] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The management of infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS) is complex. Significant variability in both practice and prevalence of ECLS use exists among centers, given the lack of evidence to guide management decisions. The purpose of this report is to review existing evidence and develop management recommendations for CDH patients treated with ECLS. This article was developed by the Extracorporeal Life Support Organization CDH interest group in cooperation with members of the CDH Study Group and the Children's Hospitals Neonatal Consortium.
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20
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Lock NE, Sawyer AA, Wise L, Bhatia J, Stansfield BK. Vitamin K and ECMO for neonatal hypoxic respiratory failure. Perfusion 2021; 37:484-492. [PMID: 33761796 DOI: 10.1177/02676591211003870] [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: 11/15/2022]
Abstract
INTRODUCTION The objectives of this retrospective cohort study were to examine the effect of vitamin K administration on hemorrhagic and thrombotic complications, blood product utilization, and outcomes in neonatal extracorporeal membrane oxygenation (ECMO). METHODS In the pilot study, complications, blood product use, and outcome data for neonates who received (n = 21) or did not receive (n = 18) a single dose of vitamin K (5 mg) immediately after initiation of ECMO for respiratory failure between 2006 and 2010 were compared. In the validation cohort, complications and outcomes were compared for 74 consecutive neonates supported with ECMO for respiratory failure who received (n = 45) or did not receive (n = 29) additional vitamin K once daily for prothrombin time (PT) ⩾14 seconds during ECMO from 2014 to 2019. RESULTS In the pilot study, vitamin K at ECMO initiation was associated with fewer thrombotic complications and similar hemorrhagic complications. The volume of fresh frozen plasma was higher in neonates who received vitamin K, but total blood product and other component volume did not differ between groups. ECMO run time, survival off ECMO, survival to discharge, and length of stay did not differ between cohorts. In the validation cohort, neonates who received additional vitamin K during ECMO had longer ECMO run time and length of stay, but no difference in mortality was observed. Further, thrombotic and hemorrhagic complications as well as blood product exposure were similar between cohorts. CONCLUSIONS These data suggest that routine vitamin K administration may have limited or no benefit during neonatal ECMO.
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Affiliation(s)
- Nicole E Lock
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Alexandra A Sawyer
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Linda Wise
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Jatinder Bhatia
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Brian K Stansfield
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
- Vascular Biology Center, Augusta University, Augusta, GA, USA
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21
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Delaplain PT, Ehwerhemuepha L, Nguyen DV, Di Nardo M, Jancelewicz T, Awan S, Yu PT, Guner YS. The development of multiorgan dysfunction in CDH-ECMO neonates is associated with the level of pre-ECMO support. J Pediatr Surg 2020; 55:830-834. [PMID: 32067809 DOI: 10.1016/j.jpedsurg.2020.01.026] [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: 01/05/2020] [Accepted: 01/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) is the most common indication for neonatal extracorporeal membrane oxygenation (ECMO), but mortality remains at 50%. Multiorgan failure can occur in 25% and has been linked to worse outcomes. We sought to examine the factors that would increase the risk of multiorgan dysfunction (MOD). METHODS The Extracorporeal Life Support Organization (ELSO) database was used to identify infants with CDH (2000-2015). The primary outcome was MOD, which was defined as the presence of organ failure in ≥2 organ systems. We used a multivariable logistic regression to examine the effect of demographics, pre-ECMO respiratory status, comorbidities, and therapies on MOD. RESULTS There were a total of 4374 CDH infants who were treated with ECMO. Overall mortality was 52.4%. The risk models demonstrated that pre-ECMO cardiac arrest (OR 1.458, CI: 1.146-1.861, p = 0.002) and hand-bagging (OR 1.461, CI: 1.094-1.963, p = 0.032) had the strongest association with MOD. In addition, other pre-ECMO indicators of disease severity (pH, HFOV, MAP, 5-min APGAR) and pre-ECMO therapies (bicarb, neuromuscular [NM] blockers) were also associated with MOD. CONCLUSIONS The level of pre-ECMO support has a significant association with the development of MOD, and initiation of ECMO prior to arrest seems to be critical to avoid complications. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Patrick T Delaplain
- University of California Irvine Medical Center, Department of Surgery, Orange, CA.
| | | | - Danh V Nguyen
- University of California, Irvine School of Medicine, Department of Medicine, Orange, CA
| | - Matteo Di Nardo
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Division of Pediatric Surgery, Memphis, TN
| | - Saeed Awan
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Information Systems, Orange, CA
| | - Peter T Yu
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Information Systems, Orange, CA
| | - Yigit S Guner
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Information Systems, Orange, CA
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