Shifting Risks and Conflicting Outcomes—ECMO for Neonates with Congenital Diaphragmatic Hernia in the Modern Era

Turek, Joseph W.; Nellis, Joseph R.; Sherwood, Brenton; Kotagal, Meera; Mesher, Andrew L.; Thiagarajan, Ravi R.; Patel, Sonali S.; Avansino, Jeffrey R.; Rycus, Peter; McMullan, D. Michael; Brogan, Thomas V.

doi:10.1016/j.jpeds.2017.08.010

Cited by 25 publications

(12 citation statements)

References 25 publications

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“…10 This observation, however, has not been paralleled among the CDH cohort receiving ECMO. 7,11 In this study, we sought to specifically examine why the mortality rate in the CDH-ECMO population has remained at approximately 50% despite consistent progress in the field. We tested the hypothesis that lack of improvement in gross mortality rate could be because of worsening risk profiles in CDH patients over the course of the study period.…”

Section: Discussionmentioning

confidence: 99%

Trends in Mortality and Risk Characteristics of Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation

et al. 2019

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Although the mortality of infants with congenital diaphragmatic hernia (CDH) has been improving since the late 1990s, this observation has not been paralleled among the CDH cohort receiving extracorporeal membrane oxygenation (ECMO). We sought to elucidate why the mortality rate in the CDH-ECMO population has remained at approximately 50% despite consistent progress in the field by examining the baseline risk profile/characteristics of neonates with CDH before ECMO (pre-ECMO). Neonates with a diagnosis of CDH were identified in the ELSO Registry from 1992 to 2015. Individual pre-ECMO risk score (RS) for mortality was categorized to pre-ECMO risk-stratified cohorts. Temporal trends based on individual-level mortality by risk cohorts were assessed by logistic regression. We identified 6,696 neonates with CDH. The mortality rates during this time period were approximately 50%. The average baseline pre-ECMO RS increased during this period: mean increase of 0.35 (95% confidence interval [CI]: 0.324-0.380). In the low-risk cohort, the likelihood of mortality increased over time: each 5 year change was associated with a 7.3% increased likelihood of mortality (odds ratio [OR]: 1.0726; 95% CI: 1.0060-1.1437). For the moderate-risk cohort, the likelihood of mortality decreased by 7.05% (OR: 0.9295; 95% CI: 0.8822-0.9793). There was no change in the odds of mortality for the high-risk cohort (OR: 0.9650; 95% CI: 0.8915-1.0446). Although the overall mortality rate remained approximately constant over time, the individual likelihood of death has declined over time in the moderate-risk cohort, increased in the low-risk cohort, and remained unchanged in the high-risk cohort.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section: Discussionmentioning

confidence: 99%

Trends in Mortality and Risk Characteristics of Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation

et al. 2019

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“…Congenital diaphragmatic hernia (CDH) is currently the most common indication for extracorporeal membrane oxygenation (ECMO) in neonates (1). Survival rates reported by the extracorporeal life support organization (ELSO) have continued to drop in the modern era (2) and systematic reviews concerning a benefit of ECMO in CDH did not find an advantage for ECMO (3–5). However, some centers and networks have demonstrated an increase in survival rates in CDH with the employment of ECMO by retrospective analysis in their series (6).…”

Section: Introductionmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation in Congenital Diaphragmatic Hernia

Rafat

Schaible

2019

Front. Pediatr.

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Congenital diaphragmatic hernia (CDH) is characterized by failure of diaphragmatic development with lung hypoplasia and persistent pulmonary hypertension of the newborn (PPHN). If conventional treatment with gentle ventilation and optimized vasoactive medication fails, extracorporeal membrane oxygenation (ECMO) may be considered. The benefits of ECMO in CDH are still controversial, since there are only few randomized trials demonstrating the advantages of this therapeutic option. At present, there is no precise prenatal and/or early postnatal prognostication parameter to predict reversibility of PPHN in CDH patients. Indications for initiating ECMO include either respiratory or circulatory parameters, which are also undergoing continuous refinement. Centers with higher case numbers and the availability of ECMO published promising survival rates, but data on long-term results, including morbidity and quality of life, are rare. Survival might be influenced by the timing of ECMO initiation and the timing of surgical repair. In this regard a trend toward early initiation of ECMO and early surgery on ECMO exists. The results concerning the cannulation modes are similar and a consensus on time limit for ECMO runs does not exist. The use of ECMO in CDH will continue to be evaluated, and prospective randomized trials and registry network are necessary to help answering the addressed questions of patient selection and management.

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“…In nearly three quarter the mode of neonatal ECMO was VA (73%), markedly higher than our 54% rate. Trend analysis of survival rates showed either no changes or a decline associated with certain diagnoses including CDH and EOS ( 15 ). Survival rates of 54% for infarctions and 44% for hemorrhages have been reported (prevalence rates of 7.2 and 7.1%, respectively) ( 15 ).…”

Section: Discussionmentioning

confidence: 99%

“…Trend analysis of survival rates showed either no changes or a decline associated with certain diagnoses including CDH and EOS ( 15 ). Survival rates of 54% for infarctions and 44% for hemorrhages have been reported (prevalence rates of 7.2 and 7.1%, respectively) ( 15 ). The incidence of abnormalities discovered in neuroimaging during or after ECMO varies from 10% to even 59% according to the literature ( 16 ).…”

Section: Discussionmentioning

confidence: 99%

Neonatal Extracorporeal Membrane Oxygenation Due to Respiratory Failure: A Single Center Experience Over 28 Years

et al. 2018

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Background: ECMO therapy is worldwide declining in the neonatal population; hence, its therapeutic value is sometimes questioned.Objectives: To report our experience with neonatal ECMO due to respiratory failure over a 28 year time period.Methods: Retrospective single center observational study including all neonates admitted to ECMO due to respiratory failure between 1989 and 2016 at Graz, Austria. Data were collected regarding survival rate, duration of ECMO, complications, length of hospital stay, changes over time, and follow-up.Results: Sixty-seven neonates were admitted and 43 (64%) needed ECMO—median birth weight 3390 grams (range 1810–4150) and gestational age 39 weeks (32–43). Survival rate was 65% (28/43); with higher rates in meconium aspiration syndrome (MAS) 89% vs. congenital diaphragmatic hernia (CDH) 46% and septic shock 44% (p = 0.005 and p = 0.006, respectively). ECMO duration was median 5 days (1–30) and veno-arterial ECMO (52%) dominated. Need for ECMO therapy decreased over time (p < 0.001). Complications occurred in 31 (72%) neonates. Five neonates had cerebral hemorrhages (11.4%) and four had cerebral infarction (9.1%). Of 26 survivors 17 (65%) showed normal neurodevelopmental outcome at median follow-up of 73 months. Motor deficits were present in one case, cognitive deficits in 9 (35%). Median length of hospital stay was 78 days in those with deficits and 29 in those with normal neurodevelopmental outcome (p < 0.001).Conclusions: Survival rate did not change over the study time but indications for ECMO did. Cognitive impairment was the major long-term deficit following neonatal ECMO being associated with longer hospital stay.

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Shifting Risks and Conflicting Outcomes—ECMO for Neonates with Congenital Diaphragmatic Hernia in the Modern Era

Cited by 25 publications

References 25 publications

Trends in Mortality and Risk Characteristics of Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation

Trends in Mortality and Risk Characteristics of Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation

Extracorporeal Membrane Oxygenation in Congenital Diaphragmatic Hernia

Neonatal Extracorporeal Membrane Oxygenation Due to Respiratory Failure: A Single Center Experience Over 28 Years

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