Extracorporeal membrane oxygenation and congenital diaphragmatic hernia: Should any infant be excluded?

Newman, Kurt D.; Anderson, Kathryn D.; Meurs, Krisa P. Van; Parson, S.; Loe, William A.; Short, Billie Lou

doi:10.1016/0022-3468(90)90216-v

Cited by 71 publications

(11 citation statements)

References 26 publications

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“…Unfortunately, marked variations in practice patterns across pediatric referral centers have made the use of these predictors difficult to interpret and none of these criteria has been appropriately validated in large controlled trials. Furthermore, ECMO survivors who would have been excluded by these criteria have been reported on [24].…”

Section: Discussionmentioning

confidence: 98%

Ex utero intrapartum treatment with extracorporeal membrane oxygenation for severe congenital diaphragmatic hernia

Kunisaki¹,

Barnewolt²,

Estroff³

et al. 2007

Journal of Pediatric Surgery

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Section: Discussionmentioning

confidence: 98%

Ex utero intrapartum treatment with extracorporeal membrane oxygenation for severe congenital diaphragmatic hernia

Kunisaki¹,

Barnewolt²,

Estroff³

et al. 2007

Journal of Pediatric Surgery

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“…A total of 39 patients were placed on venoarterial ECMO by inserting a venous drainage cannula in the right atrium through the right internal jugular vein and an arterial perfusion cannula into the arch of the aorta through the right common carotid artery as reported previously. 5,6 A total of 12 infants were placed on venovenous ECMO by placing a double lumen, single cannula through the internal jugular vein into the right atrium. This double lumen cannula allows for simultaneous venous drainage from the right atrium and arterial reinfusion toward the tricuspid valve.…”

Section: Methodsmentioning

confidence: 99%

“…5,6 Neurodevelopmental outcome in general in ECMO survivors has been encouraging. 7,8 However, infants with CDH represent a small proportion of the total ECMO population, and no detailed information is available about the quality of survival, intracranial lesions, and neurodevelopmental outcome in a large population of CDH infants treated with ECMO.…”

mentioning

confidence: 99%

Survival, Intracranial Lesions, and Neurodevelopmental Outcome in Infants With Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation

et al. 1999

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OBJECTIVE:Before the use of extracorporeal membrane oxygenation (ECMO), infants with a severe form of congenital diaphragmatic hernia (CDH) had a high mortality and morbidity. Recent studies have shown an improvement in the survival of these infants after ECMO treatment; however, the existing data do not provide sufficient information regarding the quality of survival and developmental outcome of these infants. The objective of this study was to evaluate survival, intracranial lesions, and the neurodevelopmental outcome of infants with CDH treated with ECMO. METHODS:We retrieved data for 51 (n ϭ 51) infants with CDH who were treated with ECMO at Huntington Memorial Hospital between 1985 and 1994. Their mean gestational age was 38.5 Ϯ 2.4 weeks (mean Ϯ SD); their mean birth weight was 3170 Ϯ 620 gm. Vital signs, arterial blood gases, chest radiographs, cranial and cardiac ultrasonography were routinely obtained before ECMO treatment. Cranial ultrasounds were performed daily on all infants while on ECMO; computerized tomography scans were obtained on all infants after completion of ECMO treatment. The surviving infants were followed at our neonatal follow-up clinic for neurodevelopmental assessment. RESULTS:A total of 39 infants were placed on venoarterial ECMO and 12 infants were placed on venovenous ECMO; a total of 35 infants had CDH repair before ECMO, whereas 16 infants had delayed surgery. A total of 31 infants (61%) survived. The infants who survived had a mean pH of 7.33 Ϯ 0.20, mean airway pressure of 19.6 Ϯ 5.8 cm H 2 O, and an oxygenation index (OI) of 87 Ϯ 55 before ECMO intervention. The infants who expired (n ϭ 20) had a mean pH of 7.31 Ϯ 0.15, mean airway pressure of 23.1 Ϯ 5.5 cm H 2 O, and a mean oxygenation index of 127 Ϯ 56 before ECMO treatment. Before ECMO, survivors had a significantly lower oxygenation index and a higher PaO 2 compared with nonsurvivors (p Ͻ 0.01). A total of 18 infants (35%) had abnormal central nervous system findings. Of the 51 infants, 10 had ventricular dilatation, 6 had intracranial hemorrhage, and 11 had focal or diffuse cerebral atrophy diagnosed by computerized tomography scan or at autopsy (1 patient had an infarct). Eight infants had more than one central nervous system abnormality. A total of 16 survivors had a neurodevelopmental evaluation at 12 months, and 11 of these survivors were evaluated at 24 months of age (Bayley Scales of Infant Development). The developmental progress of these infants falls within the low-average range of cognitive and motor abilities. Their mean Bayley Mental Developmental Index was 85 Ϯ 25 (50 to 145) at 24 months; their Psychomotor Developmental Index was 89 Ϯ 21 (50 to 113) at 24 months of age. Follow-up at 4 and 6 years of age is in progress. CONCLUSION:Our preliminary findings indicate that 35% of infants with severe CDH requiring ECMO had central nervous system abnormalities (intracranial lesions, including ventricular dilatation). The survival rate in our study population is consistent with recent reports. As a group, infants w...

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“…24,27,28 We previously described an initial review of 25 CDH patients who required ECMO and did not find a parameter that predicted mortality with enough certainty to exclude patients from treatment with ECMO. 27 This study represents 15 years of experience and the additional data have allowed for further analysis into the predictive values of various parameters of interest. Minimum pre-ECMO PaCO 2 >70 mm Hg was identified by the ROC curve as a cutoff value with a false-positive rate of zero for predicting mortality.…”

Section: Discussionmentioning

confidence: 99%

Predictors of survival in congenital diaphragmatic hernia patients requiring extracorporeal membrane oxygenation: CNMC 15-year experience

et al. 2010

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Objective: To review outcomes of patients with congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) at a level IIIC neonatal intensive care unit and to determine if pre-ECMO respiratory status can help predict mortality.Study Design: A single-center retrospective chart review was conducted on all infants with CDH treated with ECMO in the past 15 years. Demographic and clinical information, including pre-ECMO ventilatory and blood gas data, was collected. Differences between survivors and nonsurvivors were evaluated using independent samples t-/Mann-Whitney U-and Fisher's exact/w 2 -tests for continuous and categorical data, respectively. Cox regression analysis was performed to evaluate predictors of survival while controlling for covariates. Significant predictors were further explored with receiver operating characteristic (ROC) curve and Kaplan-Meier survival analysis.Result: Overall survival of the population of 62 patients treated with ECMO was 50%. Survivor and non-survivors were similar in birth weight, gestational age, gender, race and Apgar scores. Approximately 80% of patients in both groups had a left-sided defect. Less than half of patients were prenatally diagnosed in either group. Patients in the non-survivor group had associated anomalies (42 vs 23% for survivors) but this was not statistically significant (P ¼ 0.303). Non-survivors were more likely to be put on ECMO earlier, stay on ECMO longer and be operated upon later. On pre-ECMO blood gas analyses, survivors had higher pH and PaO 2 , and lower oxygenation index and PaCO 2 compared with non-survivors. After controlling for covariates, a lower minimum PaCO 2 and side of defect were the only independent predictors of survival. ROC curve for minimum pre-ECMO PaCO 2 had a significant area under the curve (0.72, P ¼ 0.003). Survival was 27% in babies unable to achieve a pre-ECMO PaCO 2 <60 mm Hg whereas no patients survived if their lowest pre-ECMO PaCO 2 was >70 mm Hg. Conclusion:Minimum achievable pre-ECMO PaCO 2 is an independent predictor of survival in patients with CDH requiring ECMO life support. These data provide useful prognostic information for counseling families and may facilitate direction of care in extreme cases where the degree of pulmonary hypoplasia may be incompatible with life.

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Extracorporeal membrane oxygenation and congenital diaphragmatic hernia: Should any infant be excluded?

Cited by 71 publications

References 26 publications

Ex utero intrapartum treatment with extracorporeal membrane oxygenation for severe congenital diaphragmatic hernia

Ex utero intrapartum treatment with extracorporeal membrane oxygenation for severe congenital diaphragmatic hernia

Survival, Intracranial Lesions, and Neurodevelopmental Outcome in Infants With Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation

Predictors of survival in congenital diaphragmatic hernia patients requiring extracorporeal membrane oxygenation: CNMC 15-year experience

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