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Traynor M. Lung-protective ventilation in the management of congenital diaphragmatic hernia. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000789. [PMID: 39119150 PMCID: PMC11308893 DOI: 10.1136/wjps-2024-000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 07/15/2024] [Indexed: 08/10/2024] Open
Abstract
Prioritizing lung-protective ventilation has produced a clear mortality benefit in neonates with congenital diaphragmatic hernia (CDH). While there is a paucity of CDH-specific evidence to support any particular approach to lung-protective ventilation, a growing body of data in adults is beginning to clarify the mechanisms behind ventilator-induced lung injury and inform safer management of mechanical ventilation in general. This review summarizes the adult data and attempts to relate the findings, conceptually, to the CDH population. Critical lessons from the adult studies are that much of the damage done during conventional mechanical ventilation affects normal lung tissue and that most of this damage occurs at the low-volume and high-volume extremes of the respiratory cycle. Consequently, it is important to prevent atelectasis by using sufficient positive end-expiratory pressure while also avoiding overdistention by scaling tidal volume to the amount of functional lung tissue rather than body weight. Paralysis early in acute respiratory distress syndrome improves outcomes, possibly because consistent respiratory mechanics facilitate avoidance of both atelectasis and overdistention-a mechanism that may also apply to the CDH population. Volume-targeted conventional modes may be advantageous in CDH, but determining optimal tidal volume is challenging. Both high-frequency oscillatory ventilation and high-frequency jet ventilation have been used successfully as 'rescue modes' to avoid extracorporeal membrane oxygenation, and a prospective trial comparing the two high-frequency modalities as the primary ventilation strategy for CDH is underway.
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Affiliation(s)
- Mike Traynor
- Department of Anesthesia, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
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2
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Masahata K, Nagata K, Terui K, Kondo T, Ebanks AH, Harting MT, Buchmiller TL, Sato Y, Okuyama H, Usui N. Risk Factors for Preoperative Pneumothorax in Neonates With Isolated Left-Sided Congenital Diaphragmatic Hernia: An International Cohort Study. J Pediatr Surg 2024; 59:1451-1457. [PMID: 38388286 DOI: 10.1016/j.jpedsurg.2024.01.016] [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: 07/05/2023] [Revised: 12/30/2023] [Accepted: 01/19/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND We aimed to investigate the clinical characteristics and outcomes of patients with isolated left-sided congenital diaphragmatic hernia (CDH) who developed preoperative pneumothorax and determine its risk factors. METHODS We performed an international cohort study of patients with CDH enrolled in the Congenital Diaphragmatic Hernia Study Group registry between January 2015 and December 2020. The main outcomes assessed included survival to hospital discharge and preoperative pneumothorax development. The cumulative incidence of pneumothorax was estimated by the Gray test. The Fine and Gray competing risk regression model was used to identify the risk factors for pneumothorax. RESULTS Data for 2858 neonates with isolated left-sided CDH were extracted; 224 (7.8%) developed preoperative pneumothorax. Among patients with a large diaphragmatic defect, those with pneumothorax had a significantly lower rate of survival to discharge than did those without. The competing risks model demonstrated that a patent ductus arteriosus with a right-to-left shunt flow after birth (hazard ratio [HR]: 1.78; 95% confidence interval [CI]: 1.21-2.63; p = 0.003) and large defects (HR: 1.65; 95% CI: 1.13-2.42; p = 0.01) were associated with an increased risk of preoperative pneumothorax. Significant differences were observed in the cumulative incidence of pneumothorax depending on defect size and shunt direction (p < 0.001). CONCLUSIONS Pneumothorax is a significant preoperative complication associated with increased mortality in neonates with CDH, particularly in cases with large defects. Large diaphragmatic defects and persistent pulmonary hypertension were found to be risk factors for preoperative pneumothorax development. LEVEL OF EVIDENCE LEVEL Ⅲ Retrospective Comparative Study.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan; Department of Pediatric Surgery, Aizenbashi Hospital, Osaka, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takuya Kondo
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University, Tokyo, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan.
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Kunisaki SM, Desiraju S, Yang MJ, Lakshminrusimha S, Yoder BA. Ventilator strategies in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151439. [PMID: 38986241 DOI: 10.1016/j.sempedsurg.2024.151439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
This review focuses on contemporary mechanical ventilator practices used in the initial management of neonates born with congenital diaphragmatic hernia (CDH). Both conventional and non-conventional ventilation modes in CDH are reviewed. Special emphasis is placed on the rationale for gentle ventilation and the current evidence-based clinical practice guidelines that are recommended for supporting these fragile infants. The interplay between CDH lung hypoplasia and other key cardiopulmonary elements of the disease, namely a reduced pulmonary vascular bed, abnormal pulmonary vascular remodeling, and left ventricular hypoplasia, are discussed. Finally, we provide insights into future avenues for mechanical ventilator research in CDH.
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Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins Medicine, USA.
| | - Suneetha Desiraju
- Division of Neonatology, Johns Hopkins Children's Center, Johns Hopkins Medicine, USA
| | - Michelle J Yang
- Division of Neonatology, Primary Children's Medical Center, University of Utah Health, USA
| | - Satyan Lakshminrusimha
- Division of Neonatal-Perinatal Medicine, UC Davis Children's Hospital, University of California at Davis Health, USA
| | - Bradley A Yoder
- Division of Neonatology, Primary Children's Medical Center, University of Utah Health, USA
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King S, Carr BDE, Mychaliska GB, Church JT. Surgical approaches to congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151441. [PMID: 38986242 DOI: 10.1016/j.sempedsurg.2024.151441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Surgical repair of the diaphragm is essential for survival in congenital diaphragmatic hernia (CDH). There are many considerations surrounding the operation - why the operation matters, optimal timing of repair and its relation to extracorporeal life support (ECLS) use, minimally invasive versus open approaches, and strategies for reconstruction. Surgery is both affected by, and affects, the physiology of these infants and is an important factor in determining long-term outcomes. Here we discuss the evidence and provide insight surrounding this complex decision making, technical pearls, and outcomes in repair of CDH.
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Affiliation(s)
- Sarah King
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Benjamin D E Carr
- Doernbecher Children's Hospital, Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University. Portland, OR, USA
| | - George B Mychaliska
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Joseph T Church
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA.
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Holden KI, Ebanks AH, Lally KP, Harting MT. The CDH Study Group: Past, Present, and Future. Eur J Pediatr Surg 2024; 34:162-171. [PMID: 38242150 DOI: 10.1055/s-0043-1778021] [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] [Indexed: 01/21/2024]
Abstract
The Congenital Diaphragmatic Hernia Study Group (CDHSG) is an international consortium of medical centers actively collecting and voluntarily contributing data pertaining to live born congenital diaphragmatic hernia (CDH) patients born and/or managed at their institutions. These data are aggregated to construct a comprehensive registry that participating centers can access to address specific clinical inquiries and track patient outcomes. Since its establishment in 1995, 147 centers have taken part in this initiative, including 53 centers from 17 countries outside the United States, with 95 current active centers across the globe. The registry has amassed data on over 14,000 children, resulting in the creation of over 75 manuscripts based on registry data to date. International, multicenter consortia enable health care professionals managing uncommon, complex, and diverse diseases to formulate evidence-based hypotheses and draw meaningful and generalizable conclusions for clinical inquiries. This review will explore the formation and structure of the CDHSG and its registry, outlining their functions, center participation, and the evolution of data collection. Additionally, we will provide an overview of the evidence generated by the CDHSG, with a particular emphasis on contributions post-2014, and look ahead to the future directions the study group will take in addressing CDH.
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Affiliation(s)
- Kylie I Holden
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, Texas, United States
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, Texas, United States
| | - 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, Texas, United States
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, Texas, United States
| | - 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, Texas, United States
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, Texas, United States
| | - 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, Texas, United States
- Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas McGovern Medical School, Houston, Texas, United States
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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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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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8
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Gerall C, Wallman-Stokes A, Stewart L, Price J, Kabagambe S, Fan W, Hernan R, Wung J, Sahni R, Penn A, Duron V. High-Frequency Positive Pressure Ventilation as Primary Rescue Strategy for Patients with Congenital Diaphragmatic Hernia: A Comparison to High-Frequency Oscillatory Ventilation. Am J Perinatol 2024; 41:255-262. [PMID: 34918327 DOI: 10.1055/s-0041-1740076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of this article was to evaluate high-frequency positive pressure ventilation (HFPPV) compared with high-frequency oscillatory ventilation (HFOV) as a rescue ventilation strategy for patients with congenital diaphragmatic hernia (CDH). HFPPV is a pressure-controlled conventional ventilation method utilizing high respiratory rate and low positive end-expiratory pressure. STUDY DESIGN Seventy-seven patients diagnosed with CDH from January 2005 to September 2019 who were treated with stepwise progression from HFPPV to HFOV versus only HFOV were included. Fisher's exact test and the Kruskal-Wallis test were used to compare outcomes. RESULTS Patients treated with HFPPV + HFOV had higher survival to discharge (80 vs. 50%, p = 0.007) and to surgical intervention (95.6 vs. 68.8%, p = 0.003), with average age at repair 2 days earlier (p = 0.004). Need for extracorporeal membrane oxygenation (p = 0.490), inhaled nitric oxide (p = 0.585), supplemental oxygen (p = 0.341), and pulmonary hypertension medications (p = 0.381) were similar. CONCLUSION In CDH patients who fail respiratory support with conventional ventilation, HFPPV may be used as an intermediary mode of rescue ventilation prior to HFOV without adverse effects. KEY POINTS · HFPPV may be used as an intermediary mode of rescue ventilation prior to HFOV without adverse effect.. · HFPPV is more widely available and can mitigate the limitations faced when using HFOV.. · HFPPV allows for intra- or interhospital transfer of neonates with CDH..
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Affiliation(s)
- Claire Gerall
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Aaron Wallman-Stokes
- Division of Neonatology, Department of Medicine, University of Vermont Medical Center/University of Vermont Medical Center Children's Hospital, Burlington, Vermont
| | - Latoya Stewart
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Jessica Price
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Sandra Kabagambe
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Weijia Fan
- Department of Biostatistics, Columbia University Mailman School of Public Heath, New York, New York
| | - Rebecca Hernan
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Jen Wung
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Rakesh Sahni
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Anna Penn
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Vincent Duron
- Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York
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Stewart LA, Hernan RR, Mardy C, Hahn E, Chung WK, Bacha EA, Krishnamurthy G, Duron VP, Krishnan US. Congenital Heart Disease with Congenital Diaphragmatic Hernia: Surgical Decision Making and Outcomes. J Pediatr 2023; 260:113530. [PMID: 37268035 PMCID: PMC10527207 DOI: 10.1016/j.jpeds.2023.113530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To describe the types of congenital heart disease (CHD) in a congenital diaphragmatic hernia (CDH) cohort in a large volume center and evaluate surgical decision making and outcomes based on complexity of CHD and associated conditions. STUDY DESIGN A retrospective review of patients with CHD and CDH diagnosed by echocardiogram between 01/01/2005 and 07/31/2021. The cohort was divided into 2 groups based on survival at discharge. RESULTS Clinically important CHD was diagnosed in 19% (62/326) of CDH patients. There was 90% (18/20) survival in children undergoing surgery for both CHD and CDH as neonates, and 87.5 (22/24) in those undergoing repair initially for CDH alone. A genetic anomaly identified on clinical testing was noted in 16% with no significant association with survival. A higher frequency of other organ system anomalies was noted in nonsurvivors compared with survivors. Nonsurvivors were more likely to have unrepaired CDH (69% vs 0%, P < .001) and unrepaired CHD (88% vs 54%, P < .05), reflecting a decision not to offer surgery. CONCLUSIONS Survival was excellent in patients who underwent repair of both CHD and CDH. Patients with univentricular physiology have poor survival and this finding should be incorporated into pre and postnatal counseling about eligibility for surgery. In contrast, patients with other complex lesions including transposition of the great arteries have excellent outcomes and survival at 5 years follow-up at a large pediatric and cardiothoracic surgical center.
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Affiliation(s)
- Latoya A Stewart
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Rebecca R Hernan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Christopher Mardy
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Eunice Hahn
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Vincent P Duron
- Division of Pediatric Surgery, Columbia University Irving Medical Center, New York, NY
| | - Usha S Krishnan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY; Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY.
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10
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Al Kharusi AA, Al Maawali A, Traynor M, Adreak N, Ting J, Skarsgard ED. High frequency jet ventilation for congenital diaphragmatic hernia. J Pediatr Surg 2023; 58:799-802. [PMID: 36788056 DOI: 10.1016/j.jpedsurg.2023.01.026] [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: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND The optimal role of high frequency jet ventilation (HFJV) in lung protective stabilization of congenital diaphragmatic hernia (CDH) remains uncertain. We aimed to describe our center's experience with HFJV as both a rescue (following failed stabilization with CMV) and primary ventilation mode in the management of CDH. METHODS Liveborn CDH patients treated from 2013 to 2021 in a single institution were reviewed. We compared 3 groups based on their primary and last ventilation mode prior to surgery: CMV (Group 1); HFJV (Group 2); and CMV/HFJV (Group 3). Outcomes included a composite primary outcome (≥1 of mortality, need for ECMO or need for supplemental O2 at discharge), total invasive ventilation days and development of pneumothorax. A descriptive analysis including univariate group comparisons was performed. Multivariate logistic regression models investigating the relationship between mode of ventilation and the primary outcome adjusted by potentially confounding covariates were constructed. RESULTS 56 patients (32 Group 1, 18 Group 2, 6 Group 3) were analyzed. Group 2 and 3 patients had more severe disease based on liver position, SNAP-II score, pulmonary hypertension severity, need for inotropic support, CDHSG defect size and need for patch repair. There were no group differences in survival, need for ECMO, or pneumothorax occurrence, although infants receiving HFJV required longer invasive ventilation and had a greater need for O2 at discharge. Multivariate logistic regression revealed no associations between mode of ventilation and outcome. CONCLUSIONS HFJV appears effective, both for CMV rescue and as a primary ventilation strategy in high risk CDH. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Al Anoud Al Kharusi
- Departments of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Alghalya Al Maawali
- Departments of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Traynor
- Departments of Anesthesiology, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Najah Adreak
- Departments of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph Ting
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Erik D Skarsgard
- Departments of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.
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Weems MF, Grover TR, Seabrook R, DiGeronimo R, Gien J, Keene S, Rintoul N, Daniel JM, Johnson Y, Guner Y, Zaniletti I, Murthy K. Analgesia, Sedation, and Neuromuscular Blockade in Infants with Congenital Diaphragmatic Hernia. Am J Perinatol 2023; 40:415-423. [PMID: 34044457 DOI: 10.1055/s-0041-1729877] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to describe the use, duration, and intercenter variation of analgesia and sedation in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN This is a retrospective analysis of analgesia, sedation, and neuromuscular blockade use in neonates with CDH. Patient data from 2010 to 2016 were abstracted from the Children's Hospitals Neonatal Database and linked to the Pediatric Health Information System. Patients were excluded if they also had non-CDH conditions likely to affect the use of the study medications. RESULTS A total of 1,063 patients were identified, 81% survived, and 30% were treated with extracorporeal membrane oxygenation (ECMO). Opioid (99.8%), sedative (93.4%), and neuromuscular blockade (87.9%) use was common. Frequency of use was higher and duration was longer among CDH patients treated with ECMO. Unadjusted duration of use varied 5.6-fold for benzodiazepines (median: 14 days) and 7.4-fold for opioids (median: 16 days). Risk-adjusted duration of use varied among centers, and prolonged use of both opioids and benzodiazepines ≥5 days was associated with increased mortality (p < 0.001) and longer length of stay (p < 0.001). Use of sedation or neuromuscular blockade prior to or after surgery was each associated with increased mortality (p ≤ 0.01). CONCLUSION Opioids, sedatives, and neuromuscular blockade were used commonly in infants with CDH with variable duration across centers. Prolonged combined use ≥5 days is associated with mortality. KEY POINTS · Use of analgesia and sedation varies across children's hospital NICUs.. · Prolonged opioid and benzodiazepine use is associated with increased mortality.. · Postsurgery sedation and neuromuscular blockade are associated with mortality..
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Affiliation(s)
- Mark F Weems
- Division of Neonatology, Department of Pediatrics, Le Bonheur Children's Hospital and the University of Tennessee Health Science Center, Memphis, Tennessee
| | - Theresa R Grover
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | | | - Robert DiGeronimo
- Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Jason Gien
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Sarah Keene
- Department of Pediatrics, Children's Healthcare of Atlanta at Egleston, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie Rintoul
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - John M Daniel
- Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri Kansas, Kansas City, Missouri
| | - Yvette Johnson
- Department of Neonatology, Cook Children's Hospital, Fort Worth, Texas
| | - Yigit Guner
- Children's Hospital of Orange County and University of California Irvine, Orange, California
| | | | - Karna Murthy
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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12
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Scottoline B, Jordan BK, Parkhotyuk K, Schilling D, McEvoy CT. Perioperative Improvement in Pulmonary Function in Infants with Congenital Diaphragmatic Hernia. J Pediatr 2023; 253:173-180.e2. [PMID: 36181873 DOI: 10.1016/j.jpeds.2022.09.037] [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: 05/01/2022] [Revised: 08/26/2022] [Accepted: 09/23/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to compare serial changes in pulmonary function in contemporary infants with congenital diaphragmatic hernia managed with a gentle ventilation approach. STUDY DESIGN Observational cohort, single-center study of infants ≥350/7 weeks gestation at delivery with congenital diaphragmatic hernia. Functional residual capacity (FRC), passive respiratory compliance, and passive respiratory resistance were measured presurgical and postsurgical repair and within 2 weeks of discharge. A 1-way analysis of variance for repeated measures was used to evaluate the change in FRC, passive respiratory compliance, and passive respiratory resistance over these repeated measures. RESULTS Twenty-eight infants were included in the analysis with a mean gestational age of 38.3 weeks and birth weight of 3139 g. We found a significant increase in FRC across the 3 time points (mean in mL/kg [SD]: 10.9 [3.6] to 18.5 [5.2] to 24.2 [4.4]; P < .0001). There was also a significant increase in passive respiratory compliance and decrease in passive respiratory resistance. In contrast to a previous report, there were survivors in the current cohort with a preoperative FRC of <9 mL/kg. The mean FRC measured at discharge was in the range considered within normal limits. Sixteen infants had prenatal measurements of the lung-to-head ratio, but there was no relationship between the lung-to-head ratio and preoperative or postoperative FRC measurements. CONCLUSIONS Infants with congenital diaphragmatic hernia demonstrate significant increases in FRC and improvements in respiratory mechanics measured preoperatively and postoperatively and at discharge. We speculate these improvements are due to the surgical resolution of the mechanical obstruction to lung recruitment and that after achieving preoperative stability, repair should not be delayed given these demonstrable postoperative improvements.
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Affiliation(s)
- Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR.
| | - Brian K Jordan
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Kseniya Parkhotyuk
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Diane Schilling
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Cindy T McEvoy
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR
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13
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Lum LCS, Ramanujam TM, Yik YI, Lee ML, Chuah SL, Breen E, Zainal-Abidin AS, Singaravel S, Thambidorai CR, de Bruyne JA, Nathan AM, Thavagnanam S, Eg KP, Chan L, Abdel-Latif ME, Gan CS. Outcomes of neonatal congenital diaphragmatic hernia in a non-ECMO center in a middle-income country: a retrospective cohort study. BMC Pediatr 2022; 22:396. [PMID: 35799173 PMCID: PMC9264560 DOI: 10.1186/s12887-022-03453-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most studies examining survival of neonates with congenital diaphragmatic hernia (CDH) are in high-income countries. We aimed to describe the management, survival to hospital discharge rate, and factors associated with survival of neonates with unilateral CDH in a middle-income country. METHODS We retrospectively reviewed the medical notes of neonates with unilateral CDH admitted to a pediatric intensive care unit (PICU) in a tertiary referral center over a 15-year period, from 2003-2017. We described the newborns' respiratory care pathways and then compared baseline demographic, hemodynamic, and respiratory indicators between survivors and non-survivors. The primary outcome measure was survival to hospital discharge. RESULTS Altogether, 120 neonates were included with 43.3% (52/120) diagnosed antenatally. Stabilization occurred in 38.3% (46/120) with conventional ventilation, 13.3% (16/120) with high-frequency intermittent positive-pressure ventilation, and 22.5% (27/120) with high frequency oscillatory ventilation. Surgical repair was possible in 75.0% (90/120). The overall 30-day survival was 70.8% (85/120) and survival to hospital discharge was 66.7% (80/120). Survival to hospital discharge tended to improve over time (p > 0.05), from 56.0% to 69.5% before and after, respectively, a service reorganization. For those neonates who could be stabilized and operated on, 90.9% (80/88) survived to hospital discharge. The commonest post-operative complication was infection, occurring in 43.3%. The median survivor length of stay was 32.5 (interquartile range 18.8-58.0) days. Multiple logistic regression modelling showed vaginal delivery (odds ratio [OR] = 4.8; 95% confidence interval [CI] [1.1-21.67]; p = 0.041), Apgar score [Formula: see text] 7 at 5 min (OR = 6.7; 95% CI [1.2-36.3]; p = 0.028), and fraction of inspired oxygen (FiO2) < 50% at 24 h (OR = 89.6; 95% CI [10.6-758.6]; p < 0.001) were significantly associated with improved survival to hospital discharge. CONCLUSIONS We report a survival to hospital discharge rate of 66.7%. Survival tended to improve over time, reflecting a greater critical volume of cases and multi-disciplinary care with early involvement of the respiratory team resulting in improved transitioning from PICU. Vaginal delivery, Apgar score [Formula: see text] 7 at 5 min, and FiO2 < 50% at 24 h increased the likelihood of survival to hospital discharge.
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Affiliation(s)
- Lucy Chai See Lum
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia.
| | | | - Yee Ian Yik
- Division of Pediatric Surgery, Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Mei Ling Lee
- Department of Pediatrics, Hospital Tengku Ampuan Afzan, Pahang, Malaysia
| | - Soo Lin Chuah
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Emer Breen
- Clinical Investigation Center, University of Malaya Medical Center, 5th Floor East Tower, Kuala Lumpur, Malaysia
| | | | - Srihari Singaravel
- Division of Pediatric Surgery, Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | | | - Jessie Anne de Bruyne
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Anna Marie Nathan
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Surendran Thavagnanam
- Queen Mary University of London, Barts Health NHS Trust, Royal London Children's Hospital, London, UK
| | - Kah Peng Eg
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Lucy Chan
- Department of Anesthesia, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Mohamed E Abdel-Latif
- Department of Neonatology, Centenary Hospital for Women and Children, The Canberra Hospital, Canberra, ACT, Australia.,Department of Public Health, La Trobe University, Bundoora, Melbourne, VIC, Australia
| | - Chin Seng Gan
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
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14
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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15
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Cochius - den Otter S, Deprest JA, Storme L, Greenough A, Tibboel D. Challenges and Pitfalls: Performing Clinical Trials in Patients With Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:852843. [PMID: 35498783 PMCID: PMC9051320 DOI: 10.3389/fped.2022.852843] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the lungs and diaphragm, with substantial morbidity and mortality. Although internationally established treatment guidelines have been developed, most recommendations are still expert opinions. Trials in patients with CDH, more in particular randomized controlled trials, are rare. Only three multicenter trials in patients with CDH have been completed, which focused on fetoscopic tracheal occlusion and ventilation mode. Another four are currently recruiting, two with a focus on perinatal transition and two on the treatment of pulmonary hypertension. Herein, we discuss major challenges and pitfalls when performing a clinical trial in infants with CDH. It is essential to select the correct intervention and dose, select the appropriate population of CDH patients, and also define a relevant endpoint that allows a realistic duration and sample size. New statistical approaches might increase the feasibility of randomized controlled trials in patients with CDH. One should also timely perform the trial when there is still equipoise. But above all, awareness of policymakers for the relevance of investigator-initiated trials is essential for future clinical research in this rare disease.
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Affiliation(s)
- Suzan Cochius - den Otter
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jan A. Deprest
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, United Kingdom
| | - Laurent Storme
- Metrics-Perinatal Environment and Health, University of Lille, Lille, France
- Department of Neonatology, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
- Center of Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, United Kingdom
- NIHR Biomedical Centre, Guy's and St Thomas NHS Foundation Trust and King's College London, London, United Kingdom
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
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16
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Stolar CJH, Wilson JM, Losty PD, Flake AW. Fetal surgery for moderate and severe CDH - The TOTAL trials. J Pediatr Surg 2022; 57:552-553. [PMID: 34674844 DOI: 10.1016/j.jpedsurg.2021.09.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Charles J H Stolar
- Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, United States.
| | - Jay M Wilson
- Texas Medical Center, Memorial Hermann Hospital, Houston, TX, United States
| | - Paul D Losty
- Faculty of Health and Life Sciences, University of Liverpool, UK
| | - Alan W Flake
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
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17
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Alghamdi A, Raboe E. Right Bochdalek congenital diaphragmatic hernia: a tertiary center's experience over 13 years. ANNALS OF PEDIATRIC SURGERY 2021; 17:24. [PMID: 34899880 PMCID: PMC8096469 DOI: 10.1186/s43159-021-00081-z] [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: 08/25/2020] [Accepted: 02/15/2021] [Indexed: 12/04/2022] Open
Abstract
Background Right Bochdalek congenital diaphragmatic hernia (RB-CDH) is far less common than left Bochdalek congenital diaphragmatic hernia, accounting for only 13% of cases. There are limited published data on the outcomes and survival rate of RB-CDH. We aimed at investigating the clinical characteristics and analyzing the risk factors of survival in neonates with RB-CDH treated in our center over a period of 13 years. Results Fifteen infants with RB-CDH were identified. Most of the patients were full term (74%). The mean birth weight was 2.90± 0.72 kg. The ratio of male to female was 2:1. The mean APGAR score at 1 min was 5.31±2.34, and 7.30±1.59 at 5 min. Ten patients (67%) were imaged by antenatal ultrasound. Eleven patients (73.33%) survived to go for surgical repair. The hernia sac was found in 5 patients (45%). Most hernial defects were closed in a primary fashion. The mean age at the operative repair was 8.11±9.90 days. The average NICU stay for all patients was 40.47±50.38 days. The mean follow-up period was 20.45±9.34 months. Three patients had postoperative complications. The total survival rate in neonates with RB-CDH was 9/15 (60%). Nine out of 11 (82%) neonates survived after surgical repair. Four patients (27%) died before surgical repair. Ventilation-related bilateral pneumothorax was a contributing cause of death in three patients. Birth weight was found lower in the non-survivor’s group (P < 0.05). Moreover, the degree of pulmonary hypertension was more severe among non-survivors. No statistical significance was observed between other variables and mortality. Conclusion We found that low birth weight and the presence of severe PHTN were risk factors for mortality in neonates with RB-CDH. These results are in line with previous studies on prognostic factors in CDH. Ventilator-related pneumothorax appears to be a significant contributing cause of death. Long-term follow-up studies of infants born with RB-CDH are needed as small number of cases limits large-volume RB-CDH studies.
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Affiliation(s)
| | - Enaam Raboe
- King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
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18
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Affiliation(s)
| | | | - Paul D Losty
- University of Liverpool, Liverpool, United Kingdom
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19
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Liu H, Le C, Chen J, Xu H, Yu H, Chen L, Liu H. Anesthetic management of thoracoscopic procedures in neonates: a retrospective analysis of 45 cases. Transl Pediatr 2021; 10:2035-2043. [PMID: 34584873 PMCID: PMC8429869 DOI: 10.21037/tp-21-265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/05/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Advances in medical techniques and equipment have enabled the thoracoscopic repair of certain congenital abnormalities in neonates including congenital esophageal atresia/tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH). A retrospective analysis was conducted to examine the anesthetic management of neonates (7 days or younger) undergoing thoracoscopic surgery in our hospital department, and to determine the efficacy of anesthetic management in neonates. METHODS Clinical data from 45 neonates who underwent thoracoscopic surgery in our hospital from December 2015 to March 2020 were retrospectively analyzed. A total of 25 patients underwent repair of CDH and 20 underwent repair of an EA/TEF. RESULTS All patients received general anesthesia with endotracheal intubation, standard ASA monitoring, and arterial blood gas (ABG) analysis. All patients survived the surgery. A total of 14 patients experienced decreases in SpO2, pH, PaO2, and increases in PETCO2 and PaCO2 30 minutes after CO2 insufflation. Our anesthetic management protocols are outline and analyzed. CONCLUSIONS Thorough preoperative preparation is critical for a desirable outcome in neonates undergoing a thoracoscopic repair of CDH or EA/TEF. In our cohort, intraoperative ventilation strategies included pressure control ventilation with peak airway pressure maintained at 15-25 cmH2O, a respiratory rate of 35-55 breaths/minute, a fraction of inspired oxygen (FiO2) of 60-80%, an inspiratory/expiratory ratio (I:E) of 1:1-1.5, and careful airway suctioning to clear secretions. Postoperatively, maintaining normovolemia and hemodynamic stability are critical for successful weaning of ventilatory support and extubation.
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Affiliation(s)
- Hua Liu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Chengjin Le
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Jing Chen
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Heng Xu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Hui Yu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Lin Chen
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Henry Liu
- Department of Anesthesiology and Perioperative Medicine, Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
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20
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Yang MJ, Russell KW, Yoder BA, Fenton SJ. Congenital diaphragmatic hernia: a narrative review of controversies in neonatal management. Transl Pediatr 2021; 10:1432-1447. [PMID: 34189103 PMCID: PMC8192986 DOI: 10.21037/tp-20-142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The consequences of most hernias can be immediately corrected by surgical repair. However, this isn't always the case for children born with a congenital diaphragmatic hernia. The derangements in physiology encountered immediately after birth result from pulmonary hypoplasia and hypertension caused by herniation of abdominal contents into the chest early in lung development. This degree of physiologic compromise can vary from mild to severe. Postnatal management of these children remains controversial. Although heavily studied, multi-institutional randomized controlled trials are lacking to help determine what constitutes best practice. Additionally, the results of the many studies currently within the literature that have investigated differing aspect of care (i.e., inhaled nitric oxide, ventilator type, timing of repair, role of extracorporeal membrane oxygenation, etc.) are difficult to interpret due to the small numbers investigated, the varying degree of physiologic compromise, and the contrasting care that exists between institutions. The aim of this paper is to review areas of controversy in the care of these complex kids, mainly: the use of fraction of inspired oxygen, surfactant therapy, gentle ventilation, mode of ventilation, medical management of pulmonary hypertension (inhaled nitric oxide, sildenafil, milrinone, bosentan, prostaglandins), the utilization of extracorporeal membrane oxygenation, and the timing of surgical repair.
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Affiliation(s)
- Michelle J Yang
- Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stephen J Fenton
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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21
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Fuyuki M, Usui N, Taguchi T, Hayakawa M, Masumoto K, Kanamori Y, Amari S, Yamoto M, Urushihara N, Inamura N, Yokoi A, Okawada M, Okazaki T, Toyoshima K, Furukawa T, Terui K, Ohfuji S, Tazuke Y, Uchida K, Okuyama H. Prognosis of conventional vs. high-frequency ventilation for congenital diaphragmatic hernia: a retrospective cohort study. J Perinatol 2021; 41:814-823. [PMID: 33177680 DOI: 10.1038/s41372-020-00833-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 08/19/2020] [Accepted: 09/18/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the appropriate initial ventilatory mode for neonatal congenital diaphragmatic hernia (CDH) by comparing patient prognosis following conventional mechanical ventilation (CMV) versus high-frequency oscillatory ventilation (HFO). STUDY DESIGN This multicenter retrospective cohort study was performed at 15 participating hospitals in Japan between 2011 and 2016. The 328 eligible CDH infants were classified into CMV (n = 78) and HFO groups (n = 250) to compare mortality and incidence of bronchopulmonary dysplasia (BPD). Propensity score matching was applied to reduce confounding by indication. RESULT While crude mortality was significantly higher in the HFO than the CMV group, adjusted odds ratio (OR) did not show significant difference in mortality between groups (OR of HFO group: 0.98, 95% confidence interval (CI): 0.57-1.67). Adjusted OR of BPD incidence showed no significant difference between groups (OR of HFO group: 1.66, 95%CI: 0.50-5.49). CONCLUSION Initial ventilatory mode in CDH patients, whether CMV or HFO, does not affect prognosis.
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Affiliation(s)
- Makiko Fuyuki
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan. .,Department of Public Health, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Hayakawa
- Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yutaka Kanamori
- Division of Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Shoichiro Amari
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kinki University, Faculty of Medicine, Osaka-Sayama, Japan
| | - Akiko Yokoi
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe, Japan
| | - Manabu Okawada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Tadaharu Okazaki
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan.,Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Taizou Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoko Ohfuji
- Department of Public Health, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.
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Affiliation(s)
| | | | - Jason Gien
- Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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23
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A single-center observational study on congenital diaphragmatic hernia: Outcome, predictors of mortality and experience from a tertiary perinatal center in Singapore. Pediatr Neonatol 2020; 61:385-392. [PMID: 32276768 DOI: 10.1016/j.pedneo.2020.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 01/03/2020] [Accepted: 03/05/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a common birth defect associated with significant mortality and morbidity. There is limited outcome data on CDH in the Southeast Asian region. Rapid accessibility to our CDH Perinatal Center, as a consequence of the small geographic size of our country and efficient land transportation system, has largely eliminated deaths of live outborn babies prior arrival at our center. We selected a study period when extracorporeal membrane oxygenation (ECMO) support was not available at our institution. The data will therefore be relevant in developing management guidelines and antenatal counselling for perinatal centers in this region managing CDH with limited resources, without ECMO facilities. METHODS A retrospective study of antenatally or postnatally diagnosed CDH infants born between January 2002 and June 2005 was performed. We selected this study period as ECMO support was not available over this period. We studied the demographics, clinical characteristics, postnatal predictors of mortality and outcomes of CDH infants in a single tertiary institution. RESULTS A total of 24 patients with CDH were identified. Seventy-nine percent of liveborns with CDH survived to hospital discharge. Antenatal detection rate was 83.3%. Significant postnatal predictors of mortality were preoperative pneumothorax (p = 0.035), high CRIB score (p = 0.007), low one- and five-minute Apgar score (p = 0.011, p = 0.026 respectively) and high pCO2 on initial arterial blood gas (p = 0.007). At one-year follow-up, three patients had delayed gross motor milestones which resolved subsequently. Re-admissions were required for recurrent bronchiolitis (33%) and oesophageal reflux which resolved in all cases. Two (13.3%) infants had surgical complications and needed re-admission for probable adhesive intestinal obstruction; one required adhesiolysis and the other was managed conservatively with good outcome. CONCLUSION A single-center CDH outcome in Singapore, without ECMO use, was good. This is a cohort now with long-term survival outcome which will be valuable to the neonatology community.
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24
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Yang MJ, Fenton S, Russell K, Yost CC, Yoder BA. Left-sided congenital diaphragmatic hernia: can we improve survival while decreasing ECMO? J Perinatol 2020; 40:935-942. [PMID: 32066841 DOI: 10.1038/s41372-020-0615-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/21/2020] [Accepted: 02/04/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Mortality and ECMO rates for congenital diaphragmatic hernia (CDH) remain ~30%. In 2016, we changed our CDH guidelines to minimize stimulation while relying on preductal oxygen saturation, lower mean airway pressures, stricter criteria for nitric oxide (iNO), and inotrope use. We compared rates of ECMO, survival, and survival without ECMO between the two epochs. DESIGN/METHODS Retrospective review of left-sided CDH neonates at the University of Utah/Primary Children's Hospital NICUs during pre (2003-2015, n = 163) and post (2016-2019, n = 53) epochs was conducted. Regression analysis controlled for defect size and intra-thoracic liver. RESULTS Following guideline changes, we identified a decrease in ECMO (37 to 13%; p = 0.001) and an increase in survival without ECMO (53 to 79%, p = 0.0001). Overall survival increased from 74 to 89% (p = 0.035). CONCLUSION(S) CDH management guideline changes focusing on minimizing stimulation, using preductal saturation and less aggressive ventilator/inotrope support were associated with decreased ECMO use and improved survival.
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Affiliation(s)
- Michelle J Yang
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA.
| | - Stephen Fenton
- Division of Pediatric Surgery, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Katie Russell
- Division of Pediatric Surgery, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Christian Con Yost
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
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25
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Risk factors for pneumothorax associated with isolated congenital diaphragmatic hernia: results of a Japanese multicenter study. Pediatr Surg Int 2020; 36:669-677. [PMID: 32346849 DOI: 10.1007/s00383-020-04659-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE This study aimed to elucidate the clinical characteristics of neonates with congenital diaphragmatic hernia (CDH) associated with pneumothorax and evaluate the risk factors for the development of pneumothorax. METHODS A retrospective cohort study was conducted in the 15 institutions participating in the Japanese CDH Study Group. A total of 495 neonates with isolated CDH who were born between 2011 and 2018 were analyzed in this study. RESULTS Among the 495 neonates with isolated CDH, 52 (10.5%) developed pneumothorax. Eighteen (34.6%) patients developed pneumothorax before surgery, while 34 (65.4%) developed pneumothorax after surgery. The log-rank test showed that the cumulative survival rate was significantly lower in patients with pneumothorax than in those without pneumothorax. Univariate analysis revealed significant differences between patients with pneumothorax and those without pneumothorax with regard to the best oxygenation index within 24 h after birth, mean airway pressure (MAP) higher than 16 cmH2O, diaphragmatic defect size, and need for patch closure. Multiple logistic regression analysis indicated that only the MAP was associated with an increased risk of pneumothorax. CONCLUSIONS The cumulative survival rate was significantly lower in isolated CDH patients with pneumothorax than in those without pneumothorax. A higher MAP was a risk factor for pneumothorax in CDH patients.
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Mank A, Carrasco Carrasco C, Thio M, Clotet J, Pauws SC, DeKoninck P, Te Pas AB. Tidal volumes at birth as predictor for adverse outcome in congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2020; 105:248-252. [PMID: 31256011 DOI: 10.1136/archdischild-2018-316504] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 06/15/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the predictive value of tidal volume (Vt) of spontaneous breaths at birth in infants with congenital diaphragmatic hernia (CDH). DESIGN Prospective study. SETTING Tertiary neonatal intensive care unit. PATIENTS Thirty infants with antenatally diagnosed CDH born at Hospital Sant Joan de Déu in Barcelona from September 2013 to September 2015. INTERVENTIONS Spontaneous breaths and inflations given in the first 10 min after intubation at birth were recorded using respiratory function monitor. Only expired Vt of uninterrupted spontaneous breaths was included for analysis. Receiver operating characteristics (ROC) analysis was performed and the area under the curve (AUC) was estimated to assess the predictive accuracy of Vt. MAIN OUTCOME MEASURES Mortality before hospital discharge and chronic lung disease (CLD) at day 28 of life. RESULTS There were 1.233 uninterrupted spontaneous breaths measured, and the overall mean Vt was 2.8±2.1 mL/kg. A lower Vt was found in infants who died (n=14) compared with survivors (n=16) (1.7±1.6 vs 3.7±2.1 mL/kg; p=0.008). Vt was lower in infants who died during admission or had CLD (n=20) compared with survivors without CLD (n=10) (2.0±1.7 vs 4.3±2.2 mL/kg; p=0.004). ROC analysis showed that Vt ≤2.2 mL/kg predicted mortality with 79% sensitivity and 81% specificity (AUC=0.77, p=0.013). Vt ≤3.4 mL/kg was a good predictor of death or CLD (AUC=0.80, p=0.008) with 85% sensitivity and 70% specificity. CONCLUSION Vt of spontaneous breaths measured immediately after birth is associated with mortality and CLD. Vt seems to be a reliable predictor but is not an independent predictor after adjustment for observed/expected lung to head ratio and liver position.
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Affiliation(s)
- Arenda Mank
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Cristina Carrasco Carrasco
- Division of Neonatology, Department of Pediatrics, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Marta Thio
- Newborn Research, Neonatal Services, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Jordi Clotet
- Division of Neonatology, Department of Pediatrics, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Steffen C Pauws
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Tilburg center for Cognition and Communication, Tilburg University, Tilburg, Noord-Brabant, The Netherlands
| | - Philip DeKoninck
- Obstetrics, Erasmus MC, Rotterdam, The Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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27
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Patel N, Lally PA, Kipfmueller F, Massolo AC, Luco M, Van Meurs KP, Lally KP, Harting MT. Ventricular Dysfunction Is a Critical Determinant of Mortality in Congenital Diaphragmatic Hernia. Am J Respir Crit Care Med 2020; 200:1522-1530. [PMID: 31409095 DOI: 10.1164/rccm.201904-0731oc] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Rationale: Congenital diaphragmatic hernia (CDH) is an anomaly with a high morbidity and mortality. Cardiac dysfunction may be an important and underrecognized contributor to CDH pathophysiology and determinant of disease severity.Objectives: Our aim was to investigate the association between early, postnatal ventricular dysfunction and outcome among infants with CDH.Methods: Multicenter, prospectively collected data in the CDH Study Group (CDHSG) registry, abstracted between 2015 and 2018, were evaluated. Ventricular function on early echocardiograms, defined as obtained within the first 48 hours of life, was categorized into four hierarchical groups: normal function, right ventricular dysfunction only (RVdys), left ventricular dysfunction only (LVdys), and combined RV and LV dysfunction (RV&LVdys). Univariate, multivariate, and Cox proportional hazards regression analyses were performed.Measurements and Main Results: Cardiac function data from early echocardiograms were available for 1,173 (71%) cases and categorized as normal in 711 (61%), RVdys in 182 (15%), LVdys in 61 (5%), and combined RV&LVdys in 219 (19%) cases. Ventricular dysfunction was significantly associated with prenatal diagnosis, CDHSG stage, intrathoracic liver, and patch repair (all P < 0.001). Survival varied by category: normal function, 80%; RVdys, 74%; LVdys, 57%; and RV&LVdys, 51% (P < 0.001). The adjusted risk of death (hazard ratio) for cases with LVdys was 1.96 (95% confidence interval [CI], 1.29-2.98; P = 0.020) and for cases with RV&LVdys was 2.27 (95% CI, 1.77-2.92; P = 0.011). All cardiac dysfunction categories were associated with use of extracorporeal membrane oxygenation (P < 0.005).Conclusions: Early ventricular dysfunction occurs frequently in CDH and is an independent determinant of severity and clinical outcome.
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Affiliation(s)
- Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Critical Care Medicine, University of Bonn, Bonn, Germany
| | - Anna Claudia Massolo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Scientific Institute for Research, Hospitalization and Healthcare, Rome, Italy
| | - Matias Luco
- Department of Neonatology, Pontifical Catholic University of Chile, Santiago, Chile; and
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas
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28
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Kirby E, Keijzer R. Congenital diaphragmatic hernia: current management strategies from antenatal diagnosis to long-term follow-up. Pediatr Surg Int 2020; 36:415-429. [PMID: 32072236 DOI: 10.1007/s00383-020-04625-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2020] [Indexed: 12/16/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a developmental birth defect consisting of a diaphragmatic defect and abnormal lung development. CDH complicates 2.3-2.8 per 10,000 live births. Despite efforts to standardize clinical practice, management of CDH remains challenging. Frequent re-evaluation of clinical practices in CDH reveals that management of CDH is evolving from one of postnatal stabilization to prenatal optimization. Translational research reveals promising avenues for in utero therapeutic intervention, including fetoscopic endoluminal tracheal occlusion. These remain highly experimental and demand improved antenatal diagnostics. Timely diagnosis of CDH and identification of severely affected fetuses allow time for delivery planning or in utero therapeutics. Optimal perinatal care and surgical treatment strategies are highly debated. Improved CDH mortality rates have placed increased emphasis on identifying and monitoring the long-term sequelae of disease throughout childhood and into adulthood. We review the current management strategies for CDH, highlighting where progress has been made, and where future developments have the potential to revolutionize care in this vulnerable patient population.
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Affiliation(s)
- Eimear Kirby
- Trinity College Dublin School of Medicine, Trinity Biomedical Sciences Institute, Dublin, Ireland
| | - Richard Keijzer
- Thorlakson Chair in Surgical Research, Division of Pediatric Surgery, Department of Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada. .,Department of Pediatrics and Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada. .,Department of Physiology and Pathophysiology and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada.
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29
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Marks KT, Landis MW, Lim FY, Haberman B, Kingma PS. Evaluation of Lung Injury in Infants with Congenital Diaphragmatic Hernia. J Pediatr Surg 2019; 54:2443-2447. [PMID: 31296329 DOI: 10.1016/j.jpedsurg.2019.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 06/14/2019] [Accepted: 06/23/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE The presence of lung injury and the factors that contribute to it in infants with congenital diaphragmatic hernia (CDH) have not been objectively measured during their clinical course. In adults with acute respiratory distress syndrome, higher serum levels of surfactant protein D (SP-D) are linked to lung injury and worse outcomes. We hypothesized that serum SP-D levels would be elevated in CDH infants and that the levels would correlate to the amount of lung injury present. METHODS In this retrospective cohort study, serum SP-D levels were analyzed in 37 CDH infants and 5 control infants using a commercially available enzyme-linked immunosorbent assay kit. RESULTS Infants with more severe CDH had a statistically significant increase (p < 0.001) in serum SP-D over their first month of life. SP-D levels in CDH infants were similar to control infants while on extracorporeal membrane oxygenation (ECMO) but were 2.5-fold higher (p = 0.03) than controls following ECMO termination. SP-D levels increased 1.6-fold following surgical repair of the diaphragm and were significantly higher in the second week following surgery when compared to pre-operative levels (p < 0.03). CONCLUSIONS These results demonstrate that CDH infants experience lung injury during the first week of life, around the time of surgery, and at the time of ECMO termination. Level II prognosis study.
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Affiliation(s)
- Kaitlyn T Marks
- The Perinatal Institute Cincinnati Children's Hospital Medical Center
| | - Melissa W Landis
- The Perinatal Institute Cincinnati Children's Hospital Medical Center
| | - Foong Y Lim
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center; Divisions of Pediatric General, Thoracic and Fetal Surgery, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Beth Haberman
- The Perinatal Institute Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Paul S Kingma
- The Perinatal Institute Cincinnati Children's Hospital Medical Center; Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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30
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Toussaint-Duyster LCC, van der Cammen-van Zijp MHM, de Jongste JC, Tibboel D, Wijnen RMH, Gischler SJ, van Rosmalen J, IJsselstijn H. Congenital diaphragmatic hernia and exercise capacity, a longitudinal evaluation. Pediatr Pulmonol 2019; 54:628-636. [PMID: 30741484 PMCID: PMC6593853 DOI: 10.1002/ppul.24264] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/27/2018] [Accepted: 11/20/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Children with congenital diaphragmatic hernia (CDH) suffer from long-term pulmonary morbidity. Longitudinal data of exercise capacity in these children are lacking. We hypothesized that exercise capacity would be impaired in children with CDH and deteriorates over time. We evaluated exercise capacity and its determinants in CDH patients longitudinally until 12 years of age. DESIGN Prospective longitudinal follow-up study in tertiary university hospital. PATIENTS One hundred and fourteen children with CDH born between 1999 and 2012. METHODS Exercise capacity was evaluated using the Bruce treadmill-protocol at the ages of 5, 8, and 12 years. Primary outcome parameter was standard deviation score (SDS) of maximal endurance time. Data were analyzed by using linear mixed models. RESULTS A total of 107 children (30 treated with extracorporeal membrane oxygenation [ECMO]) performed 191 reliable exercise tests. At ages 5, 8, and 12 years, the mean (95%CI) SDS endurance time was -0.44 (-0.65 to -0.24); -1.01 (-1.23 to -0.78); -1.10 (-1.40 to -0.80), respectively, all less than zero (P < 0.001). Exercise capacity declined significantly over time irrespective of ECMO-treatment (5-12 years: non-ECMO P = 0.015; ECMO P = 0.006). Duration of initial hospital stay and diffusion capacity corrected for alveolar volume were associated with SDS endurance time (P < 0.001 and P = 0.039). CONCLUSIONS In CDH patients exercise capacity deteriorates between 5 and 12 years of age, irrespective of ECMO-treatment. CDH patients may benefit from long-term assessments of exercise capacity with timely intervention.
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Affiliation(s)
- Leontien C C Toussaint-Duyster
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Orthopedics, Section of Physical Therapy, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Monique H M van der Cammen-van Zijp
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Orthopedics, Section of Physical Therapy, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Johan C de Jongste
- Department of Pediatrics, Division of Respiratory Medicine, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rene M H Wijnen
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Saskia J Gischler
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hanneke IJsselstijn
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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31
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Lee HS, Dickinson JE, Tan JK, Nembhard W, Bower C. Congenital diaphragmatic hernia: Impact of contemporary management strategies on perinatal outcomes. Prenat Diagn 2018; 38:1004-1012. [PMID: 30346634 DOI: 10.1002/pd.5376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/21/2018] [Accepted: 10/12/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study aims to review temporal changes in perinatal management and 1-year survival outcomes of cases of congenital diaphragmatic hernia (CDH) from 1996 to 2015 in Western Australia (WA). METHOD This research is a retrospective study of all cases of CDH in WA from 1996 to 2015 identified from five independent databases within the WA health network. Detailed information pertaining to pregnancy and survival outcomes were obtained from review of maternal and infant medical records. RESULTS There were 215 cases of CDH with 164 diagnosed prenatally. Between 1996 and 2010, a decline in live birth rates for CDH-affected pregnancies was observed, reaching a nadir of 5.3 per 10 000 births before increasing to a peak of 9.73 per 10 000 births in 2011-2015. A corresponding decline was seen in the number of pregnancies terminated in the same period from 8.3 to 4.6 per 10 000 births (P = 0.14) and an increase in survival of live births from 38.9% to 81.3% (P = 0.01). CONCLUSION The improved overall survival rate in infants with CDH over the last 20 years may have resulted in an increased tendency for women to continue their pregnancy with a concomitant decline in termination rates. Information from this study will help in the counselling of women following prenatal detection of CDH.
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Affiliation(s)
| | | | - Jason Kg Tan
- Princess Margaret Hospital for Children, Perth, Australia
| | - Wendy Nembhard
- Princess Margaret Hospital for Children, Perth, Australia.,The Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Resting energy expenditure in infants with congenital diaphragmatic hernia without respiratory support at time of neonatal hospital discharge. J Pediatr Surg 2018; 53:2100-2104. [PMID: 30244939 DOI: 10.1016/j.jpedsurg.2018.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 06/18/2018] [Accepted: 08/16/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Infants with congenital diaphragmatic hernia (CDH) are at risk for growth failure because of inadequate caloric intake and high catabolic stress. There is limited data on resting energy expenditure (REE) in infants with CDH. AIMS To assess REE via indirect calorimetry (IC) in term infants with CDH who are no longer on respiratory support and nearing hospital discharge with advancing post-conceptional age and to assess measured-to-predicted REE using predictive equations. METHODS A prospective cohort study of term infants with CDH who were no longer on respiratory support and nearing hospital discharge was conducted to assess REE via IC and caloric intake. Baseline characteristics and hospital course data were collected. Three day average caloric intake around time of IC testing was calculated. Change in REE with advancing post-conceptional age and advancing post-natal age was assessed. The average measured-to-predicted REE was calculated for the cohort using predictive equations [22]. RESULTS Eighteen infants with CDH underwent IC. REE in infants with CDH increased with advancing postconceptional age (r2 = 0.3, p < 0.02). The mean REE for the entire group was 53.2 +/- 10.9 kcal/kg/day while the mean caloric intake was 101.2 +/- 17.4 kcal/kg/day. The mean measured-to-predicted ratio for the cohort was in the normal metabolic range (1.10 +/- 0.17) with 50% of infants considered hypermetabolic and 11% of infants considered hypo-metabolic. CONCLUSIONS Infant survivors of CDH repair who are without respiratory support at time of neonatal hospital discharge have REE, as measured by indirect calorimetry, that increases with advancing post-conceptional age and that is within the normal metabolic range when compared to predictive equations. LEVEL OF EVIDENCE III.
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Yuan M, Li F, Xu C, Fan X, Xiang B, Huang L, Jiang X, Yang G. Thoracoscopic Treatment of Late-Presenting Congenital Diaphragmatic Hernia in Infants and Children. J Laparoendosc Adv Surg Tech A 2018; 29:77-81. [PMID: 30300095 DOI: 10.1089/lap.2018.0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Given that the application of thoracoscopic surgery to late-presenting congenital diaphragmatic hernia (CDH) in infants and children is controversial, we summarized our experiences with patients at two medical centers and aimed to discuss the safety and feasibility of thoracoscopic repair. MATERIALS AND METHODS A retrospective review of late-presenting CDH cases involving patients who underwent thoracoscopic repair from October 2010 to June 2017 was performed. Data, including patients' demographic characteristics, manipulative details, and postoperative complications, were extracted and analyzed. RESULTS A total of 59 cases were included in this study. Patients ranged in age from 2 months to 8 years (mean: 18 months). Twenty-five patients presented with shortness of breath and dyspnea. Furthermore, 34 cases were found occasionally. Forty-six left-sided hernias and 13 right-sided hernias were found. Operating time ranged from 30 to 100 minutes (mean: 55 minutes), and the amount of blood loss was 3-5 mL (mean: 3.8 mL). The size of the diaphragmatic defect ranged from 2 × 2 cm to 5 × 8 cm. The chest tubes were taken out within 24 hours. The average length of postoperative hospital stay was 5.2 ± 0.4 days (range: 4-6 days). The length of the follow-up period ranged from 3 months to 3 years (mean: 18 months), with no recurrences. CONCLUSION Thoracoscopic repair of late-presenting CDH is a safe and efficacious technique. It can facilitate the procedure and decrease the recurrence rate by shifting the focus to operative details. The prognosis is excellent once the correct operative details are achieved.
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Affiliation(s)
- Miao Yuan
- 1 Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Fei Li
- 2 Department of Pediatric Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, P.R. China
| | - Chang Xu
- 1 Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Xia Fan
- 2 Department of Pediatric Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, P.R. China
| | - Bo Xiang
- 1 Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Lugang Huang
- 1 Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Xiaoping Jiang
- 1 Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Gang Yang
- 1 Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
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Guevorkian D, Mur S, Cavatorta E, Pognon L, Rakza T, Storme L. Lower Distending Pressure Improves Respiratory Mechanics in Congenital Diaphragmatic Hernia Complicated by Persistent Pulmonary Hypertension. J Pediatr 2018; 200:38-43. [PMID: 29793868 DOI: 10.1016/j.jpeds.2018.04.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 03/09/2018] [Accepted: 04/13/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate the effects of distending pressures on respiratory mechanics and pulmonary circulation in newborn infants with congenital diaphragmatic hernia (CDH) and persistent pulmonary hypertension (PPHN). STUDY DESIGN In total, 17 consecutive infants of ≥37 weeks of gestational age with CDH and PPHN were included in this prospective, randomized, crossover pilot study. Infants were assigned randomly to receive 2 or 5 cmH2O of positive end-expiratory pressure (PEEP) for 1 hour in a crossover design. The difference between peak inspiratory pressure and PEEP was kept constant. Respiratory mechanics, lung function, and hemodynamic variables assessed by Doppler echocardiography were measured after each study period. RESULTS At 2 cmH2O of PEEP, tidal volume and minute ventilation were greater (P < .05), and respiratory system compliance was 30% greater (P < .05) than at 5 cmH2O. PaCO2 and ventilation index were lower at 2 cmH2O than at 5 cmH2O (P < .05). Although preductal peripheral oxygen saturation was similar at both PEEP levels, postductal peripheral oxygen saturation was lower (median [range]: 81% [65-95] vs 91% [71-100]) and fraction of inspired oxygen was greater (35% [21-70] vs 25% [21-60]) at 5 cmH2O. End-diastolic left ventricle diameter, left atrium/aortic root ratio, and pulmonary blood flow velocities in the left pulmonary artery were lower at 5 cmH2O. CONCLUSIONS After surgical repair, lower distending pressures result in better respiratory mechanics in infants with mild-to-moderate CDH. We speculate that hypoplastic lungs in CDH are prone to overdistension, with poor tolerance to elevation of distending pressure.
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Affiliation(s)
- David Guevorkian
- Neonatal Intensive Care, Department of Neonatology, Marie Curie Public Hospital, Charleroi, Belgium; Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, F-59000 France
| | - Sebastien Mur
- Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, F-59000 France; National Reference Center for the Rare Disease Congenital Diaphragmatic Hernia, Member of the European Reference Network on inherited and congenital anomalies ERNICA, University Hospital of Lille, F-59000 France
| | - Eric Cavatorta
- Neonatal Intensive Care, Department of Neonatology, Marie Curie Public Hospital, Charleroi, Belgium
| | - Laurence Pognon
- Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, F-59000 France; National Reference Center for the Rare Disease Congenital Diaphragmatic Hernia, Member of the European Reference Network on inherited and congenital anomalies ERNICA, University Hospital of Lille, F-59000 France
| | - Thameur Rakza
- Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, F-59000 France; National Reference Center for the Rare Disease Congenital Diaphragmatic Hernia, Member of the European Reference Network on inherited and congenital anomalies ERNICA, University Hospital of Lille, F-59000 France; EA4489, Perinatal Environment and Health, University of Lille, F-59000 France
| | - Laurent Storme
- Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, F-59000 France; National Reference Center for the Rare Disease Congenital Diaphragmatic Hernia, Member of the European Reference Network on inherited and congenital anomalies ERNICA, University Hospital of Lille, F-59000 France; EA4489, Perinatal Environment and Health, University of Lille, F-59000 France.
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Fox ZD, Jiang G, Ho KKY, Walker KA, Liu AP, Kunisaki SM. Fetal lung transcriptome patterns in an ex vivo compression model of diaphragmatic hernia. J Surg Res 2018; 231:411-420. [PMID: 30278961 DOI: 10.1016/j.jss.2018.06.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/26/2018] [Accepted: 06/20/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND The purpose of this study was to employ a novel ex vivo lung model of congenital diaphragmatic hernia (CDH) to determine how a mechanical compression affects early pulmonary development. METHODS Day-15 whole fetal rat lungs (n = 6-12/group) from nitrofen-exposed and normal (vehicle only) dams were explanted and cultured ex vivo in compression microdevices (0.2 or 0.4 kPa) for 16 h to mimic physiologic compression forces that occur in CDH in vivo. Lungs were evaluated with significance set at P < 0.05. RESULTS Nitrofen-exposed lungs were hypoplastic and expressed lower levels of surfactant protein C at baseline. Although compression alone did not alter the α-smooth muscle actin (ACTA2) expression in normal lungs, nitrofen-exposed lungs had significantly increased ACTA2 transcripts (0.2 kPa: 2.04 ± 0.15; 0.4 kPa: 2.22 ± 0.11; both P < 0.001). Nitrofen-exposed lungs also showed further reductions in surfactant protein C expression at 0.2 and 0.4 kPa (0.53 ± 0.04, P < 0.01; 0.69 ± 0.23, P < 0.001; respectively). Whereas normal lungs exposed to 0.2 and 0.4 kPa showed significant increases in periostin (POSTN), a mechanical stress-response molecule (1.79 ± 0.10 and 2.12 ± 0.39, respectively; both P < 0.001), nitrofen-exposed lungs had a significant decrease in POSTN expression (0.4 kPa: 0.67 ± 0.15, P < 0.001), which was confirmed by immunohistochemistry. CONCLUSIONS Collectively, these pilot data in a model of CDH lung hypoplasia suggest a primary aberration in response to mechanical stress within the nitrofen lung, characterized by an upregulation of ACTA2 and a downregulation in SPFTC and POSTN. This ex vivo compression system may serve as a novel research platform to better understand the mechanobiology and complex regulation of matricellular dynamics during CDH fetal lung development.
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Affiliation(s)
- Zachary D Fox
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Guihua Jiang
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kenneth K Y Ho
- Mechanical Engineering, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kendal A Walker
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Allen P Liu
- Mechanical Engineering, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Shaun M Kunisaki
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
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Aihole JS, Gowdra A, Javaregowda D, Jadhav V, Babu MN, Sahadev R. A Clinical Study on Congenital Diaphragmatic Hernia in Neonates: Our Institutional Experience. J Indian Assoc Pediatr Surg 2018; 23:131-139. [PMID: 30050261 PMCID: PMC6042159 DOI: 10.4103/jiaps.jiaps_179_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Congenital diaphragmatic hernia (CDH) is a complex developmental defect having a multifactorial etiology; i majority of cases (~80%), the cause is not known. Survival rates for patients with CDH have increased over the past decade with early prenatal detection and better postnatal management including surgery. Clinical profile and the outcome of 83 CDH neonates were studied and analyzed over a period of 12 years in our institute. Aims and Objectives: The clinical study was to analyze the clinical profile and outcome of CDH among the neonates in a tertiary care referral neonatal and pediatric center in Karnataka, India. Materials and Methods: This was a retrospective and prospective observational study conducted from January 2005 to March 2017, over a period of 12 years in a tertiary care referral neonatal and pediatric center in southern India. Clinical characteristics and risk factors of 83 neonates admitted and diagnosed with CDH were compared between survivors and nonsurvivors both preoperatively and postoperatively. Neonates with clinical and intraoperative diagnosis of diaphragmatic eventration were not included in this study. Multivariate logistic regression analysis was performed to determine independent predictors for mortality. Results: A total of 83 neonates admitted and diagnosed with CDH were included in this study; 73 of them underwent surgical repair. The total survival rate in neonates with CDH was 70/83 (84.33%) and the overall operative mortality was 3/73 (4.1%). There was a significant difference between CDH neonates who survived 70/83 (84.33%) and those who died 13/83 (15.67%), in the age on admission, 5 min Apgar score, onset of respiratory distress, preoperative ventilation, the presence of persistent pulmonary hypertension of the newborn (PPHN), high-frequency oscillatory ventilation (HFOV), and length of hospital stay with P < 0.05. Using multivariate logistic regression analysis, the following factors independently predicted mortality: onset of respiratory distress in hours (odds ratio: 0.5, 95% confidence interval: 0.37–0.82) and preoperative ventilation (odds ratio: 0.02; 95% confidence interval: 0.0028–0.1558). When we compared CDH neonates who survived after surgery (n = 70) with those who expired (n = 3) postoperatively, there was a significant difference in the gestational age in weeks, side of CDH, PPHN, HFOV and length of hospital stay with P < 0.05. Conclusion: CDHs are common on the left side with fairly good prognosis. Though, the right-sided CDH are rare; they do carry a good prognosis, as it was seen in our experience.
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Affiliation(s)
| | - Aruna Gowdra
- Department of Biochemistry, IGICH, Bengaluru, Karnataka, India
| | | | - Vinay Jadhav
- Department of Paediatric Surgery, IGICH, Bengaluru, Karnataka, India
| | - M Narendra Babu
- Department of Paediatric Surgery, IGICH, Bengaluru, Karnataka, India
| | - Ravidra Sahadev
- Department of Paediatric Surgery, IGICH, Bengaluru, Karnataka, India
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Farkouh-Karoleski C, Najaf T, Wynn J, Aspelund G, Chung WK, Stolar CJ, Mychaliska GB, Warner BW, Wagner AJ, Cusick RA, Lim FY, Schindel DT, Potoka D, Azarow K, Cotten CM, Hesketh A, Soffer S, Crombleholme T, Needelman H. A definition of gentle ventilation in congenital diaphragmatic hernia: a survey of neonatologists and pediatric surgeons. J Perinat Med 2017; 45:1031-1038. [PMID: 28130958 DOI: 10.1515/jpm-2016-0271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/28/2016] [Indexed: 01/30/2023]
Abstract
Ventilation practices have changed significantly since the initial reports in the mid 1980 of successful use of permissive hypercapnia and spontaneous ventilation [often called gentle ventilation (GV)] in infants with congenital diaphragmatic hernia (CDH). However, there has been little standardization of these practices or of the physiologic limits that define GV. We sought to ascertain among Diaphragmatic Hernia Research and Exploration; Advancing Molecular Science (DHREAMS) centers' GV practices in the neonatal management of CDH. Pediatric surgeons and neonatologists from DHREAMS centers completed an online survey on GV practices in infants with CDH. The survey gathered data on how individuals defined GV including ventilator settings, blood gas parameters and other factors of respiratory management. A total of 87 respondents, from 12 DHREAMS centers completed the survey for an individual response rate of 53% and a 92% center response rate. Approximately 99% of the respondents defined GV as accepting higher carbon dioxide (PCO2) and 60% of the respondents also defined GV as accepting a lower pH. There was less consensus about the use of sedation and neuromuscular blocking agents in GV, both within and across the centers. Acceptable pH and PCO2 levels are broader than the goal ranges. Despite a lack of formal standardization, the results suggest that GV practice is consistently defined as the use of permissive hypercapnia with mild respiratory acidosis and less consistently with the use of sedation and neuromuscular blocking agents. GV is the reported practice of surveyed neonatologists and pediatric surgeons in the respiratory management of infants with CDH.
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Abstract
Congenital diaphragmatic hernia can be approached successfully using minimally invasive techniques. Although there are may be a suggestion of higher recurrence rates with thoracoscopic repair, this may be due to the learning curve. However, open repair is associated with additional morbidity, most notably an increased rate of small bowel obstruction. Appropriate patients who have congenital diaphragmatic hernia should be offered the benefits of minimally invasive repair.
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Affiliation(s)
- Matthew S Clifton
- Department of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA 30322, USA
| | - Mark L Wulkan
- Department of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA 30322, USA.
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40
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Morini F, Capolupo I, van Weteringen W, Reiss I. Ventilation modalities in infants with congenital diaphragmatic hernia. Semin Pediatr Surg 2017. [PMID: 28641754 DOI: 10.1053/j.sempedsurg.2017.04.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Neonates with congenital diaphragmatic hernia are among the more complex patients to support with mechanical ventilation. They have particular features that add to the difficulties already present in the neonatal patient. A ventilation strategy tailored to the patient's underlying physiology rather than mode of ventilation is a crucial issue for clinicians treating these delicate patients.
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Affiliation(s)
- Francesco Morini
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Willem van Weteringen
- Department of Pediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irwin Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
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Factors associated with early recurrence after congenital diaphragmatic hernia repair. J Pediatr Surg 2017; 52:928-932. [PMID: 28359590 DOI: 10.1016/j.jpedsurg.2017.03.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/09/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The purpose of this study was to identify patient and treatment characteristics associated with early (in hospital) hernia recurrence after congenital diaphragmatic hernia (CDH) repair. METHODS Data from the Congenital Diaphragmatic Hernia Study Group registry were queried from 2007 to 2015. Recurrence of the diaphragmatic hernia after initial repair and prior to death or discharge was determined at the time of reoperation. Minimally invasive surgery (MIS) approaches included laparoscopy or thoracoscopy, and open approaches consisted of laparotomy or thoracotomy. Multivariate regression analysis was performed. RESULTS Of 3984 patients, 3332 (84%) underwent CDH repair. 76 (2.3%) patients had an early recurrence. The rate of recurrence was less variable over time for patients undergoing laparotomy vs thoracoscopy (range: 1.1-3.7% vs 1.7-8.9% annually). Timing of repair, whether performed after, during, or before ECMO did not significantly alter recurrence rates (0% vs 4.2% vs 3.0%, p=0.116). Larger defect size (C: OR 4.3, 95% CI 1.2-15.4; D: OR 7.1, 95% CI 1.7-29.1) and an MIS approach (OR 3.2, 95% CI 1.7-6.0) were the only independent predictors of recurrence. CONCLUSION Larger defect size and an MIS approach were associated with higher rates of early recurrence, while ECMO use and timing of repair with ECMO were not. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE II.
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Abstract
Congenital Diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity interfering with normal development of the lungs. The defect may range from a small aperture in the posterior muscle rim to complete absence of diaphragm. The pathophysiology of CDH is a combination of lung hypoplasia and immaturity associated with persistent pulmonary hypertension of newborn (PPHN) and cardiac dysfunction. Prenatal assessment of lung to head ratio (LHR) and position of the liver by ultrasound are used to diagnose and predict outcomes. Delivery of infants with CDH is recommended close to term gestation. Immediate management at birth includes bowel decompression, avoidance of mask ventilation and endotracheal tube placement if required. The main focus of management includes gentle ventilation, hemodynamic monitoring and treatment of pulmonary hypertension followed by surgery. Although inhaled nitric oxide is not approved by FDA for the treatment of PPHN induced by CDH, it is commonly used. Extracorporeal membrane oxygenation (ECMO) is typically considered after failure of conventional medical management for infants ≥ 34 weeks’ gestation or with weight >2 kg with CDH and no associated major lethal anomalies. Multiple factors such as prematurity, associated abnormalities, severity of PPHN, type of repair and need for ECMO can affect the survival of an infant with CDH. With advances in the management of CDH, the overall survival has improved and has been reported to be 70-90% in non-ECMO infants and up to 50% in infants who undergo ECMO.
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43
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Kadir D, Lilja HE. Risk factors for postoperative mortality in congenital diaphragmatic hernia: a single-centre observational study. Pediatr Surg Int 2017; 33:317-323. [PMID: 27986977 PMCID: PMC5310566 DOI: 10.1007/s00383-016-4032-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND The management of congenital diaphragmatic hernia (CDH) is a major challenge. The mortality is dependent on associated malformations, the severity of pulmonary hypoplasia, pulmonary hypertension and iatrogenic lung injury associated with aggressive mechanical ventilation. The aims of the study were to investigate the mortality over time in a single paediatric surgical centre, to compare the results with recent reports and to define the risk factors for mortality. METHODS The medical records of infants with CDH from two time periods: 1995-2005 and 2006-2016 were reviewed. Cox regression was used for statistical analysis. RESULTS The study included 113 infants. The mortality rate was significantly decreased in the later time period, compared to the earlier, 4.4 and 17.9%, respectively. At the early time period five patients (7.5%) were treated with ECMO and in the later time period ECMO was used in three patients (6.5%). The mortality in ECMO-treated patients was 50% in both time periods. Prenatal diagnosis, intrathoracic liver, low Apgar score and low birth weight were defined as independent risk factors for mortality. CONCLUSION Despite no significant differences in the incidence of independent risk factors and the use of ECMO between the two time periods, mortality decreased over time. The mortality was lower than previously reported. The results indicate that there are many important factors involved in a successful outcome after CDH repair. Large multicentre studies are necessary to define those critical factors and to determine optimal treatment strategies.
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Affiliation(s)
- Darya Kadir
- Department of Women's and Children's Health, Section of Pediatric Surgery, Uppsala University, 751 85, Uppsala, Sweden
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | - Helene Engstrand Lilja
- Department of Women's and Children's Health, Section of Pediatric Surgery, Uppsala University, 751 85, Uppsala, Sweden.
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden.
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Morini F, Lally KP, Lally PA, Crisafulli RM, Capolupo I, Bagolan P. Treatment Strategies for Congenital Diaphragmatic Hernia: Change Sometimes Comes Bearing Gifts. Front Pediatr 2017; 5:195. [PMID: 28959686 PMCID: PMC5603669 DOI: 10.3389/fped.2017.00195] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/23/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report treatment strategies' evolution and its impact on congenital diaphragmatic hernia (CDH) outcome. DESIGN Registry-based cohort study using the CDH Study Group database, 1995-2013. SETTING International multicenter database. PATIENTS CDH patients entered into the registry. Late presenters or patients with very incomplete data were excluded. Patients were divided into three Eras (1995-2000; 2001-2006; 2007-2013). MAIN OUTCOME MEASURES Treatment strategies and outcomes. One-way ANOVA, X2 test, and X2 test for trend were used. A Sydak-adjusted p < 0.0027 was considered significant. Prevalence or mean (SE) are reported. RESULTS Patients: 8,603; included: 7,716; Era I: 2,146; Era II: 2,572; Era III: 2,998. From Era I to Era III, significant changes happened. Some severity indicators such as gestational age, prevalence of prenatal diagnosis, and inborn patients significantly worsened. Also, treatment strategies such as the use of prenatal steroids and inhaled nitric oxide, age at operation, prevalence of minimal access surgery, and the use of surfactant significantly changed. Finally, length of hospital stay became significantly longer and survival to discharge slightly but significantly improved, from 67.7 to 71.4% (p for trend 0.0019). CONCLUSION Treatment strategies for patients registered since 1995 in the CDH Study Group significantly changed. Survival to discharge slightly but significantly improved.
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Affiliation(s)
- Francesco Morini
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Rosa Maria Crisafulli
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Yamoto M, Inamura N, Terui K, Nagata K, Kanamori Y, Hayakawa M, Tazuke Y, Yokoi A, Takayasu H, Okuyama H, Fukumoto K, Urushihara N, Taguchi T, Usui N. Echocardiographic predictors of poor prognosis in congenital diaphragmatic hernia. J Pediatr Surg 2016; 51:1926-1930. [PMID: 27663123 DOI: 10.1016/j.jpedsurg.2016.09.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to investigate echocardiographic parameters in relation to the outcomes of isolated left-sided congenital diaphragmatic hernia (CDH). METHODS This multicenter, retrospective, observational study was conducted among patients with CDH born between 2006 and 2010. Patients in this study did not have severe cardiac malformations or chromosomal aberrations. Patients with incomplete echocardiographic examinations were excluded. In total, 84 patients with left-sided isolated CDH were included in this study. The prognostic parameters were obtained from postnatal echocardiographic images within 24h after birth. RESULTS Eight patients died before 90days of birth. Univariate analysis showed that the presence of continuous right to left shunt at the ductus, left pulmonary artery diameter of <2.7mm, right pulmonary artery diameter of <3.3mm, and left ventricular diastolic diameter of <10.8mm, were the predictors of poor prognosis. Multivariate logistic regression analysis showed that right pulmonary artery diameter of <3.3mm (adjusted OR 10.28, 95% C.I.: 1.15-249.19) and left ventricular diastolic diameter of <10.8mm (adjusted OR 7.86, 95% C.I.: 1.01-82.82) were predictors of poor prognosis. CONCLUSIONS This study revealed that the predictors of poor prognosis associated with CDH include smaller right pulmonary artery and left ventricular diastolic diameters. Retrospective Study-Level II.
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Affiliation(s)
- Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan.
| | - Noboru Inamura
- Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Yutaka Kanamori
- Division of Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Hayakawa
- Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akiko Yokoi
- Department of Pediatric Surgery, Hyogo Children's Hospital, Kobe, Japan
| | - Hajime Takayasu
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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Hung WT, Huang SC, Mazloum DE, Lin WH, Yang HH, Chou HC, Wu ET, Chen CY, Tsao PN, Hsieh WS, Hsu WM, Chen YS, Lai HS. Extracorporeal membrane oxygenation for neonatal congenital diaphragmatic hernia: The initial single-center experience in Taiwan. J Formos Med Assoc 2016; 116:333-339. [PMID: 27727001 DOI: 10.1016/j.jfma.2016.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 06/19/2016] [Accepted: 06/28/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND/PURPOSE Extracorporeal membrane oxygenation (ECMO) is a treatment option for stabilizing neonates with congenital diaphragmatic hernia (CDH) in a critical condition when standard therapy fails. However, the use of this approach in Taiwan has not been previously reported. METHODS The charts of all neonates with CDH treated in our institute during the period 2007-2014 were reviewed. After 2010, patients who could not be stabilized with conventional treatment were candidates for ECMO. We compared the demographic data of patients with and without ECMO support. The clinical course and complications of ECMO were also reviewed. RESULTS We identified 39 neonates with CDH with a median birth weight of 2696 g (range, 1526-3280 g). Seven (18%) of these patients required ECMO support. The APGAR score at 5 minutes differed significantly between the ECMO and non-ECMO groups. The survival rate was 84.6% (33/39) for all CDH patients and 57.1% (4/7) for the ECMO group. The total ECMO bypass times in the survivors was in the range of 5-36 days, whereas all nonsurvivors received ECMO for at least 36 days (mean duration, 68 days). Surgical bleeding occurred in four of seven patients in the ECMO group. CONCLUSION The introduction of ECMO rescued some CDH patients who could not have survived by conventional management. Prolonged (i.e., > 36 days) ECMO support had no benefit for survival.
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Affiliation(s)
- Wan-Ting Hung
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Dania El Mazloum
- Department of Odontostomatologic Surgery and Mother and Infant's Science, Pediatric Unit, University of Verona, Verona, Italy
| | - Wen-Hsi Lin
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hui-Hsin Yang
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - En-Ting Wu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Ming Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Hong-Shiee Lai
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Abstract
OBJECTIVES The objectives of this review are to discuss the pathophysiology, clinical impact and treatment of major noncardiac anomalies, and prematurity in infants with congenital heart disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION Mortality risk is significantly higher in patients with congenital heart disease and associated anomalies compared with those in whom the heart defect occurs in isolation. Although most noncardiac structural anomalies do not require surgery in the neonatal period, several require surgery for survival. Management of such infants poses multiple challenges. Premature infants with congenital heart disease face challenges imposed by their immature organ systems, which are susceptible to injury or altered function by congenital heart disease and abnormal circulatory physiology independent of congenital heart disease. For optimal outcomes in premature infants or in infants with multiple congenital anomalies, a collaborative interdisciplinary approach is necessary.
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Grizelj R, Bojanić K, Pritišanac E, Luetić T, Vuković J, Weingarten TN, Schroeder DR, Sprung J. Survival prediction of high-risk outborn neonates with congenital diaphragmatic hernia from capillary blood gases. BMC Pediatr 2016; 16:114. [PMID: 27473834 PMCID: PMC4966580 DOI: 10.1186/s12887-016-0658-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 07/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The extent of lung hypoplasia in neonates with congenital diaphragmatic hernia (CDH) can be assessed from gas exchange. We examined the role of preductal capillary blood gases in prognosticating outcome in patients with CDH. METHODS We retrospectively reviewed demographic data, disease characteristics, and preductal capillary blood gases on admission and within 24 h following admission for 44 high-risk outborn neonates. All neonates were intubated after delivery due to acute respiratory distress, and were emergently transferred via ground ambulance to our unit between 1/2000 and 12/2014. The main outcome measure was survival to hospital discharge and explanatory variables of interest were preductal capillary blood gases obtained on admission and during the first 24 h following admission. RESULTS Higher ratio of preductal partial pressure of oxygen to fraction of inspired oxygen (PcO2/FIO2) on admission predicted survival (AUC = 0.69, P = 0.04). However, some neonates substantially improve PcO2/FIO2 following initiation of treatment. Among neonates who survived at least 24 h, the highest preductal PcO2/FIO2 achieved in the initial 24 h was the strongest predictor of survival (AUC = 0.87, P = 0.002). Nonsurvivors had a mean admission preductal PcCO2 higher than survivors (91 ± 31 vs. 70 ± 25 mmHg, P = 0.02), and their PcCO2 remained high during the first 24 h of treatment. CONCLUSION The inability to achieve adequate gas exchange within 24 h of initiation of intensive care treatment is an ominous sign in high-risk outborn neonates with CDH. We suggest that improvement of oxygenation during the first 24 h, along with other relevant clinical signs, should be used when making decisions regarding treatment options in these critically ill neonates.
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Affiliation(s)
- Ruža Grizelj
- Department of Pediatrics, University of Zagreb, School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Katarina Bojanić
- Department of Obstetrics and Gynecology, University Hospital Merkur, Zagreb, Croatia
| | - Ena Pritišanac
- Department of Pediatrics, University of Zagreb, School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Tomislav Luetić
- Department of Pediatric Surgery, University of Zagreb, School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jurica Vuković
- Department of Pediatrics, University of Zagreb, School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Toby N Weingarten
- Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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50
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Gallindo RM, Gonçalves FLL, Figueira RL, Simões ALB, Sbragia L. Standardization of pulmonary ventilation technique using volume-controlled ventilators in rats with congenital diaphragmatic hernia. Rev Col Bras Cir 2016; 41:181-7. [PMID: 25140649 DOI: 10.1590/s0100-69912014000300008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 09/28/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To standardize a technique for ventilating rat fetuses with Congenital Diaphragmatic Hernia (CDH) using a volume-controlled ventilator. METHODS Pregnant rats were divided into the following groups: a) control (C); b) exposed to nitrofen with CDH (CDH); and c) exposed to nitrofen without CDH (N-). Fetuses of the three groups were randomly divided into the subgroups ventilated (V) and non-ventilated (N-V). Fetuses were collected on day 21.5 of gestation, weighed and ventilated for 30 minutes using a volume-controlled ventilator. Then the lungs were collected for histological study. We evaluated: body weight (BW), total lung weight (TLW), left lung weight (LLW), ratios TLW / BW and LLW / BW, morphological histology of the airways and causes of failures of ventilation. RESULTS BW, TLW, LLW, TLW / BW and LLW / BW were higher in C compared with N- (p <0.05) and CDH (p <0.05), but no differences were found between the subgroups V and N-V (p> 0.05). The morphology of the pulmonary airways showed hypoplasia in groups N- and CDH, with no difference between V and N-V (p <0.05). The C and N- groups could be successfully ventilated using a tidal volume of 75 ìl, but the failure of ventilation in the CDH group decreased only when ventilated with 50 ìl. CONCLUSION Volume ventilation is possible in rats with CDH for a short period and does not alter fetal or lung morphology.
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Affiliation(s)
- Rodrigo Melo Gallindo
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Rebeca Lopes Figueira
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ana Leda Bertoncini Simões
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Lourenço Sbragia
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, SP, Brazil
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