Congenital diaphragmatic hernia repair in patients on extracorporeal membrane oxygenation: How early can we repair?

Enhancing the Survival of Congenital Diaphragmatic Hernia: Quality Improvement Initiative With a Multidisciplinary Extracorporeal Membrane Oxygenation Team Approach

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is the only treatment option that can stabilize patients with congenital diaphragmatic hernia (CDH) with severe pulmonary hypertension. This study assessed the effects of a multidisciplinary ECMO team approach (META) as part of a quality improvement initiative aimed at enhancing the survival rates of neonates with CDH.

METHODS

The medical records of infants with CDH treated at a tertiary center were retrospectively reviewed. Patients were categorized into two groups based on META implementation. The META group (P2) were given key interventions, including on-site ECMO management within the neonatal intensive care unit (NICU), use of venoarterial modality, ECMO indication as a priority even before the use of inhaled nitric oxide, and preplanned surgery following ECMO discontinuation. These approaches were compared with standard protocols in the pre-META group (P1) to assess their effects on clinical outcomes, particularly in-hospital mortality.

RESULTS

Over a 16-year period, 322 patients were included. P2 had a significantly higher incidence of non-isolated CDH and higher rate of cesarean section compared with P1. Moreover, P2 had delayed time to surgical repair (9.4 ± 8.0 days) compared with P1 (6.7 ± 7.3 days) (P = 0.004). The overall survival rate at NICU discharge was 72.7%, with a significant improvement from P1 (66.3%, 132/199) to P2 (82.9%, 102/123) (P = 0.001). Among the 68 patients who received ECMO, P2 had significantly lower baseline oxygenation index and serum lactate levels before ECMO cannulation than P1. The survival rate of patients who received ECMO also remarkably improved from P1 (21.1%, 8/38) to P2 (56.7%, 17/30). Subgroups who could be weaned from ECMO before 2 weeks after cannulation showed the best survival rate.

CONCLUSION

META significantly improved the survival rate of newborn infants with CDH. Further interventions, including prenatal intervention and novel ECMO strategies, may help improve the clinical outcomes and quality of life.

An evidence-based treatment algorithm for congenital diaphragmatic hernia

BACKGROUND

Congenital diaphragmatic hernia (CDH) affects more than 1100 newborns in the United States each year. Severity of clinical presentation is highly variable. Standardized care improves outcomes by promoting consistency in decision-making and clarifying goals of treatment, but CDH management has not yet been standardized.

METHODS

We performed a comprehensive literature review with special consideration for-cardiac dysfunction, indications for extracorporeal membrane oxygenation (ECMO), and timing of repair. In collaboration with experts across specialties, we sought to develop and implement a treatment algorithm based on current CDH literature and our own institutional experience.

RESULTS

Left ventricular (LV) hypoplasia and dysfunction is increasingly recognized as an important contributor to the severity of clinical presentation and cardiac dysfunction seen with CDH. Cardiac dysfunction is associated with poor outcomes and increased mortality. CDH-associated severe hypoxic respiratory failure refractory to medical therapy is one of the most common indications for ECMO in the neonatal period. The decision to initiate ECMO and selection of configuration should be shared by members of a multidisciplinary care team. The optimal timing of repair with respect to ECMO has been evolving in the last 3 decades.

CONCLUSION

Following our review, we recommend (1) timely and detailed cardiac evaluation with echocardiogram after birth, and (2) early repair on ECMO for high-risk patients and delayed repair post-ECMO for low-risk patients with anticipated short ECMO run. This treatment algorithm is a step toward standardization of CDH management practices, which we expect will improve CDH outcomes at our institution and others.

The Timing of Surgery for Congenital Diaphragmatic Hernia in Infants, on or after Weaning from Extracorporeal Membrane Oxygenation: A Meta-Analysis

OBJECTIVES

 We conducted a meta-analysis of trials to determine the optimal time to conduct surgery for congenital diaphragmatic hernia (CDH) in infants, on or after weaning from extracorporeal membrane oxygenation (ECMO).

METHODS

 We searched the PubMed, Embase, Scopus, and Cochrane Library databases to identify relevant articles published prior to May 2023 in which surgery was performed to treat CDH in infants. Data were collected, and continuous data were represented by the mean difference (MD) and 95% confidence interval (CI). Dichotomous data were represented by the odds ratio (OR) and 95% CI. Review Manager V.5.4 and Stata were used to synthesize results and to assess publication bias.

RESULTS

 The results showed that infants undergoing surgery after being weaned from ECMO had reduced mortality (OR, 2.40; 95% CI, 1.23-4.69; p = 0.01) and postoperative bleeding rates (OR, 16.20; 95% CI, 5.73-45.76; p < 0.00001) and reduced ECMO duration (MD, 3.47; 95% CI, 1.89-5.05; p < 0.0001) compared with those who underwent surgery while on ECMO. There was no statistically significant difference in hospital duration (MD, 5.48; 95% CI, -8.66 to 19.62; p = 0.45) or ventilator duration (MD, -1.93; 95% CI, -8.55 to 4.68; p = 0.57).

CONCLUSION

 We recommend weaning patients with CDH from ECMO before performing surgery.

Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative

OBJECTIVE

The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'.

DESIGN AND MAIN OUTCOME MEASURES

Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field.

RESULTS

Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH.

CONCLUSIONS

The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.

The role of extracorporeal life support and timing of repair in infants with congenital diaphragmatic hernia

Extracorporeal life support (ECLS) serves as a rescue therapy for patients with congenital diaphragmatic hernia (CDH) and severe cardiopulmonary failure, and only half of these patients survive to discharge. This costly intervention has a significant complication risk and is reserved for patients with the most severe disease physiology refractory to maximal cardiopulmonary support. Some contraindications to ECLS do exist such as coagulopathy, lethal chromosomal or congenital anomaly, very preterm birth, or very low birth weight, but many of these limits are being evaluated through further research. Consensus guidelines from the past decade vary in recommendations for ECLS use in patients with CDH but this therapy appears to have a survival benefit in the most severe subset of patients. Improved outcomes have been observed for patients treated at high-volume centers. This review details the evolving literature surrounding management paradigms for timing of CDH repair for patients receiving preoperative ECLS. Most recent data support early repair following cannulation to avoid non-repair which is uniformly fatal in this population. Longer ECLS runs are associated with decreased survival, and patient physiology should guide ECLS weaning and eventual decannulation rather than limiting patients to arbitrary run lengths. Standardization of care across centers is a major focus to limit unnecessary costs and improve short-term and long-term outcomes for these complex patients.

Pediatric surgical interventions on ECMO

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

Blood transfusion is associated with increased mortality for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation support

BACKGROUND AND OBJECTIVES

Blood transfusion is frequently needed to maintain adequate haemostasis and improve oxygenation for patients treated with extracorporeal membrane oxygenation (ECMO). It is more so for neonates with immature coagulation systems who require surgical intervention such as congenital diaphragmatic hernia (CDH) repair. There is growing evidence suggesting an association between blood transfusions and increased mortality. The aim of this study is to evaluate the association of blood transfusions during the peri-operative period of CDH repair, among other clinical parameters, with mortality in neonates undergoing on-ECMO CDH repair.

MATERIALS AND METHODS

We performed a single centre retrospective chart review of all neonates with CDH undergoing on-ECMO surgical repair from January 2010 to December 2020. Logistic regression was used to investigate associations with survival status.

RESULTS

Sixty-two patients met the inclusion criteria. Platelet transfusions (odds ratio [OR] 1.42, 95% confidence interval [CI]: 1.06-1.90) in the post-operative period and ECMO duration (OR 1.17, 95% CI: 1.05-1.30) were associated with increased mortality. Major bleeding complications had the strongest association with mortality (OR 10.98, 95% CI: 3.27-36.91). Gestational age, birth weight, Apgar scores, sex, blood type, right versus left CDH, venovenous versus venoarterial ECMO and duration of ECMO before CDH repair and circuit change after adjusting for ECMO duration were not significantly associated with survival.

CONCLUSION

Platelet transfusion in the post-operative period and major bleeding are associated with increased mortality in CDH neonates with surgical repair. The data suggest a need to develop robust plans for monitoring and preventing coagulation aberrancies during neonatal ECMO support.

Improved survival for infants with severe congenital diaphragmatic hernia

BACKGROUND

Survival for severe (observed to expected lung-head ratio (O:E LHR) < 25%) congenital diaphragmatic hernia (CDH) remains a challenge (15-25%). Management strategies have focused on fetal endoscopic tracheal occlusion (FETO) and/or extracorporeal membrane oxygenation therapy (ECMO) utilization.

OBJECTIVE(S)

Describe single center outcomes for infants with severe CDH.

STUDY DESIGN

Observational study of 13 severe CDH infants managed with ECMO, a protocolized DR algorithm, and early repair on ECMO with an innovative perioperative anticoagulation strategy.

RESULTS

13/140 (9.3%) infants met criteria and were managed with ECMO. 77% survived ECMO and 69% survived to discharge. 22% underwent tracheostomy. Median days on mechanical ventilation was 39 days (IQR 22:107.5) and length of stay 135 days (IQR 62.5:211.5). All infants received a gastrostomy tube (GT) and were discharged home on oxygen and pulmonary hypertension (PH) meds.

CONCLUSION

Survival for infants with severe CDH can be optimized with early aggressive intervention and protocolized algorithms (149).

Reduction in blood product transfusion requirements with early on-ECMO repair of congenital diaphragmatic hernia

Background

For infants with severe congenital diaphragmatic hernia (CDH) stabilized with extracorporeal membrane oxygenation (ECMO), early repair on ECMO improves outcome; however when compared to operative repair after ECMO, repair on ECMO is associated with increase bleeding risk and need for blood product transfusions.

Methods

A retrospective review of 54 patients with CDH placed on ECMO prior to CDH repair was performed. For the subset of patients repaired on ECMO, analysis comparing those repaired early (within 48 h of cannulation) and late (beyond 48 h) on ECMO was performed. Outcomes of interest included survival to discharge, days on ECMO, and postoperative blood product utilization.

Results

When compared to those patients repaired prior to 48 h of ECMO initiation, 57.7% of patients survived versus 40.9% of late repair patients. For those repaired early, blood product utilization was significantly less. Early repair patients received a median of 72 mL/kg packed red blood cells (PRBC) and 75 mL/kg platelets compared to 151.9 mL/kg and 98.7 mL/kg, respectively (p < 0.05 respectively). There was no difference in median days on ECMO (p = 0.38).

Conclusion

Our data supports prior reports of improved outcome with repair with 48 h of ECMO initiation and suggests early repair on ECMO is associated with less bleeding and decreased blood product requirement in the postoperative period.

Reduction of post-operative opioid use in neonates following open congenital diaphragmatic hernia repairs: A quality improvement initiative

BACKGROUND

A limited number of post-operative opioid reduction strategies have been implemented in the neonatal population. Given the potential neurodevelopment effects of prolonged opioid use, we created a quality improvement initiative to reduce opioids in our NICU and evaluated the intervention in our CDH population.

METHODS

Our opioid reduction intervention was based on standing post-operative IV acetaminophen, standardizing post-surgical sign-out between the surgical, anesthesia and NICU teams and a series of education seminars with NICU providers on post-operative pain control management. A historical control was used to perform a retrospective cohort analysis of opioid prescribing patterns in addition to a utilizing process control charts to investigate time trends in prescribing patterns.

RESULTS

Forty-five children with CDH underwent an operation were included in our investigation- 18 in our pre-intervention cohort, 6 in a roll-out cohort and 21 in our post-intervention cohort. Each cohort was clinically similar. The intervention reduced total post-operative opioid use (morphine equivalents) from 82.2 (mg/kg) to 2.9 (mg/kg) in our post-intervention group (p < 0.0001). Our maximum Neonatal Pain and Agitation Sedation Score over the first 48 post-operative hours were equivalent (p = 0.827). Safety profiles were statistically equivalent. The opioid reduction intervention reduced post-operative intubation length from 156 to 44 h (p = 0.021).

CONCLUSION

A multi-tiered intervention can decrease opioid use in post-surgical neonates with complex surgical pathology including CDH. The intervention proposed in this investigation is safe and does not increase pain or sedation scores in neonates, while lessening post-operative intubation length.

EVIDENCE LEVEL

Level II.

Computer-aided quantitative MSCT measurements may be useful for congenital lung malformations surgical approach selection

PURPOSE

To examine the association between the MSCT quantitative measurements of congenital lung malformations (CLM) and the selection of surgical approaches (lobectomy vs. lung-sparing surgery).

METHODS

This retrospective study evaluated CLM surgical cases at our institution from 2016 to 2018. MSCT quantitative measurements were generated by a semi-automated approach: the volume of the lesion (V_lesion), the volume of the lesion-involved lobe (V_lobe), the volume of the lesion-involved lung (V_lung) and the volume of the total lung (V_{total lung}). The proportions of V_lesion to V_lobe (P_lesion/lobe), V_lesion to V_lung (P_lesion/lung), and V_lesion to V _{total lung} (P_{lesion/total lung}) were calculated. We used Logistics regression to examine whether quantitative measurements were associated with the selection of surgical approaches.

RESULTS

151 patients were included (median age at surgery 6 months). 82 patients underwent lung-sparing surgery, and 69 patients underwent lobectomy. V_lesion (OR 1.51, 95% CI 1.09-2.07), P_lesion/lobe (OR 1.78, 95% CI 1.16-2.72), P_lesion/lung (OR 1.63, 95% CI 1.13-2.35), and P_{lesion/total lung} (OR 1.58, 95% CI 1.12-2.22) were positively associated with the selection of lobectomy.

CONCLUSION

The application of quantified MSCT analysis may provide insight into the quantitative characteristics of CLM, which could be potentially useful for surgical approach selection.

Vitamin K and ECMO for neonatal hypoxic respiratory failure

INTRODUCTION

The objectives of this retrospective cohort study were to examine the effect of vitamin K administration on hemorrhagic and thrombotic complications, blood product utilization, and outcomes in neonatal extracorporeal membrane oxygenation (ECMO).

METHODS

In the pilot study, complications, blood product use, and outcome data for neonates who received (n = 21) or did not receive (n = 18) a single dose of vitamin K (5 mg) immediately after initiation of ECMO for respiratory failure between 2006 and 2010 were compared. In the validation cohort, complications and outcomes were compared for 74 consecutive neonates supported with ECMO for respiratory failure who received (n = 45) or did not receive (n = 29) additional vitamin K once daily for prothrombin time (PT) ⩾14 seconds during ECMO from 2014 to 2019.

RESULTS

In the pilot study, vitamin K at ECMO initiation was associated with fewer thrombotic complications and similar hemorrhagic complications. The volume of fresh frozen plasma was higher in neonates who received vitamin K, but total blood product and other component volume did not differ between groups. ECMO run time, survival off ECMO, survival to discharge, and length of stay did not differ between cohorts. In the validation cohort, neonates who received additional vitamin K during ECMO had longer ECMO run time and length of stay, but no difference in mortality was observed. Further, thrombotic and hemorrhagic complications as well as blood product exposure were similar between cohorts.

CONCLUSIONS

These data suggest that routine vitamin K administration may have limited or no benefit during neonatal ECMO.

Congenital diaphragmatic hernia repair in patients requiring extracorporeal membrane oxygenation: are outcomes better with repair on ECMO or after decannulation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether congenital diaphragmatic hernia repair outcomes are better before or after decannulation in infants requiring extracorporeal membrane oxygenation (ECMO). A total of 884 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that infants with congenital diaphragmatic hernia requiring ECMO should undergo a trial of weaning and aim for post-decannulation repair, as this has been associated with improved survival, shorter ECMO duration and fewer bleeding complications. However, if weaning of ECMO is unsuccessful, the patient should ideally undergo early on-ECMO repair (within 72 h of cannulation), which has been associated with improved survival, less bleeding, shorter ECMO duration and fewer circuit changes compared to late on-ECMO repair. Anticoagulation protocols including perioperative administration of aminocaproic acid or tranexamic acid, as well as close perioperative monitoring of coagulation parameters have been associated with reduced bleeding risk with on-ECMO repairs.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a potentially severe anomaly that should be referred to a fetal care center with expertise in multidisciplinary evaluation and management. The pediatric radiologist plays an important role in the evaluation of CDH, both in terms of anatomical description of the anomaly and in providing detailed prognostic information for use in caring for the fetus and pregnant mother as well as planning for delivery and postnatal care. This article reviews the types of hernias, including distinguishing features and imaging clues. The most common methods of predicting severity are covered, and current fetal and postnatal therapies are explained. The author of this paper provides a handy reference for pediatric radiologists presented with a case of CDH as part of their daily practice.