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Yang MJ, Ellsworth TS, Woodward PJ, Kennedy AM, Fenton SJ, Russell KW, Byrne JLB, Yost CC, Yoder BA. Comparison of current to past outcomes in congenital diaphragmatic hernia using mri observed-to-expected total fetal lung volume. J Perinatol 2024:10.1038/s41372-024-02008-z. [PMID: 38796522 DOI: 10.1038/s41372-024-02008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/23/2023] [Accepted: 05/14/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Fetal Centers use imaging studies to predict congenital diaphragmatic hernia (CDH) prognosis and the need for fetal therapy. Given improving CDH survival, we hypothesized that current fetal imaging severity predictions no longer reflect true outcomes and fail to justify the risks of fetal therapy. METHODS We analyzed our single-center contemporary data in a left-sided CDH cohort (n = 58) by prognostic criteria determined by MRI observed-to-expected total fetal lung volumes: severe <25%, moderate 25-35%, and mild >35%. We compared contemporary survival to prior studies and the TOTAL trials. RESULTS Contemporary survival was significantly higher than past studies for all prognostic classifications (mild 100% vs 80-94%, moderate 95% vs 59-75%, severe 79% vs 13-25%; P < 0.01), and to either control or fetal therapy arms of the TOTAL trials. CONCLUSIONS Current fetal imaging criteria are overly pessimistic and may lead to unwarranted fetal intervention. Fetal therapies remain experimental. Future studies will require updated prognostic criteria.
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Affiliation(s)
- Michelle J Yang
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA.
| | - Tanner S Ellsworth
- Divisions of General Pediatrics, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Paula J Woodward
- Divisions of Radiology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Anne M Kennedy
- Divisions of Radiology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Stephen J Fenton
- Divisions of Pediatric Surgery, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Katie W Russell
- Divisions of Pediatric Surgery, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Janice L B Byrne
- Divisions of Maternal-Fetal Medicine, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Christian C Yost
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
- Divisions of Molecular Medicine Program, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Divisions of Neonatology, University of Utah School of Medicine and the Grant Scott Bonham Fetal Center at Primary Children's Hospital, Salt Lake City, UT, USA
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2
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Vandewalle RJ, Greiten LE. Diaphragmatic Defects in Infants: Acute Management and Repair. Thorac Surg Clin 2024; 34:133-145. [PMID: 38705661 DOI: 10.1016/j.thorsurg.2024.01.003] [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: 05/07/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a complex and highly variable disease process that should be treated at institutions with multidisciplinary teams designed for their care. Treatment in the neonatal period focuses on pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. Extracorporeal membrane oxygenation (ECMO) can be considered in patients refractory to medical management. Repair of CDH early during the ECMO course seems to improve mortality compared with other times for surgical intervention. The choice of surgical approach to CDH repair should consider the patient's physiologic status and the surgeon's familiarity with the operative approaches available, recognizing the pros/cons of each technique.
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Affiliation(s)
- Robert J Vandewalle
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 844, Little Rock, AR 72202, USA.
| | - Lawrence E Greiten
- Department of Surgery, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, 1 Children's Way, Slot 677, Little Rock, AR 72202, USA
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3
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Puligandla P, Skarsgard E, Baird R, Guadagno E, Dimmer A, Ganescu O, Abbasi N, Altit G, Brindle M, Fernandes S, Dakshinamurti S, Flageole H, Hebert A, Keijzer R, Offringa M, Patel D, Ryan G, Traynor M, Zani A, Chiu P. Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative. Arch Dis Child Fetal Neonatal Ed 2024; 109:239-252. [PMID: 37879884 DOI: 10.1136/archdischild-2023-325865] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
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.
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Affiliation(s)
- Pramod Puligandla
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Baird
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elena Guadagno
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexandra Dimmer
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nimrah Abbasi
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Altit
- Neonatology, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mary Brindle
- Department of Surgery, Section of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Sairvan Fernandes
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shyamala Dakshinamurti
- Department of Pediatrics and Child Health, Section of Neonatology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helene Flageole
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Audrey Hebert
- Department of Pediatrics, Division of Neonatology, Laval University, Quebec City, Quebec, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery and Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dylan Patel
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Greg Ryan
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Michael Traynor
- Department of Anesthesia, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Augusto Zani
- Department of Surgery, Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Priscilla Chiu
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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4
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Wild KT, Rintoul N, Hedrick HL, Heimall L, Soorikian L, Foglia EE, Ades AM, Herrick HM. Delivery Room Resuscitation of Infants with Congenital Diaphragmatic Hernia: Lessons Learned through Video Review. Fetal Diagn Ther 2024:000538536. [PMID: 38531327 DOI: 10.1159/000538536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Delivery room (DR) interventions for infants with congenital diaphragmatic hernia (CDH) are not well described. This study sought to describe timing and order of DR interventions and identify system factors impacting CDH DR resuscitations using a human factors framework. METHODS Single center observational study of video recorded CDH DR resuscitations documenting timing and order of interventions. The team used the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify system factors impacting DR resuscitations and time to invasive ventilation. RESULTS We analyzed 31 video recorded CDH resuscitations. We observed variability in timing and order of resuscitation tasks. The 'Internal Environment' and 'Tasks' components of the SEIPS model were prominent factors affecting resuscitation efficiency; significant room and bed spatial constraints exist, and nurses have a significant task burden. Additionally, endotracheal tube preparation was a prominent barrier to timely invasive ventilation. CONCLUSION Video review revealed variation in event timing and order during CDH resuscitations. Standardization of room set-up, equipment, and event order and reallocation of tasks facilitate more efficient intubation and ventilation, representing targets for CDH DR improvement initiatives. This work emphasizes the utility of rigorous human factors review to identify areas for improvement during DR resuscitation.
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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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Zhang H, Keszler M. Mechanical ventilation in special populations. Semin Perinatol 2024; 48:151888. [PMID: 38555219 DOI: 10.1016/j.semperi.2024.151888] [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: 04/02/2024]
Abstract
Optimal respiratory support can only be achieved if the ventilator strategy utilized for each individual patient at any given point in the evolution of their disease process is tailored to the underlying pathophysiology. The critically ill newborn infant requires individualized patient care when it comes to mechanical ventilation. This can only occur if the clinician has a good understanding of the different pathophysiologies of a variety of conditions that can lead to respiratory failure. In this chapter we describe the key pathophysiological features of bronchopulmonary dysplasia, meconium aspiration syndrome and lung hypoplasia syndromes with emphasis on congenital diaphragmatic hernia. We review available evidence to guide management an provide specific recommendations for pathophysiologically-based mechanical ventilation support.
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Affiliation(s)
- Hyayan Zhang
- Department of Neonatology, Perelman School of Medicine at the University of Pennsylvania, Newborn and Infant Chronic Lung Disease Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neonatology, Guangzhou Women and Children Medical Center, Guangzhou, China
| | - Martin Keszler
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
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7
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Moore SS, Keller RL, Altit G. Congenital Diaphragmatic Hernia: Pulmonary Hypertension and Pulmonary Vascular Disease. Clin Perinatol 2024; 51:151-170. [PMID: 38325939 DOI: 10.1016/j.clp.2023.10.001] [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: 02/09/2024]
Abstract
This review provides a comprehensive summary of the current understanding of pulmonary hypertension (PH) in congenital diaphragmatic hernia, outlining the underlying pathophysiologic mechanisms, methods for assessing PH severity, optimal management strategies, and prognostic implications.
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Affiliation(s)
- Shiran S Moore
- Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Weizamann 6, Tel-Aviv, Jaffa 6423906, Israel.
| | - Roberta L Keller
- Neonatology, UCSF Benioff Children's Hospital, 550 16th Street, #5517, San Francisco, CA 94158, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Gabriel Altit
- Neonatology, McGill University Health Centre, Montreal Children's Hospital, 1001 Décarie boulevard, Montreal, H4A Quebec; Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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8
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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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9
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Wild KT, Hedrick HL, Ades AM, Fraga MV, Avitabile CM, Gebb JS, Oliver ER, Coletti K, Kesler EM, Van Hoose KT, Panitch HB, Johng S, Ebbert RP, Herkert LM, Hoffman C, Ruble D, Flohr S, Reynolds T, Duran M, Foster A, Isserman RS, Partridge EA, Rintoul NE. Update on Management and Outcomes of Congenital Diaphragmatic Hernia. J Intensive Care Med 2023:8850666231212874. [PMID: 37933125 DOI: 10.1177/08850666231212874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Infants with congenital diaphragmatic hernia (CDH) benefit from comprehensive multidisciplinary teams that have experience in caring for the unique and complex issues associated with CDH. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies and pulmonary hypertension management, and extracorporeal membrane oxygenation, mortality and morbidity remain high. These infants have unique and complex issues that begin in fetal and infant life, but persist through adulthood. Here we will review the literature and share our clinical care pathway for neonatal care and follow up. While many advances have occurred in the past few decades, our work is just beginning to continue to improve the mortality, but also importantly the morbidity of CDH.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Maria V Fraga
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Juliana S Gebb
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Coletti
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Erin M Kesler
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - K Taylor Van Hoose
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Howard B Panitch
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Renee P Ebbert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Herkert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Hoffman
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Deanna Ruble
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabrina Flohr
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tom Reynolds
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa Duran
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Audrey Foster
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca S Isserman
- Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Emily A Partridge
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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10
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Lakshminrusimha S, Fraga MV. Longitudinal Trajectory of Ventricular Function and Pulmonary Hypertension in Congenital Diaphragmatic Hernia. J Pediatr 2023; 260:113550. [PMID: 37315779 DOI: 10.1016/j.jpeds.2023.113550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, UC Davis Children's Hospital, Sacramento, California.
| | - María V Fraga
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Rholl E, Leuthner SR. Role of palliative care in centers performing maternal-fetal interventions. Front Pediatr 2023; 11:1223710. [PMID: 37484772 PMCID: PMC10360186 DOI: 10.3389/fped.2023.1223710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/13/2023] [Indexed: 07/25/2023] Open
Abstract
Advancements in maternal-fetal interventions have allowed for direct fetal access, shifting the focus of interventions from maternal health for fetal health to a focus on sole fetal/neonatal benefit. Given that access to the fetus can only be obtained through the mother, there are ethical considerations important to consider when counseling the maternal-fetal dyad. The goals of maternal-fetal interventions range from improved fetal/neonatal survival to decreased long-term morbidities and improved quality of life. However, interventions to improve quality of life may not always achieve their desired result. Additionally, maternal-fetal interventions have risks such as premature birth and other complications that should be heavily considered as they may offset the potential benefits of the procedure. While some families elect for a maternal-fetal intervention, doing every potential postnatal intervention may not be in alignment with their goals depending on the outcome of the intervention. Given the complex, value-laden decision-making that is crucial to counseling parents about decisions surrounding maternal-fetal interventions and subsequent neonatal care, palliative care specialists should be utilized in fetal centers. Palliative care specialists are trained to assist with complex, goal concordant decision-making and can guide families and medical teams through the decision points that arise during the treatment journey.
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Affiliation(s)
- Erin Rholl
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI, United States
- Children's Wisconsin, Milwaukee, WI, United States
| | - Steven R. Leuthner
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI, United States
- Children's Wisconsin, Milwaukee, WI, United States
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Mortality in Congenital Diaphragmatic Hernia: A Multicenter Registry Study of Over 5000 Patients Over 25 Years. Ann Surg 2023; 277:520-527. [PMID: 34334632 DOI: 10.1097/sla.0000000000005113] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if risk-adjusted survival of patients with CDH has improved over the last 25 years within centers that are long-term, consistent participants in the CDH Study Group (CDHSG). SUMMARY BACKGROUND DATA The CDHSG is a multicenter collaboration focused on evaluation of infants with CDH. Despite advances in pediatric surgical and intensive care, CDH mortality has appeared to plateau. Herein, we studied CDH mortality rates amongst long-term contributors to the CDHSG. METHODS We divided registry data into 5-year intervals, with Era 1 (E1) beginning in 1995, and analyzed multiple variables (operative strategy, defect size, and mortality) to assess evolution of disease characteristics and severity over time. For mortality analyses, patients were risk stratified using a validated prediction score based on 5-minute Apgar (Apgar5) and birth weight. A risk-adjusted, observed to expected (O:E) mortality model was created using E1 as a reference. RESULTS 5203 patients from 23 centers with >22years of participation were included. Birth weight, Apgar5, diaphragmatic agenesis, and repair rate were unchanged over time (all P > 0.05). In E5 compared to E1, minimally invasive and patch repair were more prevalent, and timing of diaphragmatic repair was later (all P < 0.01). Overall mortality decreased over time: E1 (30.7%), E2 (30.3%), E3 (28.7%), E4 (26.0%), E5 (25.8%) ( P = 0.03). Risk-adjusted mortality showed a significant improvement in E5 compared to E1 (OR 0.78, 95% CI 0.62-0.98; P = 0.03). O:E mortality improved over time, with the greatest improvement in E5. CONCLUSIONS Risk-adjusted and observed-to-expected CDH mortality have improved over time.
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Lichtsinn K, Waltz PK, Azzuqa A, Church J, Graham J, Troutman J, Mahmood B. Impact of a standardized management guideline for infants with CDH: A single-center experience. J Pediatr Surg 2023; 58:389-396. [PMID: 35965150 DOI: 10.1016/j.jpedsurg.2022.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/15/2022] [Accepted: 07/25/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Infants with congenital diaphragmatic hernia (CDH) are at high risk of death, even despite extracorporeal membrane oxygenation (ECMO) support. In January 2012 we implemented a standardized clinical practice guideline (CPG) to manage infants with CDH. We hypothesized that infants with CDH managed with CPG had better clinical outcomes, less ECMO utilization, and increased survival to discharge. METHODS We conducted a retrospective pre-post study of infants with CDH admitted between January 2007 and July 2021 (n = 133). Patients were divided into Cohort 1, pre-CPG (January 2007 to December 2011, n = 54), and Cohort 2, post-CPG (January 2012 to July 2021, n = 79). RESULTS More patients in Cohort 1 were small for gestational age than in Cohort 2. No other patient demographics were different between cohorts. Cohort 2 had significantly lower ECMO utilization as compared to Cohort 1 (18% vs 50%, p<0.001). Cohort 2 had significantly higher survival to discharge compared to Cohort 1 (85% vs 57%, p<0.001). Survival for ECMO-treated patients in Cohort 2 was significantly higher than in Cohort 1 (71% vs 26%, p = 0.005). In Cohort 1, 70% of the non-survivors were repaired, of which 81% were repaired on ECMO. In Cohort 2, 8% of the non-survivors were repaired, none on ECMO. Only 3% in Cohort 2 were discharged with pulmonary hypertension medication. CONCLUSIONS A standardized CPG to manage patients with CDH decreased ECMO utilization and improved clinical outcomes including survival to discharge. Refinement of management strategies, implementation of new interventions, and meticulous care can improve outcomes in patients with CDH.
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Affiliation(s)
- Katrin Lichtsinn
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224.
| | - Paul K Waltz
- University of Pittsburgh Medical Center, Division of Pediatric General and Thoracic Surgery. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Abeer Azzuqa
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Joseph Church
- University of Pittsburgh Medical Center, Division of Pediatric General and Thoracic Surgery. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Jacqueline Graham
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Jennifer Troutman
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224
| | - Burhan Mahmood
- University of Pittsburgh Medical Center, Division of Newborn Medicine. 4401 Penn Ave, Pittsburgh, PA, USA 15224
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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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Power B. The CDH patient perspective journey. Front Pediatr 2023; 11:1052422. [PMID: 36896399 PMCID: PMC9989458 DOI: 10.3389/fped.2023.1052422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/11/2023] [Indexed: 02/23/2023] Open
Abstract
Background Congenital Diaphragmatic Hernia is a malformation of the diaphragm resulting in ongoing clinical symptoms and problems. Mortality remains high, particularly where there are other issues involved. Tracking a patient throughout their lifetime to understand the full impact on health and function is challenging. CDH UK is a registered charity supporting anyone affected by CDH. It has over 25 years of experience and a broad range of patient experience and knowledge. Aims To develop a patient journey with timepoints of significance. Methods We studied our own data and looked at what we already knew from publications and medical advisors. We recruited a focus group, plotted out stages and timepoints through their "lived" experiences using the Team Idea Mapping method. We then compared these experiences to our own data, to identify the common issues in daily life and care. Outcome We have developed a patient journey through the eyes of the patient and turned it into a patient friendly infographic. This can be used as a tool to help understand the CDH Journey throughout a patient's lifetime. CDH UK has already used this to create a first prototype of a mobile application. It has also further helped to recognize areas of patient concern and to improve services and resources. Discussion This can be used as a basis for care and research, including standards, benchmarking, transition and helping improvements in healthcare, education, family life and social settings. Potentially holding clues as to the etiology and pathology of the condition and an opportunity to further explore theories and unanswered questions. It may help improve counselling and bereavement care, resulting in better general and mental health outcomes.
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Affiliation(s)
- Beverley Power
- Management Committee, CDH UK - The Congenital Diaphragmatic Hernia Charity, King's lynn, United Kingdom
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16
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Management of the CDH patient on ECLS. Semin Fetal Neonatal Med 2022; 27:101407. [PMID: 36411199 DOI: 10.1016/j.siny.2022.101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is the most common indication for respiratory extracorporeal life support (ECLS) in neonates. The survival rate of CDH neonates treated with ECLS is 50%, and this figure has remained relatively stable over the last few decades. This is likely because the current population of CDH neonates who require ECLS have a higher risk profile [1]. The management of neonates with CDH has evolved over time to emphasize postnatal stabilization, gentle ventilation, and multi-modal treatment of pulmonary hypertension. In order to minimize practice variation, many centers have adopted CDH-specific clinical practice guidelines, however care is not standardized between different centers and outcomes vary [3]. The purpose of this review is to summarize our current understanding of issues central to the care of neonates with CDH treated with ECLS and specifically highlight how the use of the Extracorporeal Life Support Organization (ELSO) data have added to our understanding of CDH.
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Semama C, Vu S, Kyheng M, Le Duc K, Plaisant F, Storme L, Claris O, Mur S, Butin M. High-frequency oscillatory ventilation versus conventional ventilation in the respiratory management of term neonates with a congenital diaphragmatic hernia: a retrospective cohort study. Eur J Pediatr 2022; 181:3899-3906. [PMID: 35994123 DOI: 10.1007/s00431-022-04590-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/22/2022] [Accepted: 08/06/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Conventional mechanical ventilation (CMV) has been recommended as the first-line mode of respiratory support for neonates born with a congenital diaphragmatic hernia (CDH). However, older studies suggested that protective high-frequency oscillatory ventilation (HFOV) with low-mean airway pressure (MAP) may limit lung injury. We aimed to compare low-MAP HFOV with CMV in neonates with CDH in terms of patient outcomes. This retrospective cohort study was conducted in two French neonatal intensive care units: center 1 mainly used CMV, and center 2 mainly used HFOV with a low MAP. All term neonates with CDH born between 2010 and 2018 in these two centers were included. The primary outcome was the duration of oxygen therapy. Secondary outcomes were survival and duration of mechanical ventilation. A total of 170 patients (105 in center 1, 65 in center 2) were included. In center 2, 96% of patients were ventilated with HFOV versus 19% in center 1. After adjustment for perinatal data, there was no significant difference regarding duration of oxygen therapy (SHR 0.83, 95% CI [0.55-1.23], p = 0.35) or survival (HR 1.73, 95% CI [0.64-4.64], p = 0.28). Center 2 patients required longer mechanical ventilation and sedation. CONCLUSION First-line mode of mechanical ventilation was not associated with the duration of oxygen therapy or survival in neonates with CDH. WHAT IS KNOWN • Recommendations were given in favour of using the conventional mechanical ventilation in first intention in neonates with a congenital diaphragmatic hernia, since High frequency oscillation (HFO) has been associated with a higher morbidity. WHAT IS NEW • No differences between HFO and conventional mechanical ventilation were observed concerning the length of oxygen supply and the survival..
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Affiliation(s)
- Camille Semama
- Department of Neonatology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69500, Bron, France
| | - Sandrine Vu
- Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, Lille, F-59000, France
| | - Maeva Kyheng
- CHU Lille, Department of Biostatistics, F-59000, Lille, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS : evaluation des Technologies de Santé et Des Pratiques Médicales, F-59000, Lille, France
| | - Kevin Le Duc
- Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, Lille, F-59000, France
| | - Frank Plaisant
- Department of Neonatology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69500, Bron, France
| | - Laurent Storme
- Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, Lille, F-59000, France.,French Reference Centre for Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, University Hospital of Lille, Lille, F-59000, France
| | - Olivier Claris
- Department of Neonatology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69500, Bron, France.,University Claude Bernard, EA 4129, Villeurbanne, France
| | - Sébastien Mur
- Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, Lille, F-59000, France.,French Reference Centre for Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, University Hospital of Lille, Lille, F-59000, France
| | - Marine Butin
- Department of Neonatology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69500, Bron, France. .,CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, Inserm U1111, Ecole Normale Supérieure de Lyon; Université Lyon 1; CNRS, UMR5308, Lyon, France.
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18
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Cox KJ, Yang MJ, Fenton SJ, Russell KW, Yost CC, Yoder BA. Operative repair in congenital diaphragmatic hernia: How long do we really need to wait? J Pediatr Surg 2022; 57:17-23. [PMID: 35216800 DOI: 10.1016/j.jpedsurg.2022.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/13/2021] [Accepted: 01/20/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To analyze preoperative cardiopulmonary support and define preoperative stability relative to timing of surgical repair for CDH neonates not on ECMO. STUDY DESIGN We retrospectively analyzed repeated measures of oxygenation index (OI; Paw*FiO2×100/PaO2) among 158 neonates for temporal preoperative trends. We defined physiologic stability using OI and characterized ventilator days and discharge age relative to delay in repair beyond physiologic stability. RESULTS The OI in the first 24 h of life was temporally reliable and representative of the preoperative mean (ICC 0.70, 95% CI 0.61-0.77). A pre-operative OI of ≤ 9.4 (AUC 0.95) was predictive of survival. Surgical delay after an OI ≤ 9.4 resulted in increased ventilator days (1.4, 95% CI 1.1-1.9) and discharge age (1.5, 95% CI 1.2-2.0). When prospectively applied to a subsequent cohort, an OI ≤ 9.4 was again reflective of physiologic stability prior to repair. CONCLUSION OI values are temporally reliable and change minimally after 24 h age. Delay in surgical repair of CDH beyond initial stability increases ventilator days and discharge age without a survival benefit. LEVEL OF EVIDENCE Prognosis study, Level III.
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Affiliation(s)
- Kyley J Cox
- Department of Pediatrics, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, United States
| | - Michelle J Yang
- Divisions of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Healthcare, P.O. Box 581289, Salt Lake City, UT 84158-1289, United States.
| | - Stephen J Fenton
- Pediatric Surgery, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, United States
| | - Katie W Russell
- Pediatric Surgery, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, United States
| | - Christian C Yost
- Divisions of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Healthcare, P.O. Box 581289, Salt Lake City, UT 84158-1289, United States; Molecular Medicine Program, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, United States
| | - Bradley A Yoder
- Divisions of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Healthcare, P.O. Box 581289, Salt Lake City, UT 84158-1289, United States
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Grabski DF, Vavolizza RD, Roecker Z, Levin D, Swanson JR, McGahren ED, Gander JW. Reduction of post-operative opioid use in neonates following open congenital diaphragmatic hernia repairs: A quality improvement initiative. J Pediatr Surg 2022; 57:45-51. [PMID: 34686379 DOI: 10.1016/j.jpedsurg.2021.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- David F Grabski
- Department of Surgery, University of Virginia School of Medicine, 1215 Lee St, Charlottesville, VA 22904, USA.
| | - Rick D Vavolizza
- Department of Surgery, University of Virginia School of Medicine, 1215 Lee St, Charlottesville, VA 22904, USA
| | - Zoe Roecker
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Daniel Levin
- Division of Pediatric Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jonathan R Swanson
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Eugene D McGahren
- Division of Pediatric Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jeffrey W Gander
- Division of Pediatric Surgery, University of Virginia School of Medicine, Charlottesville, VA, 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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Kim F, Bernbaum J, Connelly J, Gerdes M, Hedrick HL, Hoffman C, Rintoul NE, Ziolkowski K, DeMauro SB. Survival and Developmental Outcomes of Neonates Treated with Extracorporeal Membrane Oxygenation: A 10-Year Single-Center Experience. J Pediatr 2021; 229:134-140.e3. [PMID: 33058857 DOI: 10.1016/j.jpeds.2020.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the associations between the primary indication for extracorporeal membrane oxygenation (ECMO) in neonates and neurodevelopmental outcomes at 12 and 24 months of age. STUDY DESIGN This is a retrospective cohort study of neonates treated with ECMO between January 2006 and January 2016 in the Children's Hospital of Philadelphia newborn/infant intensive care unit. Primary indication for ECMO was classified as medical (eg, meconium aspiration syndrome) or surgical (eg, congenital diaphragmatic hernia). Primary study endpoints were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Groups were compared with standard bivariate testing and multivariable regression. RESULTS A total of 191 neonates met the study's inclusion criteria, including 96 with a medical indication and 95 with a surgical indication. Survival to discharge was 71%, with significantly higher survival in the medical group (82% vs 60%; P = .001). Survivors had high rates of developmental therapies and neurosensory abnormalities. Developmental outcomes were available for 66% at 12 months and 70% at 24 months. Average performance on the Bayley-III was significantly below expected population normative values. Surgical patients had modestly lower the Bayley-III scores over time; most notably, 15% of medical infants and 49% of surgical infants had motor delay at 24 months (P = .03). CONCLUSIONS In this single-center cohort, surgical patients had lower survival rates and higher incidence of motor delays. Strategies to reduce barriers to follow-up and improve rates of postdischarge developmental surveillance and intervention in this high-risk population are needed.
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Affiliation(s)
- Faith Kim
- Division of Neonatology, Department of Pediatrics, New York Presbyterian Children's Hospital of New York/Columbia University Medical Center, New York, NY
| | - Judy Bernbaum
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James Connelly
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Marsha Gerdes
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Holly L Hedrick
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Casey Hoffman
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kristina Ziolkowski
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sara B DeMauro
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.
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