AAP paper
Does the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure change outcomes for high-risk patients with congenital diaphragmatic hernia?

https://doi.org/10.1016/j.jpedsurg.2012.03.004Get rights and content

Abstract

Purpose

In the most severe cases of congenital diaphragmatic hernia (CDH), significant barotrauma or death can occur before advanced therapies such as extracorporeal membrane oxygenation (ECMO) can be initiated. We have previously examined the use of the ex utero intrapartum treatment (EXIT) to ECMO procedure (EXIT with placement on ECMO) in high-risk infants and reported a survival advantage. We report our experience with EXIT to ECMO in a more recent cohort of our patients with most severe CDH.

Methods

Every patient with less than 15% predicted lung volume during January 2005 to December 2010 was included. We obtained data on prenatal imaging, size and location of the defect, and survival.

Results

Seventeen high-risk infants were identified. All 17 (100%) received ECMO and required a patch. Six children were delivered by EXIT to ECMO, and only 2 (33%) survived. An additional patient was delivered by EXIT to intubation with ECMO on standby and died. Of the 10 children who did not receive EXIT, 5 (50%) survived.

Conclusions

No clear survival benefit with the use of the EXIT to ECMO procedure was demonstrated in this updated report of our high-risk CDH population. The general application of EXIT to ECMO for CDH is not supported by our results.

Section snippets

Methods

We prospectively studied all high-risk patients with CDH from January 2005 to December 2010 under an approved institutional review board protocol (M02-10-240). Prenatally diagnosed infants with CDH were referred to the Advanced Fetal Care Center. We defined high-risk lesions based on fetal magnetic resonance imaging measurements, a method previously reported by our group [11]. Percentage of predicted lung volume (PLV) was calculated by the same 2 radiologists, and all lesions with less than 15%

Results

A total of 17 high-risk infants were identified. Seven received EXIT to ECMO, and 10 received standard delivery (3 vaginal deliveries and 7 cesarean deliveries). One hundred percent of the non-EXIT group required ECMO. The demographics of our cohort are summarized in Table 1. The gestational age at birth and birth weight were similar between groups, with the average being 37.4 weeks gestation and 2.83 kg, respectively. The average gestational age at prenatal imaging was similar. There were more

Discussion

The management of CDH continues to be controversial and challenging. Many studies have examined ways to predict high-risk patients and mortality [13], [14], but there have been very few convincing demonstrations that the high mortality associated with the highest risk patients can be ameliorated. Our inclusion criteria of looking at percentage of PLV less than 15% accurately predicated high risk. At our institution, ECMO is only used 36% of the time, and our survival with our total ECMO

Acknowledgments

Thank you to the outstanding team at Children's Hospital Boston, including the obstetricians, neonatologists, pediatric intensivists, respiratory therapists, and nurses for continuing to provide outstanding care for these and all other very challenging patients. Thank you to the CDH Study Group for providing us with the records of the patients.

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