Predictors of the need for extracorporeal membrane oxygenation and survival in congenital diaphragmatic hernia: a center's 10‐year experience

Odibo, Anthony O.; Najaf, Tasnim; Vachharajani, Akshaya; Warner, Barbara; Mathur, Amit M.; Warner, Brad W.

doi:10.1002/pd.2508

Cited by 22 publications

(25 citation statements)

References 15 publications

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“…A recent study by Jani et al [35] reported the O/E LHR be associated with BPD, defined as oxygen dependency at day 28, and the duration of ventilation. In contrast to our findings, need for ECMO therapy was not associated with the O/E LHR in a recent study [36] . However, in this study the authors pointed out that the indications for ECMO therapy varied widely in their study centers [36] .…”

Section: Discussioncontrasting

confidence: 56%

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Actual Outcome in Infants with Congenital Diaphragmatic Hernia: The Role of a Standardized Postnatal Treatment Protocol

et al. 2011

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Background: Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly with a high rate of mortality and morbidity. Objective: Our aim was to determine a possible effect of standardized treatment on outcome in infants with CDH. Methods: All prenatally diagnosed patients with unilateral CDH born alive between January 2006 and December 2009 at the Erasmus MC or the University Hospital Mannheim were eligible for inclusion. Patients who underwent a fetal tracheal occlusion were excluded. From November 1, 2007, all CDH patients were treated according to a standardized treatment protocol. Patients were divided into two chronological groups according to their date of birth: without standardized treatment (group 1, Jan 2006–Oct 2007) and with standardized treatment (group 2, Nov 2007–Dec 2009). Outcome measures were mortality by day 28, bronchopulmonary dysplasia (BPD), defined as oxygen dependency at day 28, and need for extracorporeal membrane oxygenation (ECMO) therapy. Uni- and multivariate analyses were performed. Results: 167 patients were included. By day 28, 18% of the infants had died. Of the patients who were alive at day 28, 49% had BPD. An ECMO procedure was performed in 31% of the patients. Overall mortality for all included patients was 22%. In group 1, overall mortality was 33% and in group 2 overall mortality was 12% (p = 0.004). A standardized treatment protocol was independently associated with a reduced risk for mortality by day 28 (OR 0.28, 95% CI 0.11–0.68). Higher observed-to-expected lung-to-head ratios were independently associated with a lower risk for mortality by day 28 (OR 0.97, 95% CI 0.95–0.99), BPD (OR 0.97, 95% CI 0.94–0.98) and need for ECMO (OR 0.98, 95% CI 0.96–0.99). An intrathoracic position of the liver was independently associated with an increased risk for BPD (OR 3.12, 95% CI 1.41–6.90) and need for ECMO therapy (OR 3.25, 95% CI 1.54–6.88). Conclusion: Survival rates in patients with CDH increased significantly after the implementation of a standardized treatment protocol.

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Section: Discussioncontrasting

confidence: 56%

“…In contrast to our findings, need for ECMO therapy was not associated with the O/E LHR in a recent study [36] . However, in this study the authors pointed out that the indications for ECMO therapy varied widely in their study centers [36] . In our centers, ECMO criteria were well defined and did not change over time.…”

Section: Discussioncontrasting

confidence: 56%

Actual Outcome in Infants with Congenital Diaphragmatic Hernia: The Role of a Standardized Postnatal Treatment Protocol

et al. 2011

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“…Hutcheon et al [14] showed that neonatal and infant mortality significantly decreased with advancing gestation, from 25 and 36% at 37 weeks of gestation, respectively, to 17 and 20% at 40 weeks of gestation, respectively. Moreover, a study from Odibo et al [15] among 107 CDH cases found that gestational age at delivery was inversely correlated to the need for ECMO. However, Safavi et al [16] found no difference in mortality when dividing gestational age at delivery categorically as under 37 weeks, 37-38 weeks and 39 weeks or beyond.…”

Section: Resultsmentioning

confidence: 99%

Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update

et al. 2016

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In 2010, the congenital diaphragmatic hernia (CDH) EURO Consortium published a standardized neonatal treatment protocol. Five years later, the number of participating centers has been raised from 13 to 22. In this article the relevant literature is updated, and consensus has been reached between the members of the CDH EURO Consortium. Key updated recommendations are: (1) planned delivery after a gestational age of 39 weeks in a high-volume tertiary center; (2) neuromuscular blocking agents to be avoided during initial treatment in the delivery room; (3) adapt treatment to reach a preductal saturation of between 80 and 95% and postductal saturation >70%; (4) target PaCO₂ to be between 50 and 70 mm Hg; (5) conventional mechanical ventilation to be the optimal initial ventilation strategy, and (6) intravenous sildenafil to be considered in CDH patients with severe pulmonary hypertension. This article represents the current opinion of all consortium members in Europe for the optimal neonatal treatment of CDH.

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“…The lung-to-head ratio (LHR), particularly LHR<1, 10–18 and thoracic liver position (as compared to abdominal position) have been shown to be predictors of both death and need for ECMO use. 11,14–16,18,19 More recently it has been demonstrated that increasingly abnormal stomach position is a strong predictor of not only death and ECMO, but also need for prolonged neonatal respiratory support. 20 This is likely due to the relationship of stomach position to liver position.…”

Section: Introductionmentioning

confidence: 99%

Fetal ultrasound markers of severity predict resolution of pulmonary hypertension in congenital diaphragmatic hernia

Lusk

Wai

Moon-Grady

et al. 2015

American Journal of Obstetrics and Gynecology

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Objective Congenital diaphragmatic hernia (CDH) results in morbidity and mortality due to lung hypoplasia and persistent pulmonary hypertension (PH). We sought to define the relationship between fetal ultrasound markers of severity in CDH and the time to resolution of neonatal PH. Study design We conducted a retrospective study of fetuses with an antenatal ultrasound and left-sided CDH cared for at the University of California San Francisco (2002–12). Fetal liver position was classified on ultrasound as abdominal (entire liver within the abdomen) or thoracic (any portion of the liver within the thorax). Fetal stomach position was classified from least to most aberrant: abdominal, anterior left chest, mid-posterior left chest, or retrocardiac (right chest). Lung-to-head ratio (LHR) was determined from available scans at 20–29 weeks gestational age (GA). Routine neonatal echocardiograms were performed weekly for up to 6 weeks or until PH resolved, or until discharge. PH was assessed by echocardiogram using a hierarchy of ductus arteriosus level shunt, interventricular septal position, and tricuspid regurgitant jet velocity. Days to PH-free survival was defined as the age at which pulmonary artery pressure was estimated to be <2/3 systemic blood pressure. Cox proportional hazards models adjusted for GA at birth, era of birth, fetal surgery, and GA at ultrasound (LHR model only), with censoring at 100 days. Results Of 118 patients, fetal markers were available as follows: LHR (n=53), liver position (n=112), and stomach position (n=80). Fewer infants resolved PH if they had LHR<1 (p=0.006), thoracic liver position (p=0.001), or more aberrant stomach position (p<0.001). There was also a decreased rate of resolution of PH in infants with LHR <1 (hazard ratio 0.30, p=0.007), thoracic liver position (hazard ratio 0.38, p<0.001), and more aberrant stomach position (hazard ratios 0.28, p=0.002; 0.1, p<0.001; 0.07 p<0.001). Conclusion Fetal ultrasound markers of CDH severity are predictive not just of mortality but also of significant morbidity. LHR<1, thoracic liver, and aberrant stomach position are associated with delayed time to resolution of PH in infants with CDH and may be used to identify fetuses at high risk of persistent PH.

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Predictors of the need for extracorporeal membrane oxygenation and survival in congenital diaphragmatic hernia: a center's 10‐year experience

Abstract: The study confirms the LHR, GA at delivery and liver herniation as significant prenatal predictors of the need for ECMO or survival in cases with CDH. This information is helpful for counseling women with fetuses complicated by CDH.

Cited by 22 publications

References 15 publications

Actual Outcome in Infants with Congenital Diaphragmatic Hernia: The Role of a Standardized Postnatal Treatment Protocol

Actual Outcome in Infants with Congenital Diaphragmatic Hernia: The Role of a Standardized Postnatal Treatment Protocol

Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update

Fetal ultrasound markers of severity predict resolution of pulmonary hypertension in congenital diaphragmatic hernia

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