Role of ECMO in congenital diaphragmatic hernia

Abstract

Congenital diaphragmatic hernia (CDH) is typified morphologically by failure of diaphragmatic development with accompanying lung hypoplasia and persistent pulmonary hypertension of the newborn (PPHN). Patients who have labile physiology and low preductal saturations despite optimal ventilatory and inotropic support may be considered for extracorporeal membrane oxygenation (ECMO). Systematic reviews into the benefits of ECMO in CDH concluded that any benefit is unclear. Few randomised trials exist to demonstrate clear benefit and guide management. However, ECMO may have its uses in those that have reversibility of their respiratory disease. A few centres and networks have demonstrated an increase in survival rate by post hoc analysis (based on a difference in referral patterns with the availability of ECMO) in their series. One issue may be that of careful patient selection with regard to reversibility of pathophysiology. At present, there is no single test or prognostication that predicts reversibility of PPHN and criteria for referral for ECMO is undergoing continued refinement. Overall survival is similar between cannulation modes. There is no consensus on the time limit for ECMO runs. The optimal timing of surgery for patients on ECMO is difficult to definitively establish, but it seems that repair at an early stage (with careful perioperative management) is becoming less of a taboo, and may improve outcome and help with either coming off ECMO or decisions on withdrawal later. The provision of ECMO will continue to be evaluated, and prospective randomised trial are needed to help answer question of patient selection and management.

Neonatal Extracorporeal Membrane Oxygenation Due to Respiratory Failure: A Single Center Experience Over 28 Years

“…This is comparable to our survival rate of 46% in case of CDH over the last 20 years. Thus we agree with the authors ( 17 ) that survival rates for neonates with CDH receiving ECMO have continued to drop although the safety of ECMO has improved over the last decade. A recent review found that any benefits of ECMO in CDH remain unclear; and hence leaves the reader with more questions than answers.…”

“…In neonates with CDH on ECMO almost one-half (48.1%) survived to discharge, representing a significant decline in survival over the past 25 years ( 17 ). This is comparable to our survival rate of 46% in case of CDH over the last 20 years.…”

“…Answers looked for as regarding prognostication that predicts reversibility of pulmonary hypertension. Criteria for referral for ECMO or optimal timing of surgery for patients on ECMO are still in debate ( 17 ). In a prospective observational cohort study of 514 consecutive neonatal and pediatric patients with a survival rate of 55% intracranial hemorrhage was diagnosed in 16% (near to our 11.4% rate) that was independently associated with a higher risk of mortality ( 18 ).…”

Congenital diaphragmatic hernia presenting with symptoms within the first day of life; outcomes from a non-ECMO centre in Denmark

“…Many established ECMO-centres provide treatment for CDH-infants, when conventional therapy fails. As very few randomised trails evaluating ECMO treatment include CDH-patients, the indication of impact on survival is primarily based on case and retrospective cohort studies [9,19]. Also, comparing outcome between centres can be challenging due to differences in patient selection, variations in indications and cut-off values for initiating ECMO treatment [9,20].…”

Perioperative Complications of Congenital Diaphragmatic Hernia Repair

“…Surgery may improve respiratory function by restoring normal anatomy and even help coming off ECMO. 49,50 Some authors reported the implementation of a specific anticoagulant protocol to reduce bleeding complications for patients operated during ECMO, using tranexamic acid, with good outcomes. 51 Also, some details during surgery should be taken into account, namely the cautious use of electrocautery, limited blunt and sharp dissection, and use of prosthetic patch repair.…”