Abstract
Some newborns with congenital diaphragmatic hernia (CDH) and severe pulmonary hypertension cannot be saved by conventional treatment and may obtain some benefit from extracorporeal membrane oxygenation (ECMO) as a bridging measure until adequate hematosis is possible. Early prediction of the insufficiency of “optimal” assistance is still unclear; we reviewed our recent experience with CDH patients in an attempt to evaluate the real need for ECMO in our institution. Between 1987 and 1994, 47 newborns with CDH manifested in the first 24 h were treated with maximal ventilatory assistance (including high-frequency ventilation in 12 cases) and vasoactive drugs prior to surgical repair. In order to summarize the ventilatory and blood-gas parameters, we determined oxygenation index (OI) and ventilatory index (VI) and compared the results in survivors and nonsurvivors. Overall survival was 60% (2 cases of Fryns' syndrome were excluded from analysis). OI was 10.3±5.7 (mean ± SD) for survivors and 46.2 ± 37.8 for nonsurvivors (P < 0.01). VI was 460.9±303 and 1,532±500.6, respectively (P <0.01). Bayesian analysis and receiver operating characteristic curves enabled us to select a threshold value of OI of 20 as the best means of predicting survival in our current conditions (sensitivity: 0.7, specificity: 0.83). The generally accepted figure of 40 had a sensitivity of 1 but a specificity of only 0.44. For VI, the best threshold value was 1,100 (sensitivity: 0.93, specificity: 0.94), whereas the generally used figure of 1,000 had 0.89 and 1, respectively. According to our results, with our current management conditions, approximately 50% of our CDH patients might have obtained some benefit from ECMO.
Similar content being viewed by others
References
Anderson HL III, Snedecor SM, Otsu T, Barlett RH (1993) Multicenter comparision of conventional venoarterial access versus venovenous double-lumen catheter access in newborn infants undergoing extracorporeal membrane oxygenation. J Pediatr Surg 28: 530–535
Atkinson JA, Ford EG, Humphries B, Kitagawa H, Lew C, Garg M, Bui K (1991) The impact of extracorporeal membrane support in the treatment of congenital diaphragmatic hernia. J Pediatr Surg 26: 791–793
Barlett RH, Gazzaniga AB, Fong SN (1977) Extracorporeal membrane oxygenator support for cardiopulmonary failure. J Thorac Cardiovasc Surg 73: 375–386
Beals DA, Schloo BL, Vacanti JP, Reid LM, Wilson JM (1992) Pulmonary growth and remodeling in infants with high-risk congenital diaphragmatic hernia. J Pediatr Surg 27: 997–1002
Beck JR, Shultz EK (1986) The use of relative operating characteristic (ROC) curves in test performance evaluation. Arch Pathol Lab Med 110: 13–20
Bohn DJ, Filler JRM, Ein SH, Wesson DE, Shandling B, Stephens C, Barker GA (1984) The relationship between PaCO2 and ventilation parameters in predicting survival in congenital diaphragmatic hernia. J Pediatr Surg 19: 666–671
Boix-Ochoa J, Perguero G, Seijo G (1974) Acid-base balance and blood gases in prognosis and therapy of congenital diaphragmatic hernia. J Pediatr Surg 9: 49–57
Breaux CW, Rouse TM, Cain WS, Georgeson KE (1991) Improvement in survival of patients with congenital diaphragmatic hernia utilizing a strategy of delayed repair after medical and/or extracorporeal membrane oxygenation stabilization. J Pediatr Surg 26: 333–338
Cartlidge PHT, Mann NP, Kapila L (1986) Preoperative stabilisation in congenital diaphragmatic hernia. Arch Dis Child 61: 1226–1228
Ehren H, Frenckner B, Palmer K (1992) Diaphragmatic hernia in infancy and childhood — 20 years experence. Eur J Pediatr Surg 2: 327–331
German JC, Worcester C, Gazzaniga AB, Huxtable RF, Amlie RN, Brahmbhatt N, Barlett RH (1980) Techical aspects in the management of the meconium aspiration syndrome with extracorporeal circulation. J Pediatr Surg 12: 378–383
Glick PL, Leach CL, Besner GE, Egan EA, Morin FC, Malanowska-Kantoch A, Robinson LK, Brody A, Lele AS, McDonell M, Holm B, Rodgers BT, Msall ME, Courey NG, Karp MP, Allen JE, Jewett TC, Cooney DR (1992) Pathophysiology of congenital diaphragmatic hernia III: exogenous surfactant therapy for the high-risk neonate with CDH. J Pediatr Surg 27: 866–869
Hanley JA, McNeil BJ (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143: 29–36
Harrington J, Raphaely RC, Downes JJ (1982) Relationship of alveolar-arterial oxygen tension difference in diaphragmatic hernia of the newborn. Anesthesiology 56: 473–476
Haugen SE, Linker D, Eik-Nes S, Kufaas T, Vik T, Eggen BM, Brubakk AM (1991) Congenital diaphragmatic hernia: determination of the optimal time for operation by echocardiographic monitoring of the pulmonary arterial pressure. J Pediatr Surg 26: 560–562
Kobayashi H, Puri P (1994) Plasma endothelin levels in congenital diaphragmatic hernia. J Pediatr Surg 29: 1258–1261
Iritani I (1984) Experimental study on embryogenesis of congenital diaphragmatic hernia. Anat Embryol 169: 133–139
Karl SR, Ballantine TVN, Snider MT (1983) High-frequency ventilation at rates of 375 to 1800 cycles per minute in four neonates with congenital diaphragmatic hernia. J Pediatr Surg 18: 822–828
Kinsella JP, Neish SR, Ivy DD, Shaffer E, Abman SH (1993) Clinical responses to prolonged treatment of persistent pulmonary hypertension of the newborn with low doses of inhaled nitric oxide. J Pediatr 123: 103–108
Lassaletta L, Queizan A, Benavent I, Jaureguizar E, Cabrera R (1980) Tratamiento postoperatorio de la hernia diafragmática congénita con vasodilatadores pulmonares. Ann Esp Pediatr 13: 651–656
Marsh TD, Wilkerson SA, Cook LN (1988) Extracorporeal membrane oxygenation selection criteria: partial pressure of arterial oxygen versus alveolar-arterial oxygen gradient. Pediatrics 82: 162–166
Molenaar JC, Bos AP, Hazebroek FWJ, Tibboel D (1991) Congenital diaphragmatic hernia, what defect? J Pediatr Surg 26: 248–254
Murcia J, Prada C, Lassaletta L (1985) Estado actual del tratamiento de la hernia diafragmática congénita. Ann Esp Pediatr 23: 439–444
Norden MA, Butt W, McDougall P (1994) Predictors of survival for infants with congenital diaphragmatic hernia. J Pediatr Surg 29: 1442–1446
O'Rourke PP, Crone RK, Vacanti JP, Ware JH, Lillehei CW, Parad RB, Epstein MF (1989) Extracorporeal membrane oxygenation and conventional medical therapy in neonates with persistent pulmonary hypertension of the newborn: a prospective randomized study. Pediatrics 84: 957–963
O'Rourke PP, Lillehei CW, Crone RK, Vacanti JP (1991) The effect of extracorporeal membrane oxygenation on the survival of neonates with high-risk congenital diaphragmatic hernia: 45 cases from a single institution. J Pediatr Surg 26: 147–152
Rosenberg AA, Kennaugh J, Koppenhafer SL, Loomis M, Chatfield BA, Abman SH (1993) Elevated immunoreactive endothelin1 levels in newborn infants with persistent pulmonary hypertension. J Pediatr 123: 109–114
Ryan DP, Doody DP (1992) Treatment of acute pulmonary failure with extracorporeal support: 100% survival in a pediatric population. J Pediatr Surg 27: 1111–1117
Shaw KS, Filiatrault D, Yazbeck S, St-Vil D (1994) Improved survival for congenital diaphragmatic hernia, based on prenatal ultrasound diagnosis and referral to a combined obstretic-pediatric surgical center. J Pediatr Surg 29: 1268–1269
Van Meurs KP, Newman KD, Anderson KD, Short BL (1990) Effect of extracorporeal membrane oxygenation on survival of infants with congenital diaphragmatic hernia. J Pediatr 117: 954–960
Weber TR, Tracy TF, Connors R, Kountzman B, Pennington DG (1992) Prolonged extracorporeal support for nonneonatal respiratory failure. J Pediatr Surg 27: 1100–1105
Wilson JM, Lund DP, Lillehei CW, Vacanti JP (1991) Congenital diaphragmatic hernia: predictors of severity in the ECMO Era. J Pediatr Surg 26: 1028–1034
Wilson JM, Lund DP, Lillehei CW, O'Rourke PP, Vacanti JP (1992) Delayed repair and preoperative ECMO does not improve survival in high-risk congenital diaphragmatic hernia. J Pediatr Surg 27: 368–375
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Soto Beauregard, M.C., Murcia, J., Lassaletta, L. et al. How often is extracorporeal membrane oxygenation needed in cases of congenital diaphragmatic hernia?. Pediatr Surg Int 11, 528–531 (1996). https://doi.org/10.1007/BF00626058
Published:
Issue Date:
DOI: https://doi.org/10.1007/BF00626058