HOW OFTEN IS EXTRACORPOREAL MEMBRANE-OXYGENATION NEEDED IN CASES OF CONGENITAL DIAPHRAGMATIC-HERNIA

Some newborns with congenital diaphragmatic hernia (CDH) and severe pu lmonary hypertension cannot be saved by conventional treatment and may obtain some benefit from extracorporeal membrane oxygenation (ECMO) a s a bridging measure until adequate hematosis is possible. Early predi ction 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 1 994, 47 newborns with CDH manifested in the first 24 h were created wi th maximal ventilatory assistance (including high-frequency ventilatio n 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 res ults 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 < 0.0 1). VI was 460.9 +/- 303 and 1,532 +/- 500.6, respectively (P < 0.01). Bayesian analysis and receiver operating characteristic curves enable d us to select a threshold value of OI of 20 as the best means of pred icting survival in our current conditions (sensitivity: 0.7, specifici ty: 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 use d figure of 1,000 had 0.89 and 1, respectively. According to our resul ts, with our current management conditions, approximately 50% of our C DH patients might have obtained some benefit from ECMO.