CONGENITAL DIAPHRAGMATIC-HERNIA WITH OR WITHOUT EXTRACORPOREAL MEMBRANE-OXYGENATION - ARE WE MAKING PROGRESS

BACKGROUND: Congenital diaphragmatic hernia (CDH) continues to have a high mortality rate (24 to 57 percent) despite changing management sch emes, which include extracorporeal membrane oxygenation (ECMO) for tre atment of associated persistent pulmonary hypertension of the newborn. STUDY DESIGN: The medical records of 123 acutely symptomatic newborns with CDH treated from 1972 to 1994 were retrospectively reviewed. Pat ients were divided into three groups to compare historical treatment m odalities: group 1, no ECMO available; group 2, postoperative ECMO if necessary; and group 3, delayed repair with preoperative ECMO if neces sary, The blood pas values, alveolar-arterial oxygen gradient (A-aDO(2 )), mean airway pressure (MAP), and oxygenation (OI) and ventilation i ndices (VI) prior to treatment were compared between survivors and non survivors. Chi-square and Student's t tests were used to determine sta tistical significance. RESULTS: The overall survival rate was 41 perce nt: 27 percent in group 1, 45 percent in group 2, and 39 percent in gr oup 3. If those who were not candidates for ECMO were excluded from an alysis, the survival rate improved to 35 percent in group 1, 51 percen t in group 2, and 50 percent in group 3. No published prognostic scori ng system, such as arterial blood gas values, A-aDO(2) gradient, MAP, OI, or VI consistently distinguished survivors from nonsurvivors. Extr acorporeal membrane oxygenation decreased the mortality rate of patien ts having large defects. CONCLUSIONS: Prognostic scoring systems do no t predict which patients with CDH should be treated. Extracorporeal me mbrane oxygenation has improved survival in newborns with CDH who pres ent in early respiratory distress. There is no advantage or disadvanta ge to using ECMO prior to repair of CDH.