DELAYED REPAIR OF CONGENITAL DIAPHRAGMATIC-HERNIA WITH EARLY HIGH-FREQUENCY OSCILLATORY VENTILATION DURING PREOPERATIVE STABILIZATION

Purpose: The authors reviewed their experience in the management of CD H after the introduction of early high-frequency oscillatory ventilati on (HFOV) during the preoperative stabilization period and delayed CDH repair. Methods: This is a retrospective analysis of 24 consecutive i nfants with CDH treated at University of California, Irvine Medical Ce nter (UCIMC) during a 36-month period from January 1993 to December 19 96. Results: Two patients were excluded from the study: one fetus with a prenatal diagnosis was referred for fetal surgery; one infant recei ved CDH repair at another institution 2 weeks before transfer to UCIMC . Eight (36%) infants were inborn, and nine (41%) had a prenatal diagn osis of CDH. Median gestational age was 40 weeks (range, 29 to 42 week s). Median birth weight was 3,019 g (range, 1,205 to 4,337 g). The def ect was left sided in 18 infants (86%). Twenty-one infants were intuba ted with in 5 hours of life, 15 had an AaDO2 greater than 610, 11 had an oxygenation index greater than 40, and 11 had a pH of less than 7.2 . The median ratio of pulmonary artery pressure to systemic blood pres sure was 0.93 (range, 0.51 to 1.15) in 12 infants. Eighteen infants we re placed on HFOV within a median of 1 hour of life. Nitric oxide was given to six infants and surfactant to eight. Four infants were referr ed for extracorporeal membrane oxygenation (ECMO). Repair of CDH was p erformed on infants at a median age of 33.5 hours (range, 5.5 to 322). Six (30%) received a prosthetic patch. Overall 18 of 22 infants survi ved (81%); three survivors received ECMO. Two infants of the survivor group had congenital heart anomalies: one ventricular septal defect (V SD) and one double-outlet right ventricle with a VSD. Of the four nons urvivors, one had lethal cardiac anomalies and bilateral CDH, two had severe bilateral pulmonary hypoplasia (one received ECMO), and one inf ant was a 29-week premature baby who did not qualify for ECMO. Conclus ion: We report a survival rate of 81% (18 of 22) with the management o f CDH by delayed surgical repair, early postnatal HFOV, and selective referral for ECMO. J Pediatr Surg 33:1010-1016. Copyright (C) 1998 by W.B. Saunders Company.