CONGENITAL DIAPHRAGMATIC-HERNIA - DEVELOPING A PROTOCOLIZED APPROACH

Background/Purpose: The purpose of this study was to evaluate the evol ving outcome of newborns who have congenital diaphragmatic hernia (CDH ) using a protocolized approach to management, which includes extracor poreal membrane oxygenation (ECMO) and to present the details of such a management protocol. Methods: A retrospective chart review was condu cted of the neonatal outcome of near-term (>34 weeks' gestation) newbo rns with CDH ail referred to the Royal Alexandra Hospital either befor e or after delivery. A protocol was developed that included antenatal assessment, the use of antenatal steroids, planned delivery, use of pr ophylactic surfactant, pressure limited gentle ventilation, permissive hypercarbia and hypoxia, and venovenous ECMO, if indicated. Results: Sixty-five infants with CDH were treated from February 1989 through Au gust 1996. Twenty-three infants were inborn, 20 of whom were antenatal referrals. Overall, 51 of the 65 infants survived (78%). Thirteen of the 23 inborn infants survived with conservative management, and 10 re quired ECMO, of whom, eight were long-term survivors. Thirty-eight inf ants required ECMO, and 26 survived (68%), whereas there were only two deaths among the 27 conservatively treated infants. Eighteen of 20 in born infants with an antenatal diagnosis survived, compared with 13 of 21 (62%) outborn infants. An antenatal diagnosis before 25 weeks' ges tation was associated with a 60% survival rate. Sixty-three percent of infants whose best postductal Pao(2) value before ECMO was less than 100 torr survived, and 7 of 11 infants with a best postductal Pao(2) v alue of less than 50 torr before ECMO survived (64%). The average age at surgery progressively increased over time both for infants who rece ived ECMO (1.9 days to 8.2 days; P=.016). Conclusions: The use of a pr otocolized management for infants with CDH has been associated with im proving outcome in a population at high risk. The components (either s eparately or combined) of these protocolized approaches need to be tes ted in prospective trials to determine their true benefit. In addition , there is a need to evaluate prospectively the outcomes of infants wi th CDH born in ECMO centers compared with those infants born in other tertiary care neonatal units to determine the most appropriate managem ent of the fetus with CDH. Copyright (C) 1998 by W.B. Saunders Company .