IMPROVED RESULTS IN PATIENTS WHO HAVE CONGENITAL DIAPHRAGMATIC-HERNIAUSING PREOPERATIVE STABILIZATION, EXTRACORPOREAL MEMBRANE-OXYGENATION, AND DELAYED SURGERY

Congenital diaphragmatic hernia (CDH) is associated with pulmonary hyp oplasia. The pulmonary vascular bed may be extremely reactive to vario us stimuli, and in the treatment it is important to avoid pulmonary va sospasm. The strategy in our institution since 1990 has involved a pro longed preoperative stabilization with gentle mechanical ventilation. Pressures have been kept as low as possible, and slight hypercarbia ha s been accepted. Peak inspiratory pressures exceeding 35 cm H2O have b een avoided. Extracorporeal membrane oxygenation (ECMO) has been used according to standard inclusion criteria. Nitric oxide and high-freque ncy oscillation have been added to the therapeutic modalities during t he study period. When the patient was considered stabilized, surgical repair was undertaken after a delay of 24 to 96 hours. In patients on ECMO who could not be decannulated, surgical repair was undertaken whi le on ECMO. From 1990 through 1995, 52 patients were admitted with a d iagnosis of CDH. Forty-three of these were risk group patients present ing with respiratory distress within 6 hours after birth. A total of 4 8 patients survived (survival rate 92%), and 39 of the risk group pati ents (survival rate 91%). There were only four hospital deaths, all wi th contraindications to ECMO. It is suggested that the adopted protoco l is beneficial in the treatment of CDH and that the fraction of patie nts who have pulmonary hypoplasia incompatible with life is smaller th an previously believed. Copyright (C) 1997 by W.B. Saunders Company.