99 - Variability in Hemodynamic Support Practices for Infants with Congenital Diaphragmatic Hernia (CDH) across the Children’s Hospital Neonatal Consortium (CHNC)

Monday, May 1, 2023

9:30 AM – 11:30 AM ET

Poster Number: 99
Publication Number: 99.425

Vedanta S. Dariya, University of Texas Southwestern Medical School, Dallas, TX, United States; Sharada H. Gowda, Baylor College of Medicine, Houston, TX, United States; Abhishek Makkar, Oklahoma Childrens Hospital at OU Health, Oklahoma City, OK, United States; Ruth B. Seabrook, Nationwide Children's Hospital, Columbus, OH, United States; Burhan Mahmood, UPMC Childrens Hospital of Pittsburgh, Pittsburgh, PA, United States

Presenting Author(s)

VD

Vedanta S. Dariya, MBBS (he/him/his)

Assistant Professor of Pediatrics
University of Texas Southwestern Medical School
Dallas, Texas, United States

Background: Consensus guidelines for prenatal guidance, delivery room care, ventilator management, timing of surgery and criteria for escalation to ECMO support for babies with CDH are widely available. However, detailed guidelines for hemodynamic support based on well-defined objectives and clinical criteria are lacking. Left (LVD) and right (RVD) ventricular dysfunction are now well described in CDH patients. There is a growing understanding of the need for individualized, echocardiographically-guided management of ventricular dysfunction and associated hypotension in neonates.

Objective: To assess the variability in hemodynamic support practices for CDH patients across the CHNC.

Design/Methods: A Redcap survey questionnaire was distributed to 37 participating level IV NICUs in the CHNC to describe their CDH hemodynamic management guidelines. We requested a single representative response per institution. Only guideline-based responses were accepted to eliminate individual respondent biases. For centers reporting echo-guided decisions for vasoactive support, we queried their approach to 3 clinical scenarios 1) LVD, 2) RVD and 3) intact ventricular function (IF). Data were analyzed by descriptive statistics.

Results: The response rate was 32/37, (86%). Most survey respondents 1) had guidelines for hemodynamic support (90%) and 2) targeted BP values based on adequate signs of tissue perfusion (68%). Forty two percent of responding sites use echo-guided (EG) vasoactive support decision-making, 42% have pre-determined algorithms (non-echo guided (NEG)) while 16% have no vasoactive medication algorithm (Fig. 1). Milrinone, Alprostadil and Hydrocortisone are used in 84%, 48% and 93% of centers. At centers with NEG (Fig. 2), volume is the most common 1st line agent. For EG centers, inotropy selection varied in response to cardiac function (Figure 3). Maximal vasoactive support (MVS) is most commonly (62%) described as ≥ 3 vasoactive agents and the commonest indication (81%) for ECMO. Dopamine use is contraindicated at 4 centers.

Conclusion(s): Our survey uncovered variability in practices across the CHNC in vasoactive agent selection, dosing regimens, and adjunct therapy use during the management of patients with CDH. This is the first detailed survey that we know of to describe the variation in guidelines for vasoactive agent use across North America. The results of this survey will serve as a starting point to evaluate the risks and benefits of specific vasoactive agent usage with a goal of creating evidence-based, best-practice guidelines.