Critical Care 3
Katrin Lichtsinn, MD (she/her/hers)
UPMC Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania, United States
Infants with congenital diaphragmatic hernia (CDH) experience high morbidity and mortality. Patients with severe disease frequently do poorly despite standardized care and extracorporeal membrane oxygenation (ECMO).
Objective: Describe clinical variables associated with ECMO utilization and non-survival in patients with CDH at a regional referral center for neonatal ECMO support.
Single-center retrospective chart review of infants with CDH admitted from January 2007 to July 2021. Demographic and clinical variables were compared using two-sample t-tests and Chi-square or Fisher’s exact tests for patients treated with and without ECMO as well as survivors and non-survivors. Logistic regression was used to identify clinical variables associated with ECMO utilization and non-survival to discharge.
Results: 133 patients were eligible of which 86.5% underwent surgical repair, 28% had liver herniation, 31% utilized ECMO, and 74% survived to discharge. Pooled survival for ECMO patients was 42% (vs 88% for non-ECMO patients), but improved over time after implementation of a standardized guideline in 2012. Most ECMO patients and non-survivors had an antenatal diagnosis with lower 1- and 5-minute APGAR scores (Table 1). ECMO patients had more liver herniation, lower pH and higher PaCO2 on admission, more severe pulmonary hypertension (PH) on their first echo, and more ventilator and supplemental oxygen (O2) days (Table 2). All ECMO patients received inhaled nitric oxide (iNO) and most utilized vasopressors, hydrocortisone, and sildenafil. Most ECMO patients had delayed open patch repairs while most non-ECMO patients had early primary thoracoscopic repairs. More non-survivors had liver herniation, pre-op pneumothorax, severe PH on the first echo, and delayed open patch repair (Table 2). Almost all non-survivors were treated with iNO and most required vasopressors, hydrocortisone, and sildenafil. Most ECMO survivors at discharge required long-term pulmonary and feeding support. Regression analysis showed liver herniation, hypercarbia on admission, and vasopressor use increased the odds of requiring ECMO (Table 3). There was also an increased association of sildenafil use in patients treated with ECMO support. Only ECMO utilization significantly increased the odds of non-survival at discharge.
Conclusion(s): Liver herniation, hypercarbia, and vasopressor use increased the likelihood of ECMO support, which in turn increased the likelihood of non-survival. Better understanding of variables associated with disease severity and clinical course may help further standardize care and improve outcomes.