Original Article
Role of admission gas exchange measurement in predicting congenital diaphragmatic hernia survival in the era of gentle ventilation☆,☆☆

https://doi.org/10.1016/j.jpedsurg.2014.03.011Get rights and content

Abstract

Background/Purpose

Neonates with significant congenital diaphragmatic hernia (CDH) require cardiopulmonary support. Management has been characterized by progressive abandonment of hyperventilation. Ability to prognosticate outcomes using measures of ventilation and oxygenation with gentle ventilation remains unclear. We sought to determine whether assessment of gas exchange at the time of NICU admission is predictive of survival in this current era.

Methods

Neonates with CDH admitted to a Children’s Hospital from 1995 to 2006 were evaluated for demographics, blood gas (ABG) measurements and ventilator settings for the first 48 hours, and discharge outcome.

Results

One-hundred-and-nineteen CDH patients were admitted, 88 (74%) survived. Mean admission ABG pCO2 was higher in infants who died compared to survivors (86 ± 48 versus 49 ± 20, p ≤ 0.001); positive predictive value (PPV) for mortality of pCO2 ≥ 80 mmHg was 0.71. Mean first hour preductal oxygen saturation (preductalO2Sat) was lower in infants who died compared to survivors (81 ± 17 versus 97 ± 5, p < 0.001); PPV for mortality of preductalO2Sat < 85% was 0.82. Eleven patients met both pCO2 and preductalO2Sat criteria, and 10 (91%) died, PPV of 0.92. Within hours of admission, pCO2 and preductalO2Sat differences between survivors and nonsurvivors lost significance.

Conclusion

Admission pCO2 and preductalO2Sat may be useful in predicting survival in neonatal CDH. The differential in gas exchange between survivors and nonsurvivors loses significance with contemporary neonatal care.

Section snippets

Study type and setting

This is an Institutional Review Board-approved retrospective case series of all newborns admitted with a diagnosis of CDH to the neonatal intensive care unit (NICU) at Children’s Hospital of Wisconsin between January 1995 and December 2006. A tertiary academic hospital with an active obstetrical service is physically connected to the Children’s Hospital; births at this tertiary academic hospital are considered ‘inborn’ as ambulance or air transport is not required. Newborns admitted with a CDH

Cohort survival

Table 1 shows the characteristics of the study cohort. During the study period, 119 patients with CDH were admitted to the NICU and 88 (74%) survived to discharge. The Wisconsin Death Registry query and review of hospital records revealed death of one study patient after discharge. Table 2 shows characteristics associated with mortality. Infants with an associated major anomaly (n = 17) had the lowest survival (41%). Exclusion of patients with associated major anomalies increased the cohort

Discussion

In this retrospective case series of 119 CDH patients admitted to a tertiary NICU and managed with contemporary ventilation techniques, we found that initial admission pCO2 and preductalO2Sat during the first hour are important for prognostication of survival. However, within hours of admission, the predictive value of these parameters lost their significance. These data are consistent with the concept that the initial arterial pCO2 and first hour preductalO2Sat remain indicative of the

References (21)

  • D.J. Bohn et al.

    The relationship between PaCO2 and ventilation parameters in predicting survival in congenital diaphragmatic hernia

    J Pediatr Surg

    (1984)
  • P.P. O’Rourke et al.

    Use of the postductal PaO2 as a predictor of pulmonary vascular hypoplasia in infants with congenital diaphragmatic hernia

    J Pediatr Surg

    (1988)
  • J.F. Germain et al.

    Can blood gas values predict pulmonary hypoplasia in antenatally diagnosed congenital diaphragmatic hernia?

    J Pediatr Surg

    (1996)
  • D. Bohn et al.

    Ventilatory predictors of pulmonary hypoplasia in congenital diaphragmatic hernia, confirmed by morphologic assessment

    J Pediatr

    (1987)
  • A.W. Dibbins et al.

    Mortality from neonatal diaphragmatic hernia

    J Pediatr Surg

    (1974)
  • H. Mishalany et al.

    Congenital diaphragmatic hernias: eleven years experience

    Arch Surg

    (1979)
  • C. Stolar et al.

    Selective use of extracorporeal membrane oxygenation in the management of congenital diaphragmatic hernia

    J Pediatr Surg

    (1988)
  • D.W. Kays et al.

    Detrimental effects of standard medical therapy in congenital diaphragmatic hernia

    Ann Surg

    (1999)
  • D. Bohn

    Congenital diaphragmatic hernia

    Am J Respir Crit Care Med

    (2002)
  • B.A. Yoder et al.

    Does a highest pre-ductal O(2) saturation < 85% predict non-survival for congenital diaphragmatic hernia?

    J Perinatol

    (2012)
There are more references available in the full text version of this article.

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☆

Conflict of Interest: All authors have no conflict of interest relevant to this article to disclose.

☆☆

Funding: No external funding.

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