CONGENITAL DIAPHRAGMATIC HERNIA: OUTCOME WITH CHANGING MANAGEMENT.† 1236

Abstract

Infants presenting with Congenital Diaphragmatic Hernia (CDH) continue to experience a high mortality. In an effort to evaluate changing management we reviewed our experience since introducing ECMO in Feb 1989 to August 1995. Inborn fetuses recieved Dexamethasone, electively timed delivery, low pressure resuscitation, prophylactic bovine surfactant, minimal pressure ventilation with permissive hypercarbia (PaCO2 to 70% were accepted in the first three hours with a stable BP. In the last 2 years we have avoided vigorous hyperventilation, the use of high PIP's and used HFO to lower PaCO2. In the period of this review only one infant was denied full support. Seventy-five infants were referred, 59 arrived alive and were treated in our institution, 39 after delivery, of whom 7 infants had already undergone repair, and 20 were inborn, 18 of whom had been antenatal referrals. Of 35 infants who required ECMO, (22 VA, 13VVDL) 24 survived (69%) compared to 22 of 24 (92%) who did not. For the 20 inborn infants, 17 survived (90%); compared to 26 of 39 outborn infants,(60%,NS). 15 of 18 inborn infants with an antenatal diagnosis survived(83%) compared to 10 of 18 (50%) similar outborn infants (NS). Infants treated in our first 2 years had higher mortality than those treated later (33% vs 16% NS). In the infants who required ECMO, the average time of surgery in group 1 was 4.7 days compared 8.1 days (p=0.016) in group 3. Similarly, the time to surgery was prolonged in the non-ECMO infants, 1.3 to 6.1 days (p=.01). There was an equal mortality in infants diagnosed before or after 24 weeks gestation. Seven of 11 infants whose best PaO2 `s were<50torr survived. No other criteria including Bohn's PaCO2 vs VI plots predicted outcome. Our results suggest that outcome for infants with CDH is improving and that a comprehensive protocol including antenatal assessment, planning and treatment may further reduce mortality and morbidity.