Mortality following congenital diaphragmatic hernia repair: the role of anesthesia.

Abstract

Mortality following surgical repair of congenital diaphragmatic hernia (CDH) remains high. The volume and type of perioperative intravenous fluid administered, baro-trauma, oxygen toxicity, and the duration of anesthesia are thought to affect outcome in surgical populations. The aim of this retrospective observational study was to determine whether the perioperative volume or type of fluids and/or the duration of anesthesia were associated with postoperative mortality and if mortality was predicted by the oxygenation index (OI) prior to or following CDH surgical repair. The records of infants with a left-sided CDH and without other congenital anomalies, who underwent surgical repair between April 2009 and March 2015, were examined. The oxygenation index was used to "quantify" the severity of lung function abnormality and reported as the best OI on day 1 after birth (OIBEST ), the OI immediately prior to surgery (OIPRE ) and at 1, 6, 12, and 24h postsurgery (OI1h , OI6h , OI12h , OI24h ), respectively. The change in the OI index (delta OI) was calculated by subtracting OIPRE from postoperative OIs. The records of 37 CDH infants (median gestational age 35.8, range 31.5-41.4weeks) were assessed; six died postoperatively. Neither the duration of anesthesia, the volume of crystalloids or colloids administered, nor the peak inflation pressures used during surgical repair were significantly correlated with postoperative mortality. Neither fetal tracheal occlusion nor use of a parietal patch significantly influenced mortality. The postoperative OI1h , OI6h , OI12h showed weak evidence for a difference between survivors and nonsurvivors. An OI24h of ≥5.5 predicted mortality with 100% sensitivity (95% CI, confidence intervals (CI) 40-100) and 93.1% specificity (95% CI, 77-99). Neither the volume of intraoperative fluids administered nor the duration of anesthesia was associated with postoperative death. The OI 24h postsurgery was the best predictor of an increased risk of mortality.