Preoperative AaDO2 as an indicator for physiologic stabilization for repair in infants with congenital diaphragmatic hernia: A multicenter retrospective study

Abstract

BackgroundAppropriate timing of surgery for neonates with congenital diaphragmatic hernia (CDH) generally has been considered after cardiopulmonary stabilization. However, few reports clearly showed the definition of physiologic stabilization for surgery, while many studies have addressed hours of life for timing of repair. The aim of this study is to elucidate an optimal respiratory condition for repair in CDH. MethodsA retrospective chart review was conducted of 81 isolated CDH patients who were born and treated in three children's hospitals during Jan. 2009 through Sep.2018. To find an optimal respiratory condition for repair, alveolar-arterial oxygen difference (AaDO2) and oxygenation index (OI) right before surgery was investigated, as well as prenatal prognostic factors (observed/expected lung-to-head ratio (o/e LHR) and liver up), patients’ demographics (sex, gestational weeks, birth weight, Apgar scores), and the 30-day survival. Multivariate logistic regression analysis adjusting for the antenatal severity combined with o/e LHR and liver position was performed. ResultsAmong 81patients, 75 patients underwent surgery. The data of AaDO2 and OI right before surgery were available in 73 patients. Among 73 patients, six died in total, and of those, two out of five with extracorporeal membrane oxygenation (ECMO) died. The 30-day mortality in the subset of the fourth quartile of AaDO2 (≥340 mmHg) was significantly higher (odds Ratio (OR) 9.23 95% confidence interval (CI) 1.18072.11 P = 0.03). While mortality of the fourth quartile of OI (≥8) was also higher, it was marginally significant (OR 6.52 95% CI 0.93–45.59 p = 0.06). ConclusionsAaDO2 less than 340 mmHg could be a useful stabilization index for safe surgery in neonates with CDH.