Less is more: ECMO utilization and outcomes in congenital diaphragmatic hernia

Abstract

Purpose: Infants with congenital diaphragmatic hernia (CDH) have varying degrees of pulmonary hypoplasia leading to cardiopulmonary derangements such as pulmonary hypertension. Extracorporeal membranous oxygenation (ECMO) can be necessary for survival in some patients. Our institution implemented a change in the NICU critical care management guideline for neonates with CDH in 2016. Indications for ECMO remained the same in the revised guideline. This study evaluated survival and surgical outcomes in CDH patients who underwent repair before and after this guideline change.

Methods: Using an internal institutional registry, we identified a retrospective cohort of all CDH patients treated at our institution between January 2003 and December 2024. Patients were stratified based on year of birth before 2016 or 2016 and after. A retrospective chart review was conducted to extract primary and secondary outcome variables, which were analyzed using bivariate comparisons.

Results: A retrospective cohort of 389 patients with CDH was identified. Two hundred twenty-nine patients were treated before 2016, and 160 during or after 2016. ECMO was performed on 71 (31.0 %) patients prior to 2016 and 15 (9.4 %) patients during or after 2016 (p < 0.001). ECMO runs and repairs on ECMO significantly decreased for patients with the most severe defect sizes (C, D). Survival was not significantly different for A, B, or C defects and was significantly improved in the most severe defects (D) (90.9 % vs 42.9 %, p < 0.001) after the guideline change. Complications from ECMO, massive bleeding events, and thrombosis were not statistically different between time points.

Conclusion: Changes in clinical management guideline, but not indications for ECMO, resulted in fewer ECMO runs and fewer CDH repairs on ECMO. Overall survival improved, including a significant improvement in survival for the most severe defect subgroup (D). ECMO complications, bleeding, and clotting were not different between groups, indicating that the risks of ECMO were not affected by the guideline changes.

Level of evidence: IV.

Keywords: Congenital diaphragmatic hernia; ECMO; Extracorporeal membranous oxygenation; Meta-analysis; Muscle flap repair; Pediatric surgery.