Top

Published in:

01-11-2018 | Original Article

Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC)

Authors: Sarah B. Cairo, Mary Arbuthnot, Laura A. Boomer, Michael W. Dingeldein, Alexander Feliz, Samir Gadepalli, Chris R. Newton, Robert Ricca Jr., Adam M. Vogel, David H. Rothstein, On behalf of the American Pediatric Surgical Association, Surgical Critical Care Committee

Published in: Pediatric Surgery International | Issue 11/2018

Abstract

Purpose

Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO.

Methods

Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC).

Results

Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5–15 CDH repairs were reported annually per institution; 26–50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III–IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4–5 weeks.

Conclusions

Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions.

Level of evidence

V (expert opinion).

Available only for authorised users

Morini F, Goldman A, Pierro A (2006) Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia: a systematic review of the evidence. Eur J Pediatr Surg 16(6):385–391CrossRef

Kays DW et al (2013) Long-term maturation of congenital diaphragmatic hernia treatment results: toward development of a severity-specific treatment algorithm. Ann Surg 258(4):638–644 (discussion 644–5) PubMedPubMedCentral

Puligandla PS et al (2015) Management of congenital diaphragmatic hernia: a systematic review from the APSA outcomes and evidence based practice committee. J Pediatr Surg 50(11):1958–1970CrossRef

Seetharamaiah R et al (2009) Factors associated with survival in infants with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: a report from the Congenital Diaphragmatic Hernia Study Group. J Pediatr Surg 44(7):1315–1321CrossRef

Keijzer R, Puri P (2010) Congenital diaphragmatic hernia. Semin Pediatr Surg 19(3):180–185CrossRef

Bokman CL et al (2015) Determinants of survival and resource utilization for pediatric extracorporeal membrane oxygenation in the United States 1997–2009. J Pediatr Surg 50(5):809–814CrossRef

Paden ML et al (2014) Update and outcomes in extracorporeal life support. Semin Perinatol 38(2):65–70CrossRef

Ryan CA et al (1994) Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia and cardiac malformations. J Pediatr Surg 29(7):878–881CrossRef

Vaja R et al (2017) The use of extracorporeal membrane oxygenation in neonates with severe congenital diaphragmatic hernia: a 26-year experience from a tertiary centre†. Eur J Cardiothorac Surg 52:552–557CrossRef

10.

Bryner BS et al (2009) Congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: does timing of repair matter? J Pediatr Surg 44(6):1165–1171 (discussion 1171–2) CrossRef

11.

Hsu C-C, Sandford BA (2007) The Delphi technique: making sense of consensus. Practical Assess Res Eval 12(10):1–8

12.

Grushka JR et al (2009) Effect of hospital case volume on outcome in congenital diaphragmatic hernia: the experience of the Canadian Pediatric Surgery Network. J Pediatr Surg 44(5):873–876CrossRef

13.

Salazar JH et al (2016) Regionalization of pediatric surgery: trends already underway. Ann Surg 263(6):1062–1066CrossRef

14.

Morini F et al (2017) Treatment strategies for congenital diaphragmatic hernia: change sometimes comes bearing gifts. Front Pediatr 5:195CrossRef

15.

Barbaro RP et al (2017) Pediatric Extracorporeal Life Support Organization registry international report 2016. ASAIO J 63(4):456–463CrossRef

16.

Kays DW et al (2015) Outcomes in the physiologically most severe congenital diaphragmatic hernia (CDH) patients: whom should we treat? J Pediatr Surg 50(6):893–897CrossRef

17.

Guner YS et al (2009) Outcome analysis of neonates with congenital diaphragmatic hernia treated with venovenous vs venoarterial extracorporeal membrane oxygenation. J Pediatr Surg 44(9):1691–1701CrossRef

18.

Dimmitt RA et al (2001) Venoarterial versus venovenous extracorporeal membrane oxygenation in congenital diaphragmatic hernia: the Extracorporeal Life Support Organization Registry, 1990–1999. J Pediatr Surg 36(8):1199–1204CrossRef

19.

Chapman RL et al (2009) Patient selection for neonatal extracorporeal membrane oxygenation: beyond severity of illness. J Perinatol 29(9):606–611CrossRef

20.

Kuo KW et al (2017) Should extracorporeal membrane oxygenation be offered? An international survey. J Pediatr 182:107–113CrossRef

21.

Biscotti M et al (2015) Extracorporeal membrane oxygenation use in patients with traumatic brain injury. Perfusion 30(5):407–409CrossRef

22.

Cho HJ et al (2017) Anticoagulation therapy during extracorporeal membrane oxygenator support in pediatric patients. Chonnam Med J 53(2):110–117CrossRef

23.

Anton-Martin P et al (2017) Coagulation profile is not a predictor of acute cerebrovascular events in pediatric extracorporeal membrane oxygenation patients. ASAIO J Pediatr Circulatory Support 63:793–801

24.

Botden SM et al (2017) Bilateral congenital diaphragmatic hernia: prognostic evaluation of a large international cohort. J Pediatr Surg 52(9):1475–1479CrossRef

25.

Delaplain PT et al (2017) Cannulating the contraindicated: effect of low birth weight on mortality in neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation. J Pediatr Surg 52:2018–2025CrossRef

26.

Harting MT, Lally KP (2014) The Congenital Diaphragmatic Hernia Study Group registry update. Semin Fetal Neonatal Med 19(6):370–375CrossRef

27.

Stevens TP et al (2002) Survival in early- and late-term infants with congenital diaphragmatic hernia treated with extracorporeal membrane oxygenation. Pediatrics 110(3):590–596CrossRef

28.

Kays DW et al (2014) Extracorporeal life support in patients with congenital diaphragmatic hernia: how long should we treat? J Am Coll Surg 218(4):808–817CrossRef

29.

Tiruvoipati R et al (2007) Predictors of outcome in patients with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation. J Pediatr Surg 42(8):1345–1350CrossRef

30.

Fallon SC et al (2013) Repair of congenital diaphragmatic hernias on Extracorporeal Membrane Oxygenation (ECMO): does early repair improve patient survival? J Pediatr Surg 48(6):1172–1176CrossRef

31.

Karimova A et al (2009) Neonatal extracorporeal membrane oxygenation: practice patterns and predictors of outcome in the UK. Arch Dis Child Fetal Neonatal Ed 94(2):F129–F132CrossRef

Title: Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC)
Authors: Sarah B. Cairo
Mary Arbuthnot
Laura A. Boomer
Michael W. Dingeldein
Alexander Feliz
Samir Gadepalli
Chris R. Newton
Robert Ricca Jr.
Adam M. Vogel
David H. Rothstein
On behalf of the American Pediatric Surgical Association, Surgical Critical Care Committee
Publication date: 01-11-2018
Publisher: Springer Berlin Heidelberg
Published in: Pediatric Surgery International / Issue 11/2018
Print ISSN: 0179-0358
Electronic ISSN: 1437-9813
DOI: https://doi.org/10.1007/s00383-018-4337-y

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC)

Abstract

Purpose

Methods

Results

Conclusions

Level of evidence

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Level of evidence

Please log in to get access to this content

Other articles of this Issue 11/2018

Peritoneal dialysis catheter placement, outcomes and complications

Can time to healing in pediatric blunt splenic injury be predicted?

Clinical characteristic comparison of low birth weight and very low birth weight preterm infants with neonatal necrotizing enterocolitis: a single tertiary center experience from eastern China

Single center protocol driven care in 150 patients with gastroschisis 1998–2017: collaboration improves results

Advances in understanding the association between Down syndrome and Hirschsprung disease (DS–HSCR)

A safe and efficacious preventive strategy in the high-risk surgical neonate: cycled total parenteral nutrition