Impact of Target Blood Gases on Outcome in Congenital Diaphragmatic Hernia (CDH)

Abstract

Introduction: Neonatal intensive care unit (NICU) stabilization strategies which normalize physiology according to predetermined blood gas targets may contribute to observed improved survival rates of patients with CDH. The purpose of our study was to compare risk-adjusted outcomes of CDH patients managed with or without blood gas targets established at NICU admission.

Methods: Cases were collected from a national CDH network between May 2005 and November 2007. On NICU admission, the responsible neonatologist was asked to establish target ranges for pH, pCO₂, pO₂, and pre/post-ductal O₂ saturation. The outcomes analyzed were mortality, need for ECMO, days of mechanical ventilation/supplemental oxygen, and length of stay.

Results: Of 147 CDH infants, 63 had admission blood gas targets. Severity of illness and gestational age in both groups were comparable (SNAP-II score). Infants with blood gas targets had a significantly lower mortality than those without (Hazard ratio 0.27, p=0.006).

Conclusions: Blood gas targets for the management of infants with CDH are associated with improved survival. Although the willingness to create and use stabilization targets to guide early NICU care may be a surrogate for other factors (experience, staffing, lack of interest), it is clearly associated with improved survival in CDH.

congenital diaphragmatic hernia - survival - blood gas targets - protocolized care

References

• 1 Boloker J, Bateman DA, Wung JT. et al . Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea/spontaneous respiration/elective repair.  J Pediatr Surg. 2002;  37 357-366
• 2 Grushka JR, Laberge JM, Puligandla P. et al . Effect of hospital case volume on outcome in congenital diaphragmatic hernia: the experience of the Canadian Pediatric Surgery Network.  J Pediatr Surg. 2009;  44 873-876
• 3 Wilson JM, Lund DP, Lillehei CW. et al . Congenital diaphragmatic hernia – a tale of two cities: the Boston experience.  J Pediatr Surg. 1997;  32 401-405
• 4 Okawada M, Okazaki T, Yamataka A. et al . Efficacy of protocolized management for congenital diaphragmatic hernia. A review of 100 cases.  Pediatr Surg Int. 2006;  22 925-930
• 5 Migliazza L, Bellan C, Alberti D. et al . Retrospective study of 111 cases of congenital diaphragmatic hernia treated with early high-frequency oscillatory ventilation and presurgical stabilization.  J Pediatr Surg. 2007;  42 1526-1532
• 6 Finer NN, Tierney A, Etches PC. et al . Congenital diaphragmatic hernia: developing a protocolized approach.  J Pediatr Surg. 1998;  33 1331-1337
• 7 Stevens TP, van Wijngaarden E, Ackerman KG. et al . Timing of delivery and survival rates for infants with prenatal diagnoses of congenital diaphragmatic hernia.  Pediatrics. 2009;  123 494-502
• 8 Javid PJ, Jaksic T, Skarsgard ED. et al . Survival rate in congenital diaphragmatic hernia: the experience of the Canadian Neonatal Network.  J Pediatr Surg. 2004;  39 657-660
• 9 Skarsgard ED, MacNab YC, Qiu Z. et al . SNAP-II predicts mortality among infants with congenital diaphragmatic hernia.  J Perinatol. 2005;  25 315-319
• 10 Chien LY, Whyte R, Thiessen P. et al . Snap-II predicts severe intraventricular hemorrhage and chronic lung disease in the neonatal intensive care unit.  J Perinatol. 2002;  22 26-30
• 11 Lim L, Rozycki HJ. Postnatal SNAP-II scores in neonatal intensive care unit patients: relationship to sepsis, necrotizing enterocolitis, and death.  J Matern Fetal Neonatal Med. 2008;  21 415-419
• 12 Graham B. Diagnosis, diagnostic criteria, and consensus.  Hand Clin. 2009;  25 43-48 vi
• 13 McFetridge B, Gillespie M, Goode D. et al . An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit.  Nurs Crit Care. 2007;  12 261-269

Correspondence