title: Cardiac arrest before repair or extracorporeal membrane oxygenation cannulation does not increase the mortality rate associated with congenital diaphragmatic hernia.
abstract: Despite recent advances in the management of high-risk congenital diaphragmatic hernia (CDH), mortality remains high. Deaths occur later because infants with inadequate pulmonary parenchyma are treated aggressively but eventually succumb to respiratory failure. In an attempt to identify absolute predictors of mortality the authors examined retrospectively their experience with CDH to determine if cardiac arrest before repair or initiation of extracorporeal membrane oxygenation (ECMO) invariably increased mortality. The authors reviewed the charts of 119 infants who had high-risk CDH treated between 1981 and 1994. They were divided into two groups: those that suffered cardiopulmonary arrest (CA, n = 21) before CDH repair or ECMO cannulation; and those that did not (NCA, N = 98). The authors compared mortality rate, ventilatory parameters, duration of, and complications on ECMO, as well as length of hospitalization between groups. Twenty-one infants suffered CA before initiation of ECMO support or CDH repair. Three infants (14%) suffered CA before arrival at our institution; seven (33%) after, and 11 (53%) both before and after arrival. There was no difference between the CA and NCA groups in terms of birth weight, gestational age, race and gender mix, or pregnancy and delivery complications. Five-minute Apgar scores were significantly lower in the CA group compared with the NCA group (4.6 v 5.7, P = .04). The CA group also had significantly worse "best postductal" blood gas and ventilatory parameters. There was no significant difference in length of hospitalization, time from admission to ECMO cannulation or CDH repair, or incidence of complications while on ECMO between the two groups. CA cases were more likely to require ECMO support (76% v 48%, P = .02) and to stay on ECMO for a more prolonged period than NCA cases (5.8 v 3.8 days, P = NS). However, there was no significant difference in overall survival between CA and NCA cases (43% v 51%, P = NS). Cardiopulmonary arrest before repair of CDH or ECMO cannulation is not a univariate independent predictor of mortality and therefore should not preclude these high-risk infants from maximum intensive care therapy, including ECMO cannulation.
authors.affiliation: Department of Surgery, University of Pittsburgh School of Medicine, and Children's Hospital of Pittsburgh, PA, USA.
authors.forename: A P
authors.initials: AP
authors.lastname: Courcoulas
authors.forename: K K
authors.initials: KK
authors.lastname: Reblock
authors.forename: M I
authors.initials: MI
authors.lastname: Rowe
authors.forename: H R
authors.initials: HR
authors.lastname: Ford
mesh_terms: D000704:Analysis of Variance; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006323:Heart Arrest / Q000150:complications*; D006548:Hernia, Diaphragmatic / Q000150:complications / Q000401:mortality* / Q000601:surgery; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D010414:Pennsylvania / Q000453:epidemiology; D011379:Prognosis; D012131:Respiratory Insufficiency / Q000150:complications; D015996:Survival Rate; D013997:Time Factors