title: Stability prior to surgery in Congenital Diaphragmatic Hernia: is it necessary?
abstract: BACKGROUND
  Delaying surgery for infants with CDH until they achieve clinical stability is common practice. Stability, however, is inconsistently defined, and many infants fail to reach pre-established criteria. We sought to determine if infants undergoing surgery without meeting pre-established criteria could achieve meaningful survival.
  
  
  METHODS
  All infants in the CAPSNet database were analyzed (2005-2010). Patients undergoing operative repair were divided into two groups based on whether they met strict (FiO2<0.40, conventional ventilation, preductal saturation >92%, no inotropes or vasodilators), or lenient (FiO2 <0.60, conventional ventilation, preductal saturation >88%, no vasodilators) criteria. Univariate analyses were performed comparing characteristics of those who survived after surgery (N=273) with those who did not (N=21).
  
  
  RESULTS
  294 patients (85%) survived to surgery. Predictors of post-operative survival included prenatal liver position (p=0.003), preoperative oxygen requirements (p=0.008), preoperative inotropes (p<0.0001), and non-conventional ventilation (p=0.004). Infants meeting strict criteria had increased survival (99%; p<0.0001). Infants meeting lenient criteria constituted 70% of survivors. Nearly one-third of survivors met neither strict nor lenient criteria.
  
  
  CONCLUSIONS
  Infants with CDH can achieve good survival even when criteria for pre-operative stability are not met. We suggest that all infants should be repaired even if lenient criteria for ventilatory, inotrope, or vasodilator requirements are not achieved.
authors.affiliation: The Montreal Children's Hospital, Division of Pediatric General and Thoracic Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Alana L
authors.initials: AL
authors.lastname: Beres
authors.forename: Pramod S
authors.initials: PS
authors.lastname: Puligandla
authors.forename: Mary E
authors.initials: ME
authors.lastname: Brindle
mesh_terms: D000015:Abnormalities, Multiple / Q000628:therapy; D002170:Canada / Q000453:epidemiology; D002316:Cardiotonic Agents / Q000627:therapeutic use; D015897:Comorbidity; D016208:Databases, Factual; D015199:Extracorporeal Membrane Oxygenation / Q000706:statistics & numerical data; D005260:Female; D006548:Hernia, Diaphragmatic / Q000097:blood / Q000601:surgery*; D065630:Hernias, Diaphragmatic, Congenital; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D006976:Hypertension, Pulmonary / Q000151:congenital / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy; D007231:Infant, Newborn; D008099:Liver / Q000002:abnormalities; D008168:Lung / Q000002:abnormalities; D008171:Lung Diseases / Q000628:therapy; D008297:Male; D009569:Nitric Oxide / Q000627:therapeutic use; D010100:Oxygen / Q000097:blood; D010102:Oxygen Inhalation Therapy / Q000706:statistics & numerical data; D018579:Patient Selection; D011300:Preoperative Care / Q000379:methods / Q000706:statistics & numerical data*; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D014463:Ultrasonography; D019564:Unnecessary Procedures; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D002316:Cardiotonic Agents; D014665:Vasodilator Agents; D009569:Nitric Oxide; D010100:Oxygen