title: Extracorporeal life support in patients with congenital diaphragmatic hernia: how long should we treat?
abstract: BACKGROUND
  Congenital diaphragmatic hernia (CDH) is a frequently lethal birth defect and, despite advances, extracorporeal life support (ie, extracorporeal membrane oxygenation [ECMO]) is commonly required for severely affected patients. Published data suggest that CDH survival after 2 weeks on ECMO is poor. Many centers limit duration of ECMO support.
  
  
  METHODS
  We conducted a single-institution retrospective review of 19 years of CDH patients treated with ECMO, designed to evaluate which factors affect survival and duration of ECMO and define how long patients should be supported.
  
  
  RESULTS
  Of two hundred and forty consecutive CDH patients without lethal associated anomalies, 96 were treated with ECMO and 72 (75%) survived. Eighty required a single run of ECMO and 65 survived (81%), 16 required a second ECMO run and 7 survived (44%). Of patients still on ECMO at 2 weeks, 56% survived, at 3 weeks 46% survived, and at 4 weeks, 43% of patients still on ECMO survived to discharge. After 5 weeks of ECMO, survival had dropped to 15%, and after 40 days of ECMO support there were no survivors. Apgar score at 1 minute, Apgar score at 5 minutes, and Congenital Diaphragmatic Hernia Study Group predicted survival all correlated with survival on ECMO, need for second ECMO, and duration of ECMO. Lung-to-head ratio also correlated with duration of ECMO. All survivors were discharged breathing spontaneously with no support other than nasal cannula oxygen if needed.
  
  
  CONCLUSIONS
  In patients with severe CDH, improvement in pulmonary function sufficient to wean from ECMO can take 4 weeks or longer, and might require a second ECMO run. Pulmonary outcomes in these CDH patients can still be excellent, and the assignment of arbitrary ECMO treatment durations <4 weeks should be avoided.
authors.affiliation: Department of Surgery, Division of Pediatric Surgery, University of Florida, Gainesville, FL. Electronic address: david.kays@surgery.ufl.edu.
authors.forename: David W
authors.initials: DW
authors.lastname: Kays
authors.affiliation: Department of Surgery, Division of Pediatric Surgery, University of Florida, Gainesville, FL.
authors.forename: Saleem
authors.initials: S
authors.lastname: Islam
authors.affiliation: Intermountain Medical Center and the University of Utah, Salt Lake City, UT.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Richards
authors.affiliation: Department of Surgery, Division of Pediatric Surgery, University of Florida, Gainesville, FL.
authors.forename: Shawn D
authors.initials: SD
authors.lastname: Larson
authors.affiliation: Department of Surgery, Division of Pediatric Surgery, University of Florida, Gainesville, FL.
authors.forename: Joy M
authors.initials: JM
authors.lastname: Perkins
authors.affiliation: Department of Surgery, Division of Pediatric Surgery, University of Florida, Gainesville, FL.
authors.forename: James L
authors.initials: JL
authors.lastname: Talbert
mesh_terms: D003131:Combined Modality Therapy; D003661:Decision Support Techniques; D015199:Extracorporeal Membrane Oxygenation; D006548:Hernia, Diaphragmatic / Q000401:mortality / Q000601:surgery / Q000628:therapy; D065630:Hernias, Diaphragmatic, Congenital; D059685:Herniorrhaphy; D006801:Humans; D007231:Infant, Newborn; D016015:Logistic Models; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome