Journal of pediatric surgery
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Comparative Study Clinical Trial
Effect of extracorporeal life support on survival when applied to all patients with congenital diaphragmatic hernia.
Extracorporeal life support (ECLS) has been used for neonates with congenital diaphragmatic hernia (CDH) and respiratory failure at the authors' hospital since June 1981. In 1988, criteria for inclusion in ECLS were broadened to include "nonhoneymoon" infants (honeymoon: best postductal PaO2 of > 50 mm Hg). To evaluate the impact of this approach on the treatment of CDH, the authors reviewed the records of all newborns managed at their institution, since the availability of ECLS in 1981, who were symptomatic with CDH in the first 24 hours of life (n = 111). ⋯ The data demonstrate that the number of CDH patients managed at our institution each year has increased (1981 to 1987 = 6, 1988 to 1993 = 14) as has the severity of associated respiratory insufficiency (% of patients with best PaO2 of < or = 50 mm Hg: 1981 to 1987 = 6%, 1988 to 1993 = 28%). Overall, the survival rate was lower for patients in the expanded ECLS group (59% v 75%; P = .121). When the survival rates for patients supported with ECLS postoperatively were compared for the expanded and early groups, a significant difference (59% v 80%; P < .05) was noted.(ABSTRACT TRUNCATED AT 250 WORDS)
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The incidence of inguinal hernia and incarceration is high among premature infants. Optimal timing, anesthetic technique, and long-term results of hernia repair in hospitalized premature infants remain undefined. The authors reviewed the records of 52 consecutively treated premature infants who underwent bilateral inguinal herniorrhaphy under general anesthesia before discharge from the intensive care nursery. ⋯ One recurrence was identified, representing 4% of the long-term follow-up group and 2% of the initial population. Two patients had asymmetric testicular volumes suggestive of unilateral atrophy. The short- and long-term results suggest that repair under general anesthesia can be safely performed before discharge from the intensive care nursery.
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The authors reviewed the Extracorporeal Life Support Organization (ELSO) data base of all neonates placed on extracorporeal membrane oxygenation for whom CDH was diagnosed between January 1989 and December 1991. For 483 neonates, there were complete data concerning timing of the hernia repair in relation to ECMO. The overall incidence of hemorrhage was 43% (57% among nonsurvivors, 32% among survivors; P < .05). ⋯ The incidence of hemorrhagic complications did not differ significantly among the 3 years (P > .05). Repair of the hernia defect while on bypass was associated with significantly greater bleeding complications. These data should be useful in the planning of future prospective trials.
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With the increase in popularity of delayed repair of congenital diaphragmatic hernia (CDH), many institutions are using extracorporeal membrane oxygenation (ECMO) to stabilize patients preoperatively. This practice has led to controversy regarding whether the repair should be performed while the patient is on ECMO or after decannulation. This report details the authors' experience with repair of CDH on ECMO. ⋯ Additionally, four of the nine patients in group I required reexploration because of hemorrhage; this was not required for any patient in group II (P = .005). Although the survival rates differed, this may have been because of a bias in patient selection between the two groups. From these preliminary data, the authors conclude that repair of congenital diaphragmatic hernia on ECMO can be performed safely, with a minimum of hemorrhagic complications.(ABSTRACT TRUNCATED AT 250 WORDS)
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Extracorporeal life support (ECLS) is a recognized treatment for neonatal respiratory distress unresponsive to other forms of therapy. Variations of this technique are being developed in an effort to extend its applicability and safety. Extracorporeal CO2 removal (ECCO2R) is one such modification that requires blood flows of 20% to 50% of cardiac output and therefore lends itself to percutaneous venous cannulation. ⋯ A low-frequency ventilation technique was employed using an FIO2 of 1.0 and a rate of 5 breaths per minute. PEEP was increased incrementally to maintain the PaO2 above 80 mm Hg. After initiation of ECCO2R, the arterial PaO2 increased to 165 +/- 109 mm Hg, with PEEP above 15 cm H2O, and PaCO2 decreased to 37 +/- 5 mm Hg, with a bypass flow rate of 15 mL/kg/min.(ABSTRACT TRUNCATED AT 250 WORDS)