Pediatric
Surgery
A. Tubbs
TY 7263849
1
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35 week 2.2kg infant with known L CDH to a 30 year old G6 P4 AA female via SVD
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Intubated at 7 minutes of birth when she became apneic. Initially on minimal vent settings in
NICU without need for ECMO.
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DOL 2 hypotension and bradycardia requiring pressor support and continued to worsen over the
next two days
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DOL 5 ECMO, stabilized
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Day 8 ECMO dramatically worsened with white out on the CXR and never recovered
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Day 14 R chest tube placed for effusion, 50ml serous drainage, minimal improvement
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Day 15 overnight flows gradually decreased, O2 sat in 20’s for several hours, coded as changing
the circuit
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Stabilized over the weekend
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DOL 22/ ECMO Day 18 proceeded with L CDH repair on ECMO with gortex patch
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Agenesis of the entire left hemidiaphragm except small anterior rim
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Entire bowel in the chest with minimal lung tissue
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Heparin bleeding
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Chest tube and skin only closure
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Actively resuscitated all night and POD 1 with ~700ml from chest tube
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POD 2 hypotension requiring max doses of dopamine and dobutamine, anuria
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Withdrawal of care
TY 7263849
3
Analysis of Complication
14
•
Was the complication potentially avoidable?
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•
Would avoiding the complication change the
outcome for the patient?
–
•
No
Yes
What factors contributed the complication?
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Patient disease
–
–
–
–
Agenesis of the diaphragm
Minimal good lung tissue
Prematurity
ECMO/Heparin
Congenital Diaphragmatic Hernia
15
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Malformation of the diaphragm allowing bowel to
herniate into the thoracic cavity before birth resulting in
pulmonary hypoplasia and pulmonary hypertension
Most are left sided and are associated with malrotation
~50% of survivors are treated with ECMO
Overall survival rate is 60%, less with prematurity
Delayed repair
6
Survival in early- and late-term infants
with congenital diaphragmatic hernia
treated with ECMO.
Stevens TP, Chess PR, et al. Pediatrics. 2002 Sep;110(3):590-6.
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Retrospective cohort study of all infants in the
ELSO registry placed on ECMO over past 25
yrs
Early term 38-39w, Late term 40-41w
53% v 63% survival rate, shorter ECMO
duration, shorter hospital stay and fewer
complications
7
Cardiac arrest before repair or ECMO
cannulation does not increase the
mortality rate associated with CDH.
Courcoulas AP, Reblock KK, Rowe MI, Ford HR. J Pediatric Surg.
1997 Jul;32(7):952-6.
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Retrospective review 119 infants
21 suffered arrest before repair or cannulation
No sign difference in birth wts, GA, race/gender,
preg/delivery complications
Significant number of those that arrested
required ECMO for prolonged time
No sign difference in overall survival
8
Factors associated with survival in
infants with CDH requiring ECMO: a
report from the CDH study group.
Seetharamaiah R, et al. J Pediatric Surg. 2009
Jul;44(7):1315-21.
 3100 children
 Survivors:
Greater gestational age
 Greater birth weights
 Less often prenatally diagnosed
 Required ECMO for shorter period of time (9 +/- 5 v.
12 +/- 5)
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Take Home Points
18
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Delayed repair of CDH
50% CDH infants require ECMO
Survival rate ~60%, decreased with decreased
gestational age and birth weight
Shorter duration of ECMO associated with
improved survival
Not optimal to repair on ECMO