175 PREDICTORS OF MORTALITY AND POOR NEURODEVELOPMENTAL OUTCOME IN INFANTS WITH CONGENITAL DIAPHRAGMATIC HERNIA REQUIRING EXTRACORPOREAL MEMBRANE OXYGENATION. (1st January 2005)

• Record Type: Journal Article
• Authors: Deulofeut, R.; Heard, M.; Wagoner, S.; Larossa, M.; Carter, S.; Adams, I.; Dykes, F.; Sola, A.
• Is Part Of: Journal of investigative medicine. Volume 53:Number 1(2005)
• Page Start: S283
• Page End: S283
• Publication Date: 2005-01-01
• Subjects: Clinical medicine -- Periodicals; Medicine -- Research -- Periodicals; Medicine; Research -- United States; Clinical medicine; Medicine -- Research; Periodicals; 616.075
• DOI: 10.2310/6650.2005.00006.174
• Languages: English
• ISSNs: 1081-5589

Abstract

Abstract : Background: Mortality in severe congenital diaphragmatic hernia (CDH), defined as requirement for extracorporeal membrane oxygenation (ECMO), remains variable. Predictors of mortality and poor long-term neurodevelopmental outcome have not been well described. Objective: To describe mortality and poor neurodevelopmental outcome in CDH-ECMO infants and identify associated risk factors pre-ECMO. Methods: We retrieved data for CDH-ECMO infants at CHOA (1991-2004). Predictive risk factors included pre-ECMO birth weight (BW), gestational age (GA), pH, PaO2, PaCO2, oxygenation index (OI), mean airway pressure (MAP), prothrombin time (PT), and others. Chi square, Student t-test, and logistic regression were used when appropriate (significance: p < .05). Results: Of 70 infants with CDH-ECMO, 12 (17.14%) were placed on venoarterial ECMO, 58 (82.85%) on venovenous ECMO (3 converted to arterial). GA was 38.2 ± 1.9 w; BW was 3160 ± 480 g. A total of 47 (67%) infants survived. There was no difference in pre-ECMO MAP (18.3 ± 3.9 CM H2O vs. 18.8 ± 4.7 CM H2O) or OI (54.6 ± 23.4 vs. 66.3 ± 32.9) between survivors and nonsurvivors. Before ECMO, nonsurvivors had a significantly higher PaCO2 (70 ≤ 24.2 vs. 57.9 ± 19.8 torr; p = .034), lower pH (7.17 ± 0.14 vs. 7.24 ± 0.14; p = .038) and higher PT (44.6 ± 6.2 vs. 18.7 ± 4.9; p = .042). A total of 23 (49%) survivors had neurodevelopmental evaluation (Bayley Scales of Infant Development) at 12 months and 18 (38%) at 24 months of age. At 12 months, mean Mental Developmental Index (MDI) was 84.77 ± 17.59 (50 to 107) and the Psychomotor Developmental Index (PDI) was 75.16 ± 21.29 (50 to 108). At 24 months, MDI was 84.23 ± 18.34 (50 to 115) and PDI was 71.58 ± 19.61 (50 to 103). At 12 and 24 months 13% of the infants had an MDI ≤ 70 and 38% had a PDI ≤ 70. A significantly higher OI pre-ECMO was predictive of MDI/PDI > 70 (59.1 ± 11.1 vs. 42.4 ± 15.6; p = .017). Conclusion: In this population, 67% of infants CDH-ECMO survive to discharge. Higher PaCO2, lower pH, and higher PT pre-ECMO were significant predictors for mortality. CDH-ECMO survivors are at risk for cognitive delay and more severe neuromotor delay at 12 and 24 months of age. Higher OI pre-ECMO was a significant predictor for worse long-term outcome. Risk/benefit of using ECMO before prolonged hypercarbia, acidemia, coagulopathy, and high OI needs to be evaluated.