Sarah B Cairo1, Mary Arbuthnot2, Laura A Boomer3, Michael W Dingeldein4, Alexander Feliz5, Samir Gadepalli6, Chris R Newton7, Robert Ricca2, Adam M Vogel8, David H Rothstein9,10. 1. Department of Pediatric Surgery, John R. Oishei Children's Hospital, 1001 Main Street, Buffalo, NY, 14203, USA. scairo2@gmail.com. 2. Department of Pediatric and General Surgery, Naval Medical Center Portsmouth, Portsmouth, USA. 3. Department of Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, USA. 4. Department of Pediatric Surgery, Rainbow Babies and Children Hospital, Cleveland, USA. 5. Department of Pediatric Surgery, University of Tennessee Health Sciences, Memphis, USA. 6. C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, USA. 7. Department of Pediatric Surgery, University of California at San Francisco Benioff Children's Hospital Oakland, San Francisco, USA. 8. Department of Pediatric General Surgery, Texas Children's Hospital, Houston, USA. 9. Department of Pediatric Surgery, John R. Oishei Children's Hospital, 1001 Main Street, Buffalo, NY, 14203, USA. 10. Department of Surgery, Jacobs School of Medicine, State University of New York, University at Buffalo, Buffalo, USA.
Abstract
PURPOSE: Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO. METHODS: Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC). RESULTS: Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5-15 CDH repairs were reported annually per institution; 26-50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III-IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4-5 weeks. CONCLUSIONS: Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions. LEVEL OF EVIDENCE: V (expert opinion).
PURPOSE: Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO. METHODS: Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC). RESULTS: Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5-15 CDH repairs were reported annually per institution; 26-50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III-IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4-5 weeks. CONCLUSIONS: Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions. LEVEL OF EVIDENCE: V (expert opinion).
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