Impact of delayed repair and elective high-frequency oscillatory ventilation on survival of antenatally diagnosed congenital diaphragmatic hernia: first application of these strategies in the more "severe" subgroup of antenatally diagnosed newborns

被引:52
作者
Desfrere, L
Jarreau, PH
Dommergues, M
Brunhes, A
Hubert, P
Nihoul-Fekete, C
Mussat, P
Moriette, G
机构
[1] UFR Cochin Port Royal, Serv Med Neonatale, F-74679 Paris 14, France
[2] Hop Necker Enfants Malad, Serv Reanimat Pediat Polyvalente, Paris, France
关键词
congenital diaphragmatic hernia; antenatal diagnosis; postnatal management; high-frequency oscillatory ventilation; intensive care unit; neonate;
D O I
10.1007/s001340051284
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
Objective: a) To analyze the influence of a new management strategy on the outcome of neonates with antenatally diagnosed congenital diaphragmatic hernia (CDH); b) to determine early prognosis respiratory factors with the new strategy. Design: Retrospective study. Setting: Level III perinatal center. Patients and method: Between 1985 and 1997, 51 consecutive neonates with antenatally diagnosed CDH were admitted to our level III neonatal intensive care unit. Before 1992 (period 1; n = 19), we used conventional mechanical ventilation and early surgery requiring transfer. Since 1992 (period 2; n = 32), we prospectively tested a new approach including (a) systematically use of high-frequency oscillatory ventilation (HFOV) regardless of the initial clinical severity, (b) delayed surgery following stabilization requiring transfer to a different surgical unit, but (c) no transfer of unstable patients with surgery under HFOV in our neonatal intensive care unit (n = 10). The two cohorts were comparable in terms of potential ante and postnatal prognostic indicators. Results: Survival was improved with the new strategy: 21/32 (66 %) vs. 5/19 (26 %); P < 0.02. This improvement between periods 1 and 2 was due to a decrease in both preoperative and postoperative deaths in the later period. The better survival during period 2 was associated with the appearance of very late deaths, frequent pleural effusions, and the survival of more severe forms having evolved to a chronic respiratory insufficiency. Survivors were ventilated for longer time with longer duration of oxygen supplementation. The best oxygenation index (OI), alveolar arterial difference and oscillation amplitude (PIP) during the first 24 h, but not the best PaCO2, were the most reliable prognostic indicators during period 2. An OI less than or equal to 10 with a P/P less than or equal to 55 cmH(2)O was associated with a very good prognosis (94 % survival). Conclusions: The prognosis of antenatally diagnosed CDH was improved by systematic HFOV on admission, no systematic transfer, and delayed surgery. This improvement is associated with modification of postnatal outcome.
引用
收藏
页码:934 / 941
页数:8
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