From
StayCurrentMD
IFMSS 2019 Clinical Studies
With Dr. Steven Fenton & Dr. Uchenna Kennedy & Dr. Oliulinka Olutoye & Dr. Nina Bentz · hosted by Dr. Beth Rymeski & Dr. Ray Hankey
Chapter 1 of 5 · Evidence & Research
CDH protocol
CDH Protocol Change and ECMO Reduction at Primary Children's Hospital
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What the experts said
Primary Children's Hospital ECMO program was established in 2003, with first CDH protocol implemented in 2007
The 2016 CDH protocol change places infants on high frequency oscillator immediately after intubation with decreased mean airway pressure
The protocol minimizes stimulation, uses sedation, and does not perform echocardiography within the first 24 hours if prenatal echo exists
Oxygen management is based on preductal saturations only, with no routine postductal saturation monitoring
Oxygen resuscitation starts at FIO2 of 0.4 instead of 1.0
Inhaled nitric oxide and other vasodilators or pressor agents are used only for clinically significant hypoperfusion
Median mean airway pressure decreased from 13 to 11 after protocol implementation
Higher mean airway pressure compromises gas exchange and lung vascularization, potentially increasing pulmonary hypertension
The protocol is applied to all prenatally diagnosed CDH cases regardless of severity
ECMO utilization rate decreased from 37% to 13% after protocol implementation
Overall survival rate increased from 74% to 89% after protocol implementation
Survival improvement was statistically significant for liver-down CDH cases
Survival increased for liver-up CDH cases but was not statistically significant
Since 2016, 97% of CDH cases received prenatal MRI compared to 24% before the fetal center was established
In the study period since 2016, there were 53 isolated left CDH cases after exclusions
Among CDH cases with MRI total fetal lung volume observed-to-expected less than 15%, ECMO utilization was 38% rather than the expected 100%
ECMO criteria include PAO2 never rising above 50 and inability to get CO2 levels below 100
The MRI less than 15% group had 50% survival
The CDH protocol is implemented by the entire neonatology group, not individual providers
Changing clinical culture was one of the hardest aspects of implementing the protocol
In premature infants with giant omphalocele born before 34 weeks, neonatal intubation rates were significantly higher compared to those born after 34 weeks
Neonatal death rate in preterm giant omphalocele was 26% versus 6% in the term group, a statistically significant difference
Tracheostomy and ventilator dependence at discharge occurred at a rate of 31% in the preterm omphalocele group, though not statistically significant
34 weeks gestational age was chosen as the cutoff based on fetal lung maturity being significantly better after this point
Prenatal diagnosis of esophageal atresia relies on three main findings: polyhydramnios, small stomach, and distended proximal esophageal pouch
Air in the stomach on postnatal radiographs confirms the presence of a distal tracheoesophageal fistula
Almost all cases of pure esophageal atresia had a small stomach on prenatal imaging
Small stomach size on prenatal imaging does not discriminate between pure esophageal atresia and EA with tracheoesophageal fistula
Approximately 43% of esophageal atresia cases with distal tracheoesophageal fistula also had a small stomach on prenatal imaging
Both ultrasound and MRI were unable to distinguish pure esophageal atresia from EA with TEF based on stomach appearance
Prior data shows higher rates of anxiety and depression in patients with prenatal fetal anomaly diagnoses
There are no current guidelines for mental health screening in the population with prenatally diagnosed fetal anomalies
Over one-third of mothers with prenatally diagnosed fetal anomalies screened positive for depression, anxiety, and PTSD
Only 25% to 33% of mothers who screened positive for mental health disorders had prior histories of psychiatric diagnoses
Overall resilience scores were lower in the population of mothers with prenatally diagnosed fetal anomalies
There was no difference in maternal mental health screening results between pre-consultation and post-consultation with the pediatric surgeon
Data in the trauma literature shows no correlation between disease or injury severity and development of PTSD