pediatric surgery a. tubbs. 1 ty 7263849 35 week 2.2kg infant with known l cdh to a 30 year old g6...
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Pediatric SurgeryA. Tubbs
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TY 7263849
35 week 2.2kg infant with known L CDH to a 30 year old G6 P4 AA female via SVD Intubated at 7 minutes of birth when she became apneic. Initially on minimal vent
settings in NICU without need for ECMO.
DOL 2 hypotension and bradycardia requiring pressor support and continued to worsen over the next two days
DOL 5 ECMO, stabilized Day 8 ECMO dramatically worsened with white out on the CXR and never recovered Day 14 R chest tube placed for effusion, 50ml serous drainage, minimal
improvement Day 15 overnight flows gradually decreased, O2 sat in 20’s for several hours, coded
as changing the circuit Stabilized over the weekend DOL 22/ ECMO Day 18 proceeded with L CDH repair on ECMO with gortex patch
Agenesis of the entire left hemidiaphragm except small anterior rim
Entire bowel in the chest with minimal lung tissue
Heparin bleeding
Chest tube and skin only closure
Actively resuscitated all night and POD 1 with ~700ml from chest tube POD 2 hypotension requiring max doses of dopamine and dobutamine, anuria
Withdrawal of care
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TY 7263849
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Analysis of Complication
• Was the complication potentially avoidable?– No
• Would avoiding the complication change the outcome for the patient?– Yes
• What factors contributed the complication?– Patient disease
– Agenesis of the diaphragm– Minimal good lung tissue
– Prematurity– ECMO/Heparin
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Congenital Diaphragmatic Hernia
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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
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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.
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
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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.
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
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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
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