Nakayama D K, Motoyama E K, Tagge E M
Department of Pediatric Surgery, Children's Hospital of Pittsburgh, PA 15213-3417.
J Pediatr. 1991 May;118(5):793-9. doi: 10.1016/s0022-3476(05)80048-4.
To determine whether preoperative stabilization and delay of operative repair of congenital diaphragmatic hernia (CDH) may decrease operative risk, we performed serial pulmonary function tests on 22 newborn infants with CDH and on four infants without pulmonary hypoplasia (two with ileal atresia and two with tracheoesophageal anomalies) who served as control subjects. We used 2 passive respiratory mechanics technique to measure respiratory system compliance. All patients with CDH had respiratory distress immediately after birth, and required mechanical ventilation. Thirteen babies underwent emergency repair (six survived, seven died); nine of them received extracorporeal membrane oxygenation (ECMO) after the operation (two survived, seven died). Operative repair was delayed deliberately for 2 to 11 days in nine infants with severe hypoxemia. Six immediately received ECMO for 4 to 10 days; one died of intraventricular hemorrhage, and five survived and later underwent surgical repair. The seventh patient did not receive ECMO but appeared to have respiratory distress syndrome of infancy and improved after administration of synthetic surfactant. Improvement was seen in two additional infants who received conventional assisted ventilation during a 48-hour delay before surgery, and survived. In all, eight of nine infants who underwent preoperative stabilization survived (p less than 0.05 compared with survival after emergency surgery). Following surgical repair immediately after birth, respiratory system compliance improved only slightly during the first week of life, a time when control infants had a rapid increase in respiratory system compliance (p less than 0.001). In contrast, respiratory system compliance increased nearly twofold in the nine patients undergoing preoperative stabilization (p less than 0.02). Preoperative ECMO was associated with an increase in respiratory system compliance of more than 60% for 1 week, a significant difference from respiratory system compliance among patients undergoing emergency CDH repair (p less than 0.05). These observations provide physiologic evidence of possible benefits of preoperative stabilization before repair of CDH.
为了确定先天性膈疝（CDH）术前稳定病情并延迟手术修复是否可降低手术风险，我们对22例患有CDH的新生儿以及4例无肺发育不全的婴儿（2例患有回肠闭锁，2例患有气管食管畸形）进行了系列肺功能测试，这4例婴儿作为对照。我们采用2种被动呼吸力学技术来测量呼吸系统顺应性。所有患有CDH的患者出生后立即出现呼吸窘迫，并需要机械通气。13例婴儿接受了急诊修复（6例存活，7例死亡）；其中9例术后接受了体外膜肺氧合（ECMO）治疗（2例存活, 7例死亡）。9例严重低氧血症的婴儿被故意延迟手术修复2至11天。6例立即接受了4至10天的ECMO治疗；1例死于脑室内出血，5例存活，随后接受了手术修复。第7例患者未接受ECMO治疗，但似乎患有婴儿呼吸窘迫综合征，在给予合成表面活性剂后病情好转。另外2例婴儿在手术前延迟48小时接受传统辅助通气，存活下来。总之，9例接受术前病情稳定治疗的婴儿中有8例存活（与急诊手术后的存活率相比，P<0.05）。出生后立即进行手术修复后，呼吸系统顺应性在出生后的第一周仅略有改善，而此时对照婴儿的呼吸系统顺应性迅速增加（P<0.001）。相比之下，9例接受术前病情稳定治疗的患者呼吸系统顺应性增加了近两倍（P<0.02）。术前使用ECMO可使呼吸系统顺应性在1周内增加超过60%，与急诊CDH修复患者的呼吸系统顺应性有显著差异（P<0.05）。这些观察结果提供了生理学证据，表明CDH修复术前进行病情稳定治疗可能有益。
