Jancelewicz Tim, Paton Elizabeth A, Jones Jorie, Weems Mark F, Lally Pamela A, Langham Max R
Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
J Pediatr Surg. 2019 May;54(5):932-936. doi: 10.1016/j.jpedsurg.2019.01.020. Epub 2019 Jan 31.
Management of CDH is highly variable from center to center, as are patient outcomes. The purpose of this study was to examine risk-stratified survival and extracorporeal membrane oxygenation (ECMO) rates at a single center, and to determine whether adverse outcomes are related to patient characteristics or management.
A retrospective single-center review of CDH patients was performed, and outcomes compared to those reported by the CDH Study Group (CDHSG) registry. Patient demographics, disparities, and clinical characteristics were examined to identify unique features of the cohort. A model derived using the registry that estimates probability of ECMO use or death in CDH newborns was used to risk-stratify patients and assess mortality rates. Observed over expected (O/E) ECMO use rates were calculated to measure whether "excess" or "appropriate" ECMO use was occurring.
There were 81 CDH patients treated between 2004-2017, and 5034 in the CDHSG registry. Mortality in ECMO-treated patients was higher than the registry. Socioeconomic variables were not significantly associated with outcomes. The strongest predictors of mortality were ECMO use and early blood gas variables. The risk model accurately predicted ECMO use with a c-statistic of 0.79. Compared with the registry, the disparity in mortality rates was greatest for moderate-risk patients. O/E ECMO use was highest in low and moderate-risk patients.
ECMO use is a more consistent predictor of mortality than CDH severity at a single center, and there is relative overuse of ECMO in lower-risk patients. Risk stratification allows for more accurate institutional assessment of mortality and ECMO use, and other centers could consider such an adjusted analysis to identify opportunities for outcomes improvement.
III.
先天性膈疝（CDH）的治疗在不同中心差异很大，患者的治疗结果也是如此。本研究的目的是在单一中心研究风险分层后的生存率和体外膜肺氧合（ECMO）使用率，并确定不良结局是否与患者特征或治疗管理有关。
对CDH患者进行了一项回顾性单中心研究，并将结果与CDH研究组（CDHSG）登记处报告的结果进行比较。研究了患者的人口统计学、差异和临床特征以确定该队列的独特特征。使用登记处得出的一个估计CDH新生儿使用ECMO或死亡概率的模型对患者进行风险分层并评估死亡率。计算观察到的与预期的（O/E）ECMO使用率，以衡量是否存在“过度”或“适当”使用ECMO的情况。
2004年至2017年间共治疗了81例CDH患者，CDHSG登记处有5034例。接受ECMO治疗的患者死亡率高于登记处。社会经济变量与治疗结果无显著相关性。死亡率的最强预测因素是ECMO的使用和早期血气变量。风险模型以0.79的c统计量准确预测了ECMO的使用情况。与登记处相比，中度风险患者的死亡率差异最大。低风险和中度风险患者的O/E ECMO使用率最高。
在单一中心，ECMO的使用比CDH严重程度更能持续预测死亡率，并且低风险患者中存在ECMO相对过度使用的情况。风险分层有助于对死亡率和ECMO使用情况进行更准确的机构评估，其他中心可以考虑进行这种调整分析以确定改善治疗结果的机会。
III级
