12327Vanderbilt University School of Medicine, Nashville, TN, USA.
Department of Surgery, 5718Vanderbilt University Medical Center, Nashville, TN, USA.
Am Surg. 2022 Aug;88(8):1814-1821. doi: 10.1177/00031348221084941. Epub 2022 Mar 25.
For critically ill congenital diaphragmatic hernia (CDH) patients on high frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and/or inhaled nitric oxide (iNO), operative repair in the neonatal intensive care unit (NICU) has been proposed to avoid complications during transport to an operating room (OR). This study compared neonates with CDH who received herniorrhaphy in the NICU or OR, with a subgroup analysis considering only patients supported with ECMO.
Patients admitted to the NICU in the first 2 weeks of life at a free-standing children's hospital between July 2004 and September 2021 were examined. Patients were categorized according to location of CDH repair, and impact on operative complications and survival was compared.
185 patients were admitted to the NICU with posterolateral CDH and received operative repair. 48 cases were operated on at the bedside in the NICU and 137 in the OR. Patients repaired in the NICU had higher use of HFOV, pulmonary vasodilators, and ECMO (all < .001). Children repaired in the NICU experienced significantly higher in-hospital death and overall mortality ( < .001). However, in multivariate analysis, repair location was not a significant predictor of survival to discharge in patients receiving ECMO. No significant difference in surgical site infection was detected for operative location ( = .773).
Congenital diaphragmatic hernia repair in the NICU occurred more frequently among higher risk patients who experienced worse survival. The rate of surgical site infection appeared similar overall and across subgroups suggesting adequate sterility and technique for bedside procedures, when necessary, despite restricted access to advanced operative equipment.
对于接受高频振荡通气（HFOV）、体外膜肺氧合（ECMO）和/或吸入一氧化氮（iNO）治疗的危重症先天性膈疝（CDH）患者，已经提出在新生儿重症监护病房（NICU）进行手术修复，以避免在转运至手术室（OR）过程中出现并发症。本研究比较了在 NICU 或 OR 接受疝修补术的 CDH 新生儿，并进行了亚组分析，仅考虑接受 ECMO 支持的患者。
在 2004 年 7 月至 2021 年 9 月期间，在一家独立的儿童医院的 NICU 中，对生命前 2 周入院的患者进行了检查。根据 CDH 修复的位置对患者进行分类，并比较了对手术并发症和存活率的影响。
185 名患有后外侧 CDH 的患者被收入 NICU 并接受了手术修复。48 例在 NICU 床边手术，137 例在 OR 手术。在 NICU 接受修复的患者更常使用 HFOV、肺血管扩张剂和 ECMO（均 <.001）。在 NICU 接受修复的患儿住院期间死亡和总死亡率显著更高（ <.001）。然而，在多变量分析中，对于接受 ECMO 的患者，修复位置不是生存至出院的显著预测因素。手术部位感染在手术部位无显著差异（ =.773）。
在 NICU 进行 CDH 修复的患者更常发生在风险较高的患者中，这些患者的存活率更差。总体而言和各亚组之间，手术部位感染的发生率似乎相似，这表明在必要时，尽管无法获得先进的手术设备，但床边操作的无菌性和技术是足够的。
