体外膜肺氧合时机对先天性膈疝修补术术中出血风险的影响。

The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk.

机构信息

Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States; Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL 33701, United States.

Department of Surgery, Boston Children's Hospital, Boston, MA 02115, United States.

出版信息

J Pediatr Surg. 2023 Sep;58(9):1656-1662. doi: 10.1016/j.jpedsurg.2022.12.030. Epub 2023 Jan 3.

DOI:10.1016/j.jpedsurg.2022.12.030

PMID:36709093

Abstract

BACKGROUND

The optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion.

METHODS

A retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression.

RESULTS

102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48-39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20-85) vs. those who did not (median 9 mg/dL, IQR 7-13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737).

CONCLUSION

We demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO.

LEVEL OF EVIDENCE

Level III cohort study.

摘要

背景

体外膜肺氧合（ECMO）支持治疗的先天性膈疝（CDH）婴儿的手术修复最佳时机仍存在争议。许多中心认为，手术出血风险是决定需要 ECMO 支持的婴儿进行 CDH 修复的首选时机的主要因素。本研究比较了 ECMO 支持下早期与延迟修复 CDH 时的手术出血情况。

方法

回顾性分析了 1995 年至 2021 年期间 146 例在 ECMO 支持下行 CDH 修复的婴儿。早期修复发生在 ECMO 插管后 48 小时内（ER），延迟修复发生在 48 小时后（DR）。手术出血的定义是需要再次手术以止血或减压。

结果

102 例婴儿行 ER，44 例婴儿行 DR。DR 组手术出血更为频繁（36% vs 5%，p<0.001），优势比为 11.7（95%CI：3.48-39.3，p<0.001）。出血患儿（中位数 63mg/dL，IQR 20-85）的修复日血尿素氮水平明显升高，而未出血患儿（中位数 9mg/dL，IQR 7-13）（p<0.0001）。ER 组 ECMO 支持时间较短（中位数 13 天 vs 18 天，p=0.005）。两组生存率无统计学差异（ER 60% vs. DR 57%，p=0.737）。