Finer N N, Tierney A, Etches P C, Peliowski A, Ainsworth W
Department of Newborn Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, Canada.
J Pediatr Surg. 1998 Sep;33(9):1331-7. doi: 10.1016/s0022-3468(98)90001-x.
BACKGROUND/PURPOSE: The purpose of this study was to evaluate the evolving outcome of newborns who have congenital diaphragmatic hernia (CDH) using a protocolized approach to management, which includes extracorporeal membrane oxygenation (ECMO) and to present the details of such a management protocol.
A retrospective chart review was conducted of the neonatal outcome of near-term (>34 weeks' gestation) newborns with CDH all referred to the Royal Alexandra Hospital either before or after delivery. A protocol was developed that included antenatal assessment, the use of antenatal steroids, planned delivery, use of prophylactic surfactant, pressure limited gentle ventilation, permissive hypercarbia and hypoxia, and venovenous ECMO, if indicated.
Sixty-five infants with CDH were treated from February 1989 through August 1996. Twenty-three infants were inborn, 20 of whom were antenatal referrals. Overall, 51 of the 65 infants survived (78%). Thirteen of the 23 inborn infants survived with conservative management, and 10 required ECMO, of whom, eight were long-term survivors. Thirty-eight infants required ECMO, and 26 survived (68%), whereas there were only two deaths among the 27 conservatively treated infants. Eighteen of 20 inborn infants with an antenatal diagnosis survived, compared with 13 of 21 (62%) outborn infants. An antenatal diagnosis before 25 weeks' gestation was associated with a 60% survival rate. Sixty-three percent of infants whose best postductal PaO2 value before ECMO was less than 100 torr survived, and 7 of 11 infants with a best postductal PaO2 value of less than 50 torr before ECMO survived (64%). The average age at surgery progressively increased over time both for infants who did not require ECMO (1.3 days to 5.8 days; P = .01) and for infants who received ECMO (1.9 days to 8.2 days; P = .016).
The use of a protocolized management for infants with CDH has been associated with improving outcome in a population at high risk. The components (either separately or combined) of these protocolized approaches need to be tested in prospective trials to determine their true benefit. In addition, there is a need to evaluate prospectively the outcomes of infants with CDH born in ECMO centers compared with those infants born in other tertiary care neonatal units to determine the most appropriate management of the fetus with CDH.
背景/目的：本研究旨在采用包括体外膜肺氧合（ECMO）在内的标准化管理方案，评估先天性膈疝（CDH）新生儿的预后情况，并介绍该管理方案的详细内容。
对所有在分娩前后转诊至皇家亚历山德拉医院的近足月（妊娠>34周）CDH新生儿的新生儿结局进行回顾性病历审查。制定了一项方案，包括产前评估、产前类固醇的使用、计划分娩、预防性表面活性剂的使用、压力限制下的轻柔通气、允许性高碳酸血症和低氧血症，以及在必要时使用静脉-静脉ECMO。
1989年2月至1996年8月期间，共治疗了65例CDH婴儿。23例为足月儿，其中20例为产前转诊。总体而言，65例婴儿中有51例存活（78%）。23例足月儿中有13例通过保守治疗存活，10例需要ECMO，其中8例为长期存活者。38例婴儿需要ECMO，26例存活（68%），而27例接受保守治疗的婴儿中仅有2例死亡。20例产前诊断为足月儿的婴儿中有18例存活，而21例出生后转诊的婴儿中有13例存活（62%）。妊娠25周前的产前诊断与60%的存活率相关。ECMO前导管后血氧分压（PaO2）最佳值低于100托的婴儿中有63%存活，ECMO前导管后PaO2最佳值低于50托的11例婴儿中有7例存活（64%）。对于不需要ECMO的婴儿（1.3天至5.8天；P = 0.01）和接受ECMO的婴儿（1.9天至8.2天；P = 0.016），手术的平均年龄均随时间逐渐增加。
对CDH婴儿采用标准化管理与改善高危人群的预后相关。这些标准化方法的各个组成部分（单独或联合使用）需要在前瞻性试验中进行测试，以确定其真正益处。此外，有必要对在ECMO中心出生的CDH婴儿与在其他三级护理新生儿病房出生的婴儿的预后进行前瞻性评估，以确定CDH胎儿的最合适管理方法。
