Improving Survival in the Treatment of Congenital Diaphragmatic Hernia

Thirty-two infants were treated for congenital diaphragmatic hernia at our institution from 1979 to 1984. Eight were in no or minimal distress at birth and had operative intervention when they were more than 24 hours old; survival was 100%. The remaining 24 neonates required immediate intubation and ventilation followed by operation at less than 12 hours of age. Overall survival was 54% survival was 31% (4 of 13 patients, Group 1) in the first three years of the series and 82% (9 of 11 patients, Group 2) in the last three years ( p < 0.001). Apgar score, gestational age, birth weight, and incidence of associated congenital heart disease were equal for the two groups (all, p > 0.05). The two groups also were examined with reference to alveolar-arterial oxygen differences P(A-a)O 2 and mean airway pressure (MAP). The best preoperative P(A-a)O 2 was greater than 600 mm Hg for 7 neonates in Group 1 and 6 in Group 2, and survival was 0% and 71%, respectively ( p < 0.001). Infants with a postoperative MAP of 13 cm H 2O or greater had a higher mortality (100% in Group 1 and 50% in Group 2, p > 0.05). Our treatment protocol was studied to determine those methods related to improved survival. Sodium bicarbonate infusion was used earlier in Group 2 as a prophylaxis against persistent fetal circulation (PFC) ( p > 0.05). The incidence of severe PFC dropped from 85 to 54% ( p > 0.05). Higher ventilator rates rather than pressures were used to achieve equally effective ventilation. The incidence of barotrauma was reduced from 46% in Group 1 to 27% in Group 2 ( p > 0.05).