Update Course Rewind: When & How to Operate CDH Patients on ECMO 2024
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Key Takeaways
- VA ECMO remains the predominant approach for severe CDH, though VV ECMO use may increase as improved cannulas become available
- Michigan's SPHERE protocol uses 2-hour benchmarks (pH>7, PCO2<100, preductal sats>80) to guide ECMO vs comfort care decisions
- Prenatal prediction of CDH outcomes is unreliable—50% of comfort-care candidates could survive and 50% of ECMO patients don't
- Expert consensus supports offering ECMO to all isolated unilateral CDH cases with parental consent, excluding genetic/cardiac syndromes
- Early ECMO intervention is preferred over prolonged observation in severe CDH with refractory acidosis and hypoxemia
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GlobalcastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm M. Gody from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in pediatric surgery, which was held in August 2024. This year we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories. Green circles for established practices, blue squares for promising newer practices, and black diamonds for early adopter practices only. Today, pediatric surgeons, Dr. Rebecca Stark and Steven Lee will discuss the timing and techniques from performing ECMO in severe congenital diaphragmatic hernia or CDH cases. Here's our clinical scenario. Full-term neonate, known diagnosis of a left-sided very severe CDH, no known cardiac anomalies, no genetic anomalies, delivered about an hour ago, intubated and resuscitated per your institutional protocols. Let's take a look at the first vitals. Preductal sats are in the 70s, heart rate is 150, blood pressure is 35 over 25 on 100% FIO2. This is your first gas, so pH is 6.8, PA CO2 is 130 and PAO2 is 28. So the question is, what's your next move to this patient? Would you prefer a Vina Venus or VV ECMO, or Vina arterial or VA ECMO. Do you need time to reassess, or are you going to opt for comfort care? And I would be the old school person that still does VA because I'm not bold enough to go VV. It's not that old school, actually, you will see. There are lots of benefits to VV, there are lots of benefits to VA. The majority of centers, as I said, still do VA ECMO primarily for CDH babies. So both answers are totally reasonable. Dr. Stark believes this patient needs an intervention. I think you know from the prenatal imaging that the baby is at a high risk for needing ECMO, and I think the time to intervene is probably earlier rather than later. Do you feel that VV cannula availability and also concerns with certain VV cannulas um has played a role in that and now that there are different cannulas available for VV, do you think those numbers will change? I think it's possible. I do think that if you were an institution that did VV and you couldn't cannulate because the 13 French is just too big, you'd probably do VA. And I do think that there are better cannulas coming out. In terms of comfort care, Dr. Stark shared a paper that effectively highlights the most important considerations. At Michigan, they had a sphere protocol that helped them decide which babies to offer comfort care to and which babies to offer ECMO to. They were prenatally selected. If they had a severe CDH, the parents were educated that they would go on this pathway. In the delivery room, they had ECMO on standby. They would intubate, they would do ventilation and be resuscitated. Within two hours, if the pH did not meet seven, PCO2 wasn't less than 100, preductal sats weren't above 80, they were offered comfort measures only. And if they could achieve some of those things, they were offered ECMO. She compared these two groups of patients. They had equivalent survival amongst those two groups. That means that half of the patients that were being offered comfort measures could have been survivors. It also means that half of the patients that were offered ECMO did not survive. We are really bad at choosing. And if you make this decision to choose beforehand, you're going to be wrong 50% of the time, and I really strongly believe that. I know it's controversial, but I do think that if you had good prenatal counseling with the parents and they are all in for this, you should pursue ECMO for every unilateral isolated CDH. Dr. Stark clarified that she is not referring to cases involving genetic or cardiac syndromes, as she considers those to be an entirely different scenario. In summary, early ECMO intervention is often preferred in severe CDH, with Vina arterial ECMO still widely used, though Vina Venus ECMO may increase with improved cannulas. Protocols like Spear help guide ECMO versus comfort care decisions based on early postnatal indicators. Though, predicting outcomes remains imprecise. Despite controversy, many providers advocate for universally offering ECMO in cases of isolated unilateral CDH, approaching each infant as a potential survivor until proven otherwise. Thank you for watching this video.