Use of ECMO in Congenital Diaphragmatic Hernia – Changes over 15 Years

Purpose: Although extracorporeal membrane oxygenation (ECMO) is a lifesaving intervention, the role of ECMO on Congenital Diaphragmatic Hernia (CDH) survival is still controversial. In this study, we examined the relationship between ECMO utilization and its effect on CDH survival in Mannheim, Germany over the last 15 years (1991–2005).

Methods: Over the last 15 years, Mannheim neonatal & neonatal surgical unit has received 280 patients with diaphragmatic hernias. For the purpose of the study and because of different management protocols, this period was divided into 3 5-years periods. From 1991–1995, the unit received 38 patients with CDH, ECMO was employed in 19 patients. In the period 1996–2000, 58 patients were admitted in the unit and ECMO was utilized in 29 patients. During the period 2001–2005, 184 babies with diaphragmatic hernias were admitted to the unit and ECMO was indicated in 88 patients.

Results: The number of CDH referred to the unit during the last five years was five times the number of patients referred during the first 5 years. The diagnosis was prenatally known in 11 cases (29%) in the first period, and in 133 cases (72%) in the last period. The number of patients requiring ECMO was more or less the same (55%, 50%,48% in period 1,2,3). However the number of patients who died after ECMO was reduced from 66% in the first 5 years to 24% during the next 5 years and 36% in the last 5 years. The overall mortality in CDH was reduced from 50% in the period (91–95) to 24% in the second and to 20% in the last period (01–05). Most of the patients who died in the last 5 years did not have surgery because, according to the selection criteria and the protocol of management, it was clear that they were not going to survive.

Conclusion: ECMO may be used to overwhelme associated pulmonary hypertension in CDH and seems to have an impact on improved survival. The study also shows the importance of referral to a specialized unit in order to develop experience and to standarize treatment algorithms even for patients with poor prognosis. The study showed that although 50% of patients with CDH required ECMO during the different time periods, the mortality under ECMO and in general was reduced dramatically over time. Further outcome analysis is needed to optimize the use of ECMO in CDH.