The Value of Paco ₂ in Relation to Outcome in Congenital Diaphragmatic Hernia

Abstract

Background Postnatal assessment of disease severity is critical for analysis of mortality rates and development of future interventions in congenital diaphragmatic hernia (CDH).

Objective The objective of this study was to stratify the risk of mortality based on arterial Paco ₂.

Methods Retrospective analysis of infants (n = 133) with CDH admitted to a regional extracorporeal membrane oxygenation (ECMO) center in two different periods: period I (1987–1996; n = 46) and period II (2002–2010; n = 87).

Results The mortality rate (37%) was similar in both periods (p = 0.98). Paco ₂ < 60 mm Hg in the first arterial blood gas (ABG) was an independent predictor of survival in both periods (p = 0.03). The predicted survival rate was 84% if initial Paco ₂ was < 55 mm Hg. For infants with initial Paco ₂ > 55 mm Hg treated with ECMO (n = 83), the predicted survival rate was 11% if the Paco ₂ was > 88 mm Hg before the initiation of ECMO.

Conclusion Paco ₂, a surrogate of lung hypoplasia, may be useful for risk stratification in CDH. Paco ₂ < 60 mm Hg in the first ABG may indicate milder pulmonary hypoplasia. A Paco ₂ > 80 mm Hg in the first ABG and/or before ECMO may indicate severe pulmonary hypoplasia.

Keywords

extracorporeal membrane oxygenation - risk assessment - risk stratification - gentle ventilation - permissive hypercapnia - severity of disease - mortality

• References

• 1 Stege G, Fenton A, Jaffray B. Nihilism in the 1990s: the true mortality of congenital diaphragmatic hernia. Pediatrics 2003; 112 (3 Pt 1) 532-535
• 2 Colvin J, Bower C, Dickinson JE, Sokol J. Outcomes of congenital diaphragmatic hernia: a population-based study in Western Australia. Pediatrics 2005; 116 (3) e356-e363
• 3 Downard CD, Jaksic T, Garza JJ , et al. Analysis of an improved survival rate for congenital diaphragmatic hernia. J Pediatr Surg 2003; 38 (5) 729-732
• 4 Boloker J, Bateman DA, Wung JT, Stolar CJ. Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea/spontaneous respiration/elective repair. J Pediatr Surg 2002; 37 (3) 357-366
• 5 Guidry CA, Hranjec T, Rodgers BM, Kane B, McGahren ED. Permissive hypercapnia in the management of congenital diaphragmatic hernia: our institutional experience. J Am Coll Surg 2012; 214 (4) 640-645 , e1, discussion 646–647
• 6 Garcia A, Stolar CJ. Congenital diaphragmatic hernia and protective ventilation strategies in pediatric surgery. Surg Clin North Am 2012; 92 (3) 659-668 , ix
• 7 The Neonatal Inhaled Nitric Oxide Study Group (NINOS). Inhaled nitric oxide and hypoxic respiratory failure in infants with congenital diaphragmatic hernia. Pediatrics 1997; 99 (6) 838-845
• 8 Germain JF, Farnoux C, Pinquier D , et al. Can blood gas values predict pulmonary hypoplasia in antenatally diagnosed congenital diaphragmatic hernia?. J Pediatr Surg 1996; 31 (12) 1634-1639
• 9 Bohn DJ, James I, Filler RM , et al. The relationship between PaCO2 and ventilation parameters in predicting survival in congenital diaphragmatic hernia. J Pediatr Surg 1984; 19 (6) 666-671
• 10 Bohn D, Tamura M, Perrin D, Barker G, Rabinovitch M. Ventilatory predictors of pulmonary hypoplasia in congenital diaphragmatic hernia, confirmed by morphologic assessment. J Pediatr 1987; 111 (3) 423-431
• 11 Schultz CM, DiGeronimo RJ, Yoder BA ; Congenital Diaphragmatic Hernia Study Group. Congenital diaphragmatic hernia: a simplified postnatal predictor of outcome. J Pediatr Surg 2007; 42 (3) 510-516
• 12 Wung JT, Sahni R, Moffitt ST, Lipsitz E, Stolar CJ. Congenital diaphragmatic hernia: survival treated with very delayed surgery, spontaneous respiration, and no chest tube. J Pediatr Surg 1995; 30 (3) 406-409
• 13 Chess PR. The effect of gentle ventilation on survival in congenital diaphragmatic hernia. Pediatrics 2004; 113 (4) 917
• 14 Congenital Diaphragmatic Hernia Study Group. Estimating disease severity of congenital diaphragmatic hernia in the first 5 minutes of life. J Pediatr Surg 2001; 36 (1) 141-145
• 15 Baird R, MacNab YC, Skarsgard ED ; Canadian Pediatric Surgery Network. Mortality prediction in congenital diaphragmatic hernia. J Pediatr Surg 2008; 43 (5) 783-787
• 16 Logan JW, Rice HE, Goldberg RN, Cotten CM. Congenital diaphragmatic hernia: a systematic review and summary of best-evidence practice strategies. J Perinatol 2007; 27 (9) 535-549
• 17 Tracy ET, Mears SE, Smith PB , et al. Protocolized approach to the management of congenital diaphragmatic hernia: benefits of reducing variability in care. J Pediatr Surg 2010; 45 (6) 1343-1348
• 18 Haricharan RN, Barnhart DC, Cheng H, Delzell E. Identifying neonates at a very high risk for mortality among children with congenital diaphragmatic hernia managed with extracorporeal membrane oxygenation. J Pediatr Surg 2009; 44 (1) 87-93
• 19 Breiman L, Friedman JH, Olshen RA, Stone CJ. Classification and Regression trees. Chapman & Hall (Wadsworth, Inc.); New York: 1984
• 20 Marshall RJ. The use of classification and regression trees in clinical epidemiology. J Clin Epidemiol 2001; 54 (6) 603-609
• 21 Park HW, Lee BS, Lim G, Choi YS, Kim EA, Kim KS. A simplified formula using early blood gas analysis can predict survival outcomes and the requirements for extracorporeal membrane oxygenation in congenital diaphragmatic hernia. J Korean Med Sci 2013; 28 (6) 924-928
• 22 Stevens TP, Chess PR, McConnochie KM , et al. Survival in early- and late-term infants with congenital diaphragmatic hernia treated with extracorporeal membrane oxygenation. Pediatrics 2002; 110 (3) 590-596
• 23 Bagolan P, Casaccia G, Crescenzi F, Nahom A, Trucchi A, Giorlandino C. Impact of a current treatment protocol on outcome of high-risk congenital diaphragmatic hernia. J Pediatr Surg 2004; 39 (3) 313-318 , discussion 313–318
• 24 Hoffman SB, Massaro AN, Gingalewski C, Short BL. Survival in congenital diaphragmatic hernia: use of predictive equations in the ECMO population. Neonatology 2011; 99 (4) 258-265
• 25 Skarsgard ED, MacNab YC, Qiu Z, Little R, Lee SK ; Canadian Neonatal Network. SNAP-II predicts mortality among infants with congenital diaphragmatic hernia. J Perinatol 2005; 25 (5) 315-319
• 26 Gentili A, Giuntoli L, Bacchi Reggiani ML, Masciopinto F, Lima M, Baroncini S. Neonatal congenital diaphragmatic hernia: respiratory and blood-gas derived indices in choosing surgical timing. Minerva Anestesiol 2012; 78 (10) 1117-1125
• 27 Iyer NP, Mhanna MJ. Non-invasively derived respiratory severity score and oxygenation index in ventilated newborn infants. Pediatr Pulmonol 2013; 48 (4) 364-369
• 28 Jani J, Keller RL, Benachi A , et al; Antenatal-CDH-Registry Group. Prenatal prediction of survival in isolated left-sided diaphragmatic hernia. Ultrasound Obstet Gynecol 2006; 27 (1) 18-22
• 29 Lipshutz GS, Albanese CT, Feldstein VA , et al. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg 1997; 32 (11) 1634-1636
• 30 Flake AW, Crombleholme TM, Johnson MP, Howell LJ, Adzick NS. Treatment of severe congenital diaphragmatic hernia by fetal tracheal occlusion: clinical experience with fifteen cases. Am J Obstet Gynecol 2000; 183 (5) 1059-1066
• 31 Laudy JA, Van Gucht M, Van Dooren MF, Wladimiroff JW, Tibboel D. Congenital diaphragmatic hernia: an evaluation of the prognostic value of the lung-to-head ratio and other prenatal parameters. Prenat Diagn 2003; 23 (8) 634-639
• 32 Ba'ath ME, Jesudason EC, Losty PD. How useful is the lung-to-head ratio in predicting outcome in the fetus with congenital diaphragmatic hernia? A systematic review and meta-analysis. Ultrasound Obstet Gynecol 2007; 30 (6) 897-906
• 33 Jani J, Nicolaides KH, Benachi A , et al. Timing of lung size assessment in the prediction of survival in fetuses with diaphragmatic hernia. Ultrasound Obstet Gynecol 2008; 31 (1) 37-40
• 34 Mah VK, Zamakhshary M, Mah DY , et al. Absolute vs relative improvements in congenital diaphragmatic hernia survival: what happened to “hidden mortality”. J Pediatr Surg 2009; 44 (5) 877-882
• 35 Ambalavanan N, Carlo WA, Tyson JE , et al; Generic Database; Subcommittees of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Outcome trajectories in extremely preterm infants. Pediatrics 2012; 130 (1) e115-e125