Congenital diaphragmatic hernia in an era of delayed repair after medical and/or extracorporeal membrane oxygenation stabilization: a prognostic and management classification.

In November 1987 we began to practice delayed repair of acutely symptomatic congenital diaphragmatic hernia (CDH) following medical and/or extracorporeal membrane oxygenation (ECMO) stabilization. We reviewed 23 consecutive patients with CDH symptomatic at birth treated over the ensuing 2 1/2 years. The mean age at admission, age at repair, and interval from admission to repair were 4.9, 37.0, and 32.6 hours, respectively. Overall survival was 52% (12/23). ECMO was used in 14 patients with 7 survivors (50%); 4 of these patients underwent repair prior to ECMO and 10 while on ECMO. The patients were retrospectively grouped into three classes based on postductal arterial blood gas (ABG) response to conventional medical management: class A (n = 8), able to achieve and sustain adequate oxygenation (PO2 greater than 60 mm Hg) and hyperventilation (PCO2 less than 40 mm Hg); class B (n = 10), unable to sustain adequate oxygenation (PO2 less than 60 mm Hg) but able to be hyperventilated (PCO2 less than 40 mm Hg); and class C (n = 5), unable to be oxygenated (PO2 less than 60 mm Hg) or hyperventilated (PCO2 greater than 40 mm Hg). The interval from admission to repair was 13.6, 53.5, and 25.4 hours for classes A, B, and C, respectively. Two class A (25%), nine class B (90%), and three class C patients (60%) were placed on ECMO. Survival rates were 88%, 50%, and 0% for classes A, B, and C, respectively. We propose the following management protocol. Class A patients are stable and can be repaired at any convenient point after admission without prerepair ECMO; few will need it afterward.(ABSTRACT TRUNCATED AT 250 WORDS)