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Query: UMLS:C0019270 (hernia)
 15,856 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

High-frequency jet ventilation (HFJV) is one of several high-frequency techniques that are particularly valuable for treating the neonate with lung disease refractory to conventional ventilation or with pulmonary air leak. Extracorporeal membrane oxygenation (ECMO) has also emerged as a valuable rescue therapy for neonates of more than 2000 g birth weight and 34 weeks' gestation with intractable respiratory failure. With the concurrent introduction of HFJV and ECMO, the authors sought to evaluate the role of HFJV prior to the institution of ECMO therapy. The data base for 2856 neonates receiving mechanical ventilation in one unit was used to identify 73 (of 298 total) neonates treated with HFJV, who were eligible by age and weight criteria for ECMO. Patients were grouped by diagnosis, and the oxygenation index (OI) was calculated during therapy. Outcome was evaluated for mortality, and the sensitivity of the OI for predicting mortality was calculated. Neonates who survived with HFJV alone presented with an OI of 0.30 +/- 0.03 (SEM), significantly less than nonsurvivors (0.42 +/- 0.04, P = .016). Survivors responded to HFJV with a rapid decrease in OI at 1 hour (0.19 +/- 0.02, P less than .001) and 6 hours (0.15 +/- 0.01, P less than .001). Nonsurvivors did not respond significantly at 1 hour (OI = 0.33 +/- 0.04, P = not significant [NS]) or at 6 hours (OI = 0.40 +/- 0.06, P = NS). By diagnosis, neonates with respiratory distress syndrome survived more often with HFJV (28/34, 82%) than neonates with meconium aspiration (10/26, 38%) or diaphragmatic hernia (3/9, 33%). Neonates with respiratory distress syndrome seldom presented with high OI values, but the majority of those who did survived (5/7 survived with initial OI greater than or equal to 0.40).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Diagnosis-related criteria in the consideration of extracorporeal membrane oxygenation in neonates previously treated with high-frequency jet ventilation. 174 Dec 26

Deciding when to wean neonates from extracorporal membrane oxygenation (ECMO) can be difficult. The usefulness of simple measurements of pulmonary mechanics e.g., dynamic compliance (Cdyn) has been questioned. We investigated the pulmonary mechanics of eight neonates using the interrupter technique, which allows the partitioning of pulmonary mechanics into compartments representing the conducting airways and more peripheral phenomena (viscoelastic properties and "pendelluft"). Three neonates required ECMO for a congenital diaphragmatic hernia (CDH), two for hyaline membrane disease (HMO), two for meconium aspiration syndrome (MAS), and one for pneumonia. All neonates with MAS, HMD, and pneumonia were successfully weaned from ECMO when their Cdyn was 0.3 mL/cmH2O/kg or greater [mean 0.34 +/- 0.06 (SEM)]. All three neonates with CDH died and their highest Cdyn was 0.21, 0.19, and 0.09 mL/cmH2O/kg respectively (mean, 0.16 +/- 0.037). The airway resistance (Raw) and the slower component of pressure change after interruption (delta Pdiff), a measure of the more peripheral phenomena of the lung, were not significantly different in those neonates who survived and those who did not. The values for delta Pdiff in all patients were higher than those in healthy neonates. However, the Raw was not different. This suggests that the major disturbance in pulmonary mechanics was distal to the conducting airways. Those neonates who were successfully weaned from ECMO had a significantly higher Cdyn 24-48 hours prior to decannulation. Considering the lung as a two-compartment model offers no advantages when compared to the one-compartment model for the prediction of the outcome of a neonate on ECMO.
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PMID:Pulmonary mechanics and outcome of neonates on ECMO. 175 27

Congenital diaphragmatic hernia (CDH) with severe respiratory failure in the first few hours of life continues to be associated with significant mortality. Extracorporeal membrane oxygenation (ECMO) has been successfully used postoperatively to reverse the effects of severe pulmonary hypertension. Since 1984, ECMO has been required in 27 of the patients we treated with CDH. This report describes our experience with six very high-risk patients placed on ECMO prior to the operation who subsequently underwent repair of their diaphragmatic hernias while on ECMO. Two patients presented in extremis, unlikely to survive initial operative repair, and were placed on ECMO prior to the operation. All six patients had immediate respiratory distress after birth with mean Apgars of 2.3 and 3.7. The best pre-ECMO arterial blood gas (postductal) showed mean +/- SEM values of 6.97 +/- 0.1; PO2 = 54.8 +/- 5.9; PCO2 = 79.5 +/- 16.9. Immediately prior to ECMO, the mean +/- SEM ventilatory index (VI = rate x mean airway pressure) was 1,233 +/- 44, with a mean pH of 7.17 +/- 0.05; PO2 = 32 +/- 2.9; PCO2 = 59 +/- 5.3 and a mean AaDO2 of 622 +/- 4.8. The timing of the operative repair averaged 25 hours following initiation of ECMO. Three right-sided and three left-sided hernias were treated. Four were repaired through an abdominal approach, and two via thoracotomy; four required a Gortex patch closure. Postoperative bleeding was not a major problem in these heparinized patients. Four of these six patients survived, and follow-up of 2 months to 3 years shows no significant respiratory compromise.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Congenital diaphragmatic hernia repair on ECMO. 226 55

Combined high-frequency oscillatory ventilation (HFOV) and intermittent mandatory ventilation (IMV) was used in 12 neonates with inadequate gas exchange with conventional IMV. Diagnoses included diaphragmatic hernia with hypoplastic lungs, pneumonia, persistent fetal circulation, and severe respiratory distress syndrome. In most patients there was severe air leak. Within 10 hours of beginning HFOV-IMV the mean arterial PCO2 fell from 60 +/- 5 (means +/- SEM) to 38 +/- 2 mm Hg (P less than 0.01) and the mean IMV rate was reduced from 96 +/- 8 to 17 +/- 4 breaths per minute (P less than 0.001). The mean arterial-alveolar oxygen tension ratio rose from 0.05 +/- 0.01 to 0.09 +/- 0.01 (P less than 0.005). Mean airway pressure in the trachea was reduced from 16 +/- 2 to 10 +/- 3 cm H2O (P less than 0.05). Four patients died, three of whom had diaphragmatic hernias with hypoplastic lungs. Five of the eight survivors had mild bronchopulmonary dysplasia requiring supplemental oxygen. These studies demonstrate that in some neonates with respiratory failure who fail to respond to conventional IMV, combined HFOV-IMV can be successful.
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PMID:Combined high-frequency oscillatory ventilation and intermittent mandatory ventilation in critically ill neonates. 637 37

Cytokines are early responders in the cascade of host mediators after injury. The cytokine response in neonates following surgery and its prognostic significance were studied prospectively. Twenty-one patients (oesophageal atresia [5], congenital diaphragmatic hernia [4], exomphalos [4], patent vitellointestinal duct [1], anorectal anomaly [2], choledochal cyst [1], renal cyst [1], ovarian cyst [1], myelomeningocoele [1], and pyloric stenosis [1]) operated on at a median age of 3 days (range, 1 to 24 days) and 12 age-matched controls were included in the study. Plasma samples were obtained once in the controls, and serially preoperatively and at 1, 3, 6, 12, 24, 36, and 48 hours postoperatively in the patients. The levels of the cytokines, interleukin-6 (IL-6), and interleukin-8 (IL-8) were measured using the enzyme-linked immunosorbent assay (ELISA) technique. The median plasma levels of IL-6 and IL-8 in normal controls were 2.4 pg/mL and 92.0 pg/mL, respectively. Of the 21 patients, four had postoperative complications (pulmonary consolidation [2], septicaemia [1], and oesophageal leak [1]) between days 4 and 6. All 17 uncomplicated cases had an increase in IL-6 and IL-8 in the early postoperative period, with the peak occurring within 12 hours after surgery. The mean (+/- SEM) peak levels of IL-6 and IL-8 in uncomplicated cases were of 92.6 +/- 15.8 pg/mL and 230.3 +/- 45.3 pg/mL, respectively. In the four complicated cases, there was a disproportionately higher increase in both IL-6 (peaks, 305.0, 125.0, 240.0, and 220.0 pg/mL) and IL-8 (peaks, 1500.0, 340.0, 245.0, 355.0 and pg/mL), which preceded the clinical onset of complications. The early postoperative increases in plasma IL-6 and IL-8 probably represent the stress response of neonates to surgery. Furthermore, the association of an exaggerated increase in postoperative levels of plasma IL-6 and IL-8 and postoperative complications may have prognostic significance.
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PMID:Cytokine response of neonates to surgery. 807 24

Correction of a left congenital diaphragmatic hernia in a human fetus with a large volume of liver in the chest requires reduction of liver and viscera into the abdomen. This can kink the ductus venosus and cause the death of the fetus. Therefore, we have repaired surgically created diaphragmatic hernias in fetal lambs by leaving viscera in the chest wrapped in a silastic chimney. With fetal growth there is a relative reduction of hernia volume over weeks, potentially avoiding kinking the ductus venosus. In four groups of lambs lung size and static respiratory system compliance at birth were compared. Lambs treated by this new technique (silo, n = 7) were compared with lambs that had undergone immediate complete correction with a flat silastic patch in the diaphragm plus an abdominal patch (patch, n = 8), with lambs with uncorrected hernias (n = 6), and with normals (n = 8). There was no significant difference between total lung weights (131 +/- 6 g v 157 +/- 13 g, mean +/- SEM, silo v patch) and lung displacement volumes (142 +/- 7 mL v 162 +/- 14 mL) in either surgically corrected group. Lungs from those corrected by silo were significantly heavier than those with uncorrected herniae (131 +/- 6 g v 56 +/- 5 g, P < .01), but were not as heavy as normal lungs (131 +/- 6 g v 257 +/- 16 g, P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Intrathoracic silo for fetal diaphragmatic hernia: lung growth and slow reduction of abdominal viscera. 822 84

To study the potential role of endothelin-1, a potent endothelium-derived vasoconstrictor peptide, in the pathophysiology of persistent pulmonary hypertension of the newborn (PPHN), we measured arterial concentrations of immunoreactive endothelin-1 (irET-1) in 24 neonates with PPHN. Secondary diagnoses included meconium aspiration syndrome (13 patients), sepsis (2), congenital diaphragmatic hernia (1), asphyxia (1), pulmonary hemorrhage (1), aspiration of blood (1), and respiratory distress syndrome (1). Compared with irET-1 levels in umbilical cord blood in normal infants (15.1 +/- 4.1 pg/ml; mean +/- SEM) and in newborn infants with hyaline membrane disease who were supported by mechanical ventilation (11.8 +/- 1.2 pg/ml), infants with PPHN had markedly elevated circulating irET-1 levels (27.6 +/- 3.6 pg/ml; p < 0.01 vs cord blood, hyaline membrane disease). Infants with severe PPHN requiring extracorporeal membrane oxygenation (ECMO) therapy had higher irET-1 levels than infants with milder disease (31.0 +/- 4.7 for ECMO-treated infants vs 21.2 +/- 2.0 for non-ECMO-treated infants; p < 0.05). In patients treated without ECMO, irET-1 progressively decreased during the following 3 to 5 days, paralleling clinical improvement. In contrast, irET-1 concentrations remained elevated in infants with severe PPHN during ECMO therapy. We conclude that circulating irET-1 levels are elevated in newborn infants with PPHN, are positively correlated with disease severity, and decline with resolution of disease in patients who do not require ECMO therapy. Whether endothelin-1 contributes directly to the pathophysiology of PPHN or is simply a marker of disease activity remains speculative.
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PMID:Elevated immunoreactive endothelin-1 levels in newborn infants with persistent pulmonary hypertension. 815 68

Selective left ventricular hypoplasia is a recognized feature of congenital diaphragmatic hernia (CDH). It is speculated that the herniated viscera act as a space occupying lesion that inhibit normal cardiac development. The purpose of this study was to determine the effect of two separate fetal surgical interventions on subsequent cardiac development in CDH. CDH lambs were created at 80 days gestation and underwent either tracheal ligation (CDH + TL) or diaphragmatic repair (CDH + repair) at 110 days gestation. At term (141 days gestation) the hearts were harvested and fixed in 4% paraformaldehyde solution. Anatomic dissections were performed and component heart weights determined. Fresh specimens were analyzed for DNA and protein content. All weights are expressed in grams/kilogram body weight and all data as mean +/- SEM. All measurements are compared to control and CDH tissues. There were seven CDH lambs, five control lambs, five CDH + TL lambs, and five CDH + repair lambs. There were no differences in body weight (kg) between CDH, CDH + TL, CDH + repair, and control littermates. CDH lambs have significantly decreased total heart (4.88 +/- .25* vs 6.75 +/- .49, P < 0.05), left ventricular (1.65 +/- .11* vs 2.15 +/- .19, P < 0.05), septal (1.29 +/- .11* vs 1.99 +/- .21, P < 0.05), and combined atrial (0.68 +/- .06* vs 1.14 +/- .15, P < 0.05) weights (g/kg lamb) without differences in RV weights (1.26 +/- .07 vs 1.57 +/- .17, P = NS) when compared to littermate controls. No differences were found in total heart (4.82 +/- 0.38 vs 4.88 +/- 0.25), left ventricular (1.48 +/- 0.13 vs 1.65 +/- 0.11), septal (1.26 +/- 0.17 vs 1.29 +/- 0.11), combined atrial weights (0.56 +/- 0.07 vs 0.68 +/- 0.06), and right ventricular (1.52 +/- 0.12 vs 1.26 +/- 0.07) between CDH + TL and CDH lambs. There were no differences in total heart (6.60 +/- 0.29 vs 6.75 +/- 0.49), left ventricular (2.10 +/- 0.15 vs 2.15 +/- 0.19), septal (1.97 +/- 0.18 vs 1.99 +/- 0.21), combined atrial (1.10 +/- 0.10 vs 1.14 +/- 0.15), or right ventricular (1.52 +/- 0.12 vs 1.57 +/- 0.17) weights between CDH + repair and control lambs. LV and RV wall thicknesses (cm), as well as total protein and DNA content, and DNA/total protein ratios were identical in all groups. CDH lambs have a significant reduction in total heart weights mainly caused by hypoplasia of the left ventricle (left ventricular "smallness") and the interventricular septum. Removal of the herniated viscera and repair of the diaphragmatic defect correct this abnormality, but tracheal ligation does not. We speculate that although tracheal ligation reverses pulmonary hypoplasia, the enlarging lungs act as space occupying lesions that adversely affect cardiac development. Further investigations are necessary to determine the functional significance of these findings.
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PMID:Fetal surgical interventions and the development of the heart in congenital diaphragmatic hernia. 889 99

We have used an oesophageal Doppler to measure aortic blood flow velocity before, during and after induction of carbon dioxide pneumoperitoneum in 10 consecutive patients, mean age 58 yr, undergoing laparoscopic hernia repair. Derived values for stroke distance, minute distance and systemic vascular resistance showed considerable interpatient variation indicating unpredictable haemodynamic responses. Five minutes after insufflation of the abdomen there was a significant increase in mean arterial pressure from 82.5 to 103.6 mm Hg (P < 0.05) but both stroke distance and minute distance decreased significantly (mean 12.0 (SEM 1.4) cm to 9.0 (0.7) cm, P < 0.05; and 747.5 (82) cm min-1 to 596 (49) cm min-1, P < 0.05; respectively) indicating a significant decrease in cardiac output. There was a corresponding increase in the index of systemic vascular resistance from 1092 (747) to 2079 (400) (P < 0.05) which persisted after deflation of the abdomen. Oesophageal Doppler can provide continuous online haemodynamic data with a rapid response to acute changes and may have a role in non-invasive haemodynamic monitoring during laparoscopic procedures in older patients with cardiovascular disease.
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PMID:Assessment of cardiovascular changes during laparoscopic hernia repair using oesophageal Doppler. 917 64

The aim of the study was prospectively to compare the early results and outcome in 105 patients randomly allocated to undergo tension-free laparoscopic hernia repair (LHR) with transabdominal preperitoneal technique (53 patients) or open hernia repair (OHR) with mesh apposition (52 patients). The mean (SD) operation time was longer in the LHR group than in the OHR group: 49.6 (5.4) versus 33. 9 (6.2) minutes; p < 0.001. One laparoscopic case was converted to open repair to deal with a hemorrhage from an aberrant obturatory artery at the level of Cooper's ligament. Groin discomfort or pain was the most common complication after both procedures. The patients requiring none, one, two, or more than two doses of intramuscular diclofenac were, respectively, 40.4%, 40.4%, 15.4%, and 3.8% after LHR and 50.0%, 30.8%, 17.3%, and 1.9% after OHR (p = 0.69; NS). The mean +/- SEM (range) postoperative visual analog scale score, ranging from 0 (no pain) to 10 (worst pain imaginable), was 3.1 +/- 0.2 (1-7) in the LHR subset and 2.7 +/- 0.2 (1-5) in the OHR group (p = 0.14; NS); on the second postoperative day the score was 2.3 +/- 0.2 (1-6) and 1.8 +/- 0.1 (1-4), respectively (p < 0.03). The time +/- SEM (range) of resumption of pain-free normal activities and work was faster in OHR group: 6.1 +/- 0.2 (4-8) weeks versus 6.5 +/- 0.1 (4-8) weeks; p < 0.03. Our results showed that tension-free open hernia repair is superior to LHR in terms of postoperative pain with no important differences in recovery. </HEA
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PMID:Tension-free laparoscopic and open hernia repair: randomized controlled trial of early results. 1051 39


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