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

The incidence of neonatal extracorporeal membrane oxygenation (ECMO) is decreasing nationally. This decrease is presumed to be a result of the emergence of alternative technologies such as high-frequency oscillatory ventilation (HFOV), nitric oxide (NO), and surfactant therapy as well as others. The purposes of the present report were to determine just how rapidly the demographics of ECMO are changing and to determine the impact of competing technologies on ECMO use. The authors reviewed their entire ECMO experience of 455 cases (370 neonatal, 38 pediatric, and 47 cardiac). The neonatal cases also were separated into diagnostic groups: MAS (meconium aspiration syndrome), PPHN (persistent pulmonary hypertension of the newborn), RDS (respiratory distress syndrome), and sepsis. To allow statistical comparison, the patients were divided into four chronological groups, of equal 3-year duration, spanning the 12 years that ECMO has been available. The results of the analysis demonstrated four principle findings. (1) The total number of patients receiving ECMO per year was declining (P = .0001). This decline was attributable to a reduction in the total number of neonatal patients, with the exception of cases of congenital diaphragmatic hernia. (2) The complexity of each ECMO run was increasing, as evidenced by substantial increases in mean ECMO duration per patient and an increase in the incidence of patient complications on ECMO (P = .0001). (3) There has been a significant decrease in the overall survival rate for patients treated with ECMO (P = .0001). (4) The ECMO population mix has shifted away from straightforward neonatal cases and toward the more complex pediatric and cardiac cases. This demographic shift has occurred as a result of improvements in pre-ECMO management of neonatal patients, and is primarily responsible for the findings noted above. However, there also has been a worsening of condition severity within each diagnostic group, which also is partly responsible for the changes noted. If these trends continue, pediatric, cardiac, and CDH patients will likely account for the majority of ECMO patients. Consequently, existing ECMO centers must be prepared to adapt to the changing demographics by evolving programs that support pediatric, cardiac, and adult patients, in addition to neonates. Furthermore, the complexity associated with transporting these unstable older patients and the likelihood that the number of active ECMO centers will decline may require remaining ECMO centers to develop long-distance ECMO transport capabilities.
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PMID:ECMO in evolution: the impact of changing patient demographics and alternative therapies on ECMO. 886 46

Understanding the complex multisystem dysfunction in the infant with a congenital hernia of the posterolateral diaphragm is still evolving and has changed radically during the last decade. The reduction in lung mass, in conjunction with surfactant deficiency and diminished compliance, leads to initial deficiencies in oxygenation and carbon dioxide (CO2) removal. This may then be potentiated by an extremely reactive hypoplastic pulmonary arterial system. Treatment no longer is focused on the operative repair but rather on the components of the pathophysiological process that are potentially reversible. Thus, extracorporeal membrane oxygenation and delay of repair until resolution of pulmonary artery hypertension have become mainstays of therapy and are probably responsible for increasing the survival rate in the patient who presents early with respiratory distress from 50% to 65%. Still far from acceptable, these results are giving impetus to new approaches to therapy including drugs such as nitric oxide, fetal intervention including open repair, and lung transplantation.
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PMID:Congenital diaphragmatic hernia: an overview. 893 50

A number of innovative approaches have been explored in the hope of improving the outcome in newborns with congenital diaphragmatic hernia (CDH) and respiratory insufficiency. Among these are the techniques of delayed approach to the repair of the diaphragmatic hernia; permissive hypercapnia; nitric oxide and surfactant administration; intratracheal pulmonary ventilation; liquid ventilation; perfluorocarbon-induced lung growth; and lung transplantation. Although early in their clinical evolution, these interventions are developing rapidly and hold promise for improving the outcome in patients with CDH.
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PMID:Innovative therapies in the management of newborns with congenital diaphragmatic hernia. 893 55

Fetal surgery for congenital diaphragmatic hernia (CDH) is controversial. The rationale for fetal intervention remains as compelling today as it was a decade ago. There continue to be newborns delivered with CDH who have severe enough pulmonary hypoplasia to result in significant morbidity or mortality. During the past decade ECMO, high-frequency ventilation, nitric oxide, surfactant therapy, and other advances in neonatal care have been applied to newborns with severe CDH. Although some would disagree, there is little convincing evidence that these therapies have had a major impact on the morbidity rate and mortality rate of patients with severe CDH. On the other hand, fetal surgery has not yet fulfilled its early promise. Although tremendous strides have been made in operative techniques, fetal monitoring, maternal-fetal anesthesia, and tocolysis, fetal repair of CDH has proved to be a formidable challenge and has not improved on the natural history of the disease. Recent application of tracheal ligation as a relatively simple method to accelerate lung growth in utero has been promising but requires further experience. The purpose of this article is to critically assess whether there is a role for fetal surgery in the treatment of CDH, and, if so, under what selected circumstances.
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PMID:Fetal surgery for congenital diaphragmatic hernia. 893 56

Congenital diaphragmatic hernia (CDH) with severe respiratory failure is still associated with significant mortality. Modern treatment of CDH is now widely accepted to be delayed repair after stabilization. Availability of Extracorporeal Membrane Oxygenation (ECMO) led up to real improvement in survival. Several others modalities have been recently used in attempting to reduce the need for ECMO or, otherwise, to improve outcome. Multicenter controlled trial of high-frequency oscillatory ventilation (HFOV), exogenous surfactant replacement, nitric oxide (NO) inhalation and, more recently, liquid ventilation have been reported. We describe four cases of CDH treated in our ECMO-centre from 1993 to date, 25% surviving. One patient died by pulmonary hypertension and multiorgan failure while on ECMO; one by pulmonary hypertension and cardiac failure and one by sepsis, both ones far from effective ECMO weaning. All patients underwent extracorporeal bypass because of Oxygenation Index (OI) ranging 65-215. Venovenous has been always made but one patient needed early switching on venoarterial. Several trials with surfactant and nitric oxide were performed during extracorporeal bypass. In survived patient, diaphragmatic defect was repaired out of ECMO. Patients survived to the weaning underwent vascular reconstruction. Our ECMO data confirm worse prognosis for CDH rather than other ECMO requiring diseases (we report 66.7% surviving in overall ECMO application); we underline real improvement by using alternative therapies together with extracorporeal bypass and primary role of OI as predicting index for ECMO.
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PMID:[Congenital diaphragmatic hernia: the use of ECMO and other modern therapeutic strategies]. 896 31

The first description diaphragmatic hernia appeared in 1575. In 1848, Bochdalek described congenital diaphragmatic hernia (CDH) occurring through a posterolateral defect. Successful surgical treatment of CDH in an infant was first performed in 1902, whereas the first neonate operated within 24 hours of life was reported in 1946. However, early surgery did not improve survival rates and the mortality was in the region of 50%. One reason for this was that more neonates underwent surgery who previously would have died without the repair of the CDH. Pulmonary hypoplasia and pulmonary hypertension were early recognised as important reasons for the high mortality rate. In recent years, an enormous effort has been made by research groups all over the world to describe the pathogenesis and pathophysiology of CDH, and apply these findings to clinical practice. Attempts have been made to define prognostic factors. Extracorporeal membrane oxygenation (ECMO) has produced encouraging results. Fetal surgical therapy remains an option in selected cases despite huge technical and ethical problems. Recently, several new therapeutic methods have been suggested, such as high frequency oscillatory ventilation, partial liquid ventilation, nitric oxide inhalation, surfactant therapy, and fetal tracheal ligation. However, more experience is required before the value of these approaches is clear. Despite these efforts, the mortality remains unacceptably high. The challenge for the future is to continue development of therapeutic approaches in order to improve survival of neonates with CDH.
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PMID:Historical aspects of congenital diaphragmatic hernia 906 5

The first description diaphragmatic hernia appeared in 1575. In 1848, Bochdalek described congenital diaphragmatic hernia (CDH) occurring through a posterolateral defect. Successful surgical treatment of CDH in an infant was first performed in 1902, whereas the first neonate operated within 24 hours of life was reported in 1946. However, early surgery did not improve survival rates and the mortality was in the region of 50%. One reason for this was that more neonates underwent surgery who previously would have died without the repair of the CDH. Pulmonary hypoplasia and pulmonary hypertension were early recognised as important reasons for the high mortality rate. In recent years, an enormous effort has been made by research groups all over the world to describe the pathogenesis and pathophysiology of CDH, and apply these findings to clinical practice. Attempts have been made to define prognostic factors. Extracorporeal membrane oxygenation (ECMO) has produced encouraging results. Fetal surgical therapy remains an option in selected cases despite huge technical and ethical problems. Recently, several new therapeutic methods have been suggested, such as high frequency oscillatory ventilation, partial liquid ventilation, nitric oxide inhalation, surfactant therapy, and fetal tracheal ligation. However, more experience is required before the value of these approaches is clear. Despite these efforts, the mortality remains unacceptably high. The challenge for the future is to continue development of therapeutic approaches in order to improve survival of neonates with CDH.
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PMID:Historical aspects of congenital diaphragmatic hernia. 915 80

The high mortality of newborn infants with congenital diaphragmatic hernia (CDH) can be partly attributed to pulmonary hypertension causing extrapulmonary right-to-left shunting with subsequent severe hypoxemia. Inhaled nitric oxide (NO) may reduce elevated pulmonary artery pressure and has been successfully improve arterial oxygenation in some newborns with CDH. However, it is not clear whether inhaled NO will actually improve survival of newborns with CDH. We therefore investigated the effect of inhaled NO on the survival rate of newborn rats with CDH following intrauterine exposure to nitrofen. A total of 151 newborn rats (9 litters) were exposed to nitrofen on day 11 of pregnancy, After spontaneous delivery, 63 newborn rats (4 litters) were allowed to spontaneously breathe air containing NO (80 parts per million), while 88 newborn rats (5 litters) were given air without NO. Survival was checked 15 min after birth and then hourly until the animals were sacrificed at 24 h of age to verify the absence or presence of CDH. The 2 groups of newborn rats breathing air with or without NO did not differ significantly with respect to the presence or size of CDH. Twenty-four of 63 (38%) newborn rats breathing air with NO survived for 24 h, compared to 12 of 88 (14%) rats breathing air alone (p < 0.01). Of newborn rats that were actually found to have CDH (n = 113), 8 of 42 (19%) animals breathing air with NO survived for 24 h, compared to 2 of 71 (2.8%) animals breathing air alone (p < 0.01). In animals with CDH confirmed by autopsy, the median survival time was significantly longer with NO (p < 0.001) ( 2 h, interquartile range 2h-15h), than those breathing or without NO (median/interquartile range 15 min). We conclude that in the nitrofen rat CDH model, significantly improved survival rates occur with inhaled NO as a sole intervention. The combined impact of inhaled NO and mechanical ventilation remains to be determined.
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PMID:Inhaled nitric oxide increases survival rates in newborn rats with congenital diaphragmatic hernia. 916 54

The response to three levels (10 ppm, 20 ppm and 40 ppm) of nitric oxide (NO) was assessed in 30 infants, median gestational age 30 (range 24-42) weeks. All the infants required an inspired oxygen concentration of more than 0.5, despite receiving surfactant where appropriate. All but one infant had a positive response to NO (median reduction in the oxygenation index (OI) was 33%, range -9%-90%), but only 20 infants showed a greater than 20% reduction in the OI. There was no obvious relationship of the optimum NO level (i.e. that associated with the maximum reduction in OI) and either diagnosis (congenital diaphragmatic hernia, meconium aspiration syndrome, respiratory distress syndrome, pulmonary interstitial emphysema (PIE), hydrops and sepsis) or maturity, except that five of six infants with PIE responded best to 40 ppm, as did eight of nine infants less than 28 weeks gestational age. We conclude NO dosage should be individualized and NO levels up to 40 ppm should be considered in very immature infants.
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PMID:Response to nitric oxide in term and preterm infants. 926 98

Congenital diaphragmatic hernia (CDH) is associated with pulmonary hypoplasia. The pulmonary vascular bed may be extremely reactive to various stimuli, and in the treatment it is important to avoid pulmonary vasospasm. The strategy in our institution since 1990 has involved a prolonged preoperative stabilization with gentle mechanical ventilation. Pressures have been kept as low as possible, and slight hypercarbia has been accepted. Peak inspiratory pressures exceeding 35 cm H2O have been avoided. Extracorporeal membrane oxygenation (ECMO) has been used according to standard inclusion criteria. Nitric oxide and high-frequency oscillation have been added to the therapeutic modalities during the study period. When the patient was considered stabilized, surgical repair was undertaken after a delay of 24 to 96 hours. In patients on ECMO who could not be decannulated, surgical repair was undertaken while on ECMO. From 1990 through 1995, 52 patients were admitted with a diagnosis of CDH. Forty-three of these were risk group patients presenting with respiratory distress within 6 hours after birth. A total of 48 patients survived (survival rate 92%), and 39 of the risk group patients (survival rate 91%). There were only four hospital deaths, all with contraindications to ECMO. It is suggested that the adopted protocol is beneficial in the treatment of CDH and that the fraction of patients who have pulmonary hypoplasia incompatible with life is smaller than previously believed.
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PMID:Improved results in patients who have congenital diaphragmatic hernia using preoperative stabilization, extracorporeal membrane oxygenation, and delayed surgery. 926 67


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