Charlie Stolar

1026 statements · 6 topics · summaries given as host listed separately

CICU / Post-op CHD Care · guest expert Single Ventricle / HLHS · guest expert

Featured statements

▶ Ep 2 · 39:20
The problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest.
quote · Congenital Diaphragmatic Hernia
▶ Ep 2 · 33:01
If you drive it out the subclavian artery, you're going to have a very well perfused hand, and you think your preductal sats are looking really good, but the baby's not seeing the oxygen.
quote · Congenital Diaphragmatic Hernia
▶ Ep 1 · 1:10:09
this business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture.
quote · CICU / Post-op CHD Care
▶ Ep 1 · 10:13
if you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them.
quote · CICU / Post-op CHD Care
▶ Ep 3 · 17:11
ECMO is a drug delivery system for oxygen. So if the end organs are getting enough oxygen, then you're doing fine.
quote · Congenital Diaphragmatic Hernia
▶ Ep 3 · 26:07
The best drug for diaphragmatic hernia is oxygen.
quote · Congenital Diaphragmatic Hernia

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Charlie's statements about CICU / Post-op CHD Care 110 statements

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Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 1 · 2:13
quote the most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach ↗
▶ Ep 1 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies ↗
▶ Ep 1 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 1 · 3:37
clinical CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart ↗
▶ Ep 1 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side ↗
▶ Ep 1 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation ↗
▶ Ep 1 · 4:39
clinical CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty ↗
▶ Ep 1 · 5:00
clinical CDH is a medical physiologic emergency but not a surgical emergency ↗
▶ Ep 1 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues ↗
▶ Ep 1 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best ↗
▶ Ep 1 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO ↗
▶ Ep 1 · 8:31
clinical In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value ↗
▶ Ep 1 · 8:42
clinical Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning ↗
▶ Ep 1 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis ↗
▶ Ep 1 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers ↗
▶ Ep 1 · 10:13
quote if you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 1 · 10:37
clinical Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable ↗
▶ Ep 1 · 12:06
quote I think that's nonsense. ↗
▶ Ep 1 · 12:06
opinion Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies ↗
▶ Ep 1 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth ↗
▶ Ep 1 · 14:45
clinical Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function ↗
▶ Ep 1 · 15:55
clinical Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood ↗
▶ Ep 1 · 17:06
clinical ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care ↗
▶ Ep 1 · 17:44
clinical The best way to assess end-organ function is urine output ↗
▶ Ep 1 · 18:21
guideline ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more ↗
▶ Ep 1 · 19:06
clinical All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin ↗
▶ Ep 1 · 20:25
clinical When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs ↗
▶ Ep 1 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today ↗
▶ Ep 1 · 21:56
clinical CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously ↗
▶ Ep 1 · 22:15
clinical Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies ↗
▶ Ep 1 · 22:53
clinical Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia ↗
▶ Ep 1 · 24:30
quote I often joke that when people say, how do you know when to set up an ECMO circuit with a diaphragmatic hernia, it's when they get out the oscillator. ↗
▶ Ep 1 · 24:30
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit ↗
▶ Ep 1 · 25:45
opinion Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH ↗
▶ Ep 1 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 1 · 26:07
opinion The best drug for CDH is oxygen ↗
▶ Ep 1 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 1 · 26:22
clinical ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor ↗
▶ Ep 1 · 27:40
clinical The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter ↗
▶ Ep 1 · 28:15
clinical For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit ↗
▶ Ep 1 · 28:45
clinical The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start? ↗
▶ Ep 1 · 30:27
clinical VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum ↗
▶ Ep 1 · 31:00
clinical VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO ↗
▶ Ep 1 · 31:25
quote there ain't nothing like VA bypass. ↗
▶ Ep 1 · 31:53
clinical VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage ↗
▶ Ep 1 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein ↗
▶ Ep 1 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen ↗
▶ Ep 1 · 33:23
clinical Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted ↗
▶ Ep 1 · 33:55
clinical Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage ↗
▶ Ep 1 · 34:47
clinical In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium ↗
▶ Ep 1 · 34:55
clinical ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence ↗
▶ Ep 1 · 35:10
clinical Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct ↗
▶ Ep 1 · 35:29
clinical At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70% ↗
▶ Ep 1 · 36:12
clinical Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet ↗
▶ Ep 1 · 36:34
clinical The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO ↗
▶ Ep 1 · 37:38
quote I leave town after 2 weeks. ↗
▶ Ep 1 · 38:18
clinical For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair ↗
▶ Ep 1 · 39:05
clinical Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest ↗
▶ Ep 1 · 39:39
quote This is not a space occupying lesion is not the problem here ↗
▶ Ep 1 · 40:40
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours ↗
▶ Ep 1 · 41:07
clinical If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off ↗
▶ Ep 1 · 41:51
clinical Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run ↗
▶ Ep 1 · 42:39
clinical When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube ↗
▶ Ep 1 · 44:11
clinical Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage ↗
▶ Ep 1 · 45:42
clinical For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days ↗
▶ Ep 1 · 46:07
clinical Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant ↗
▶ Ep 1 · 46:28
clinical Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine ↗
▶ Ep 1 · 46:47
clinical Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times ↗
▶ Ep 1 · 47:57
clinical Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn ↗
▶ Ep 1 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 1 · 48:32
clinical The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby ↗
▶ Ep 1 · 49:37
clinical In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions ↗
▶ Ep 1 · 50:21
opinion Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest ↗
▶ Ep 1 · 53:01
quote I was very disappointed at our own data because I thought the scope approach was gorgeous. ↗
▶ Ep 1 · 54:58
clinical For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect ↗
▶ Ep 1 · 55:31
clinical Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib ↗
▶ Ep 1 · 56:11
clinical The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair ↗
▶ Ep 1 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl ↗
▶ Ep 1 · 57:59
clinical For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch ↗
▶ Ep 1 · 58:43
clinical Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue ↗
▶ Ep 1 · 1:00:23
clinical For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly ↗
▶ Ep 1 · 1:01:35
clinical Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner ↗
▶ Ep 1 · 1:02:03
clinical For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin ↗
▶ Ep 1 · 1:04:16
clinical If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail ↗
▶ Ep 1 · 1:06:31
quote neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 1 · 1:06:47
clinical The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest ↗
▶ Ep 1 · 1:06:53
quote That's how God made this lung. ↗
▶ Ep 1 · 1:07:01
clinical The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo ↗
▶ Ep 1 · 1:07:18
clinical Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding ↗
▶ Ep 1 · 1:08:53
clinical Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days ↗
▶ Ep 1 · 1:09:34
clinical CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout ↗
▶ Ep 1 · 1:09:51
clinical All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying ↗
▶ Ep 1 · 1:10:09
opinion The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture ↗
▶ Ep 1 · 1:10:09
quote this business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 1 · 1:10:28
clinical CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation ↗
▶ Ep 1 · 1:10:40
opinion Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz) ↗
▶ Ep 1 · 1:12:11
clinical Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time ↗
▶ Ep 1 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance ↗
▶ Ep 1 · 1:13:57
clinical CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended ↗
▶ Ep 1 · 1:14:09
clinical As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall ↗
▶ Ep 1 · 1:14:29
clinical Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed ↗
▶ Ep 1 · 1:14:34
clinical CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this ↗
▶ Ep 1 · 1:15:16
clinical CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair ↗
▶ Ep 1 · 1:17:35
clinical Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right ↗
▶ Ep 1 · 1:17:51
clinical For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC ↗
▶ Ep 1 · 1:18:09
clinical If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen ↗
▶ Ep 1 · 1:18:29
clinical Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically ↗
▶ Ep 1 · 1:19:11
clinical Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation ↗
▶ Ep 1 · 1:19:48
clinical For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way ↗
▶ Ep 1 · 1:20:12
clinical For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart ↗
Charlie's statements about Congenital Diaphragmatic Hernia 201 statements

Open the Congenital Diaphragmatic Hernia collection →

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 2 · 2:13
quote The most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach. ↗
▶ Ep 2 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies managed by community obstetricians. ↗
▶ Ep 2 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 2 · 3:21
quote I expect parents to leave with a sense of cautious optimism, not doom and gloom. ↗
▶ Ep 2 · 3:37
clinical CDH diagnosis is usually made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart. ↗
▶ Ep 2 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side. ↗
▶ Ep 2 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation. ↗
▶ Ep 2 · 5:00
clinical CDH is a medical physiologic emergency, not a surgical emergency. ↗
▶ Ep 2 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section. ↗
▶ Ep 2 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best. ↗
▶ Ep 2 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability. ↗
▶ Ep 2 · 7:34
epidemiological Maybe 10-15% of babies diagnosed with CDH will benefit from ECMO. ↗
▶ Ep 2 · 8:31
clinical In single-center experiences, presence of liver in the chest is of no prognostic value for CDH. ↗
▶ Ep 2 · 8:42
clinical Lung-to-head ratio (LHR) is of limited prognostic value except when very low (less than 0.8). ↗
▶ Ep 2 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis in CDH. ↗
▶ Ep 2 · 10:13
quote If you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 2 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers. ↗
▶ Ep 2 · 10:37
clinical Steroids have tremendous value for preterm labor under 35 weeks but their role in near-term CDH babies (37-39 weeks) is arguable. ↗
▶ Ep 2 · 12:06
opinion Exit-to-ECMO for CDH is essentially moving the goalposts and deck chairs around on the Titanic for non-viable babies. ↗
▶ Ep 2 · 12:06
quote The short answer is I think that's nonsense. ↗
▶ Ep 2 · 12:36
quote What you're now doing is putting what in my view is almost certainly a non-viable baby on a heart lung machine and basically moving the goalposts and moving the deck chairs around on the Titanic. ↗
▶ Ep 2 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth. ↗
▶ Ep 2 · 17:11
quote ECMO is a drug delivery system for oxygen. So if the end organs are getting enough oxygen, then you're doing fine. ↗
▶ Ep 2 · 19:06
guideline All therapy for CDH should be guided by preductal oximetry, not postductal, because all babies have some degree of pulmonary hypertension with shunting. ↗
▶ Ep 2 · 19:32
clinical If preductal saturation is 90% (PaO2 of 65 torr), the brain is doing fine because this is fetal hemoglobin. ↗
▶ Ep 2 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today because they trash lungs in a heartbeat. ↗
▶ Ep 2 · 21:56
guideline CDH babies should not be paralyzed and should have minimal sedation to maintain spontaneous breathing. ↗
▶ Ep 2 · 22:15
clinical Most CDH babies don't tolerate conventional ventilator settings (rate 40, peak pressure 25-28, PEEP 5) and require unconventional high-rate (100 breaths/min) low-pressure ventilation. ↗
▶ Ep 2 · 24:38
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO. ↗
▶ Ep 2 · 24:50
quote When I see them getting out the oscillator, I'll go prime a circuit. That's just how I think about it. ↗
▶ Ep 2 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 2 · 25:45
clinical Nitric oxide is a waste of money for CDH babies; meta-analyses show it's terrific for premature babies with immature lung disease but of no value in CDH. ↗
▶ Ep 2 · 26:07
opinion The best drug for CDH is oxygen. ↗
▶ Ep 2 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 2 · 26:22
guideline ECMO should not be used in babies under 36 weeks gestational age initially, though this has been pushed down to 35 weeks, maybe 34 weeks, with intracranial hemorrhage rates taking off below 32 weeks. ↗
▶ Ep 2 · 27:40
clinical The smallest ECMO arterial perfusion cannula available is about 8 French, and resistance is related to both length and diameter, making adequate flow difficult in very small babies. ↗
▶ Ep 2 · 28:15
clinical For ECMO candidacy, the real risk for intracranial hemorrhage is the germinal matrix, which is usually OK by 35-36 weeks gestation, so it's gestational age that matters, not size. ↗
▶ Ep 2 · 29:10
guideline The broad principle for ECMO candidacy is whether you can get out of ECMO with reasonable confidence if you get in—don't start something you can't finish. ↗
▶ Ep 2 · 29:10
quote Don't start something you can't finish. ↗
▶ Ep 2 · 30:27
clinical VV ECMO is terrific if the heart works, but in CDH the heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum. ↗
▶ Ep 2 · 31:53
quote VA bypass is basically dial in a PAO2. ↗
▶ Ep 2 · 31:53
opinion VA bypass is essentially dialing in a PaO2, while VV ECMO is much more annoying with mixing, cannula position issues, and CDH babies are generally too unstable for VV. ↗
▶ Ep 2 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful to prevent driving the arterial cannula out the subclavian artery or the venous cannula into the innominate vein. ↗
▶ Ep 2 · 33:01
quote If you drive it out the subclavian artery, you're going to have a very well perfused hand, and you think your preductal sats are looking really good, but the baby's not seeing the oxygen. ↗
▶ Ep 2 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a very well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen. ↗
▶ Ep 2 · 34:19
clinical The first few hours on ECMO can be unstable; hyperkalemia cardiac arrest can occur if blood isn't washed, but you just perfuse through it and give calcium. ↗
▶ Ep 2 · 34:55
guideline ECMO flow should be slowly increased over 45 minutes to 1.5 hours to about 100-125 cc/kg/min (about 80% of cardiac output) to reduce intracranial hemorrhage incidence. ↗
▶ Ep 2 · 36:34
clinical The hyperoxia test—turning FIO2 up to 1.0 on the ventilator while on ECMO—gives courage to begin weaning if the PaO2 rises, showing the baby can use their lungs. ↗
▶ Ep 2 · 38:18
guideline For babies stuck on ECMO at 2 weeks, ensure they are maximally dried out (bone dry, eyes sucked into back of head, turned into a prune) before considering on-ECMO repair. ↗
▶ Ep 2 · 39:14
clinical The problem in CDH is not that bowel is in the chest; the problem is growth arrest of the lungs that happened at 14-15 weeks gestation. Getting bowel out of the chest is not miraculous. ↗
▶ Ep 2 · 39:20
quote The problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest. ↗
▶ Ep 2 · 40:37
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) make clot on ECMO. A platelet thrombus lasts 48-72 hours, giving a window to operate and get off ECMO before bleeding starts. ↗
▶ Ep 2 · 41:14
guideline Preferred approach is to wean ECMO down to 20 cc/kg/min, do the operation, accept 1 day of post-op edema, then have 2-3 days to get off ECMO before bleeding starts. ↗
▶ Ep 2 · 41:51
clinical If you take a baby off ECMO then operate, every patient gets stiff after surgery, pulmonary hypertension relapses, and you're talking about a second ECMO run. ↗
▶ Ep 2 · 42:39
guideline When operating on ECMO, load with Amicar preoperatively, do it as an abdominal operation, use a patch with low threshold to avoid tension, place a Jackson-Pratt drain under the patch, and place a chest tube. ↗
▶ Ep 2 · 44:14
opinion Futility on ECMO starts to rear its head after about 2-3 weeks. ↗
▶ Ep 2 · 45:42
clinical The typical stable CDH baby not requiring ECMO takes 3-4 days to wean to minimal ventilator settings (FIO2 0.4, conventional settings) before repair. ↗
▶ Ep 2 · 46:07
guideline Use the infant ventilator instead of an anesthesia machine intraoperatively because infant anesthesia machines have high dead space and are not very compliant. ↗
▶ Ep 2 · 46:47
guideline For repair timing, three variables matter: pre/post-ductal gradient on pulse ox, right ventricle dilation on echo, and RV pressure versus LV pressure (RV should be no more than systemic). ↗
▶ Ep 2 · 48:32
clinical The thoracoscopic approach for CDH is gorgeous with a sparkling view, but the recurrence rate is really high—about 25% in under a year in Dr. Stolar's series of 35 stable kids. ↗
▶ Ep 2 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 2 · 50:02
clinical The APSA outcomes committee meta-analysis came to a very similar conclusion about high thoracoscopic CDH recurrence rates. ↗
▶ Ep 2 · 55:02
guideline For open CDH repair, need a real subcostal incision (not a small two-finger incision), rotate the liver out of chest and abdomen, eviscerate bowel, and mobilize the posterior leaflet like unrolling a window shade down to rib. ↗
▶ Ep 2 · 56:06
clinical The medial part of CDH repair is hardest because sometimes the esophagus or aorta is hanging out with nothing to sew to. ↗
▶ Ep 2 · 56:28
guideline When there's no diaphragm to sew to medially, make an upside-down U-shaped incision on the pericardium and rotate that down to where the diaphragm would be to begin the repair. ↗
▶ Ep 2 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike Vicryl which saws tissue. ↗
▶ Ep 2 · 57:59
guideline Favor non-biologic material like 1mm Gore-Tex for patches, and anchor the patch to the ribs laterally by getting a needle around the rib. ↗
▶ Ep 2 · 58:43
guideline Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out taking a deep breath; over time it gets incorporated into fibrous tissue. ↗
▶ Ep 2 · 1:00:23
guideline For thoracoscopic CDH repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and put solid organs (spleen or left liver lobe) in last to plug the hole and keep bowel down. ↗
▶ Ep 2 · 1:04:16
guideline If you can see through the diaphragm tissue (it's nothing but pleura and peritoneum), resect it back to muscle for a fresh edge to sew together, or the plication will fail. ↗
▶ Ep 2 · 1:06:31
quote Neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 2 · 1:06:47
guideline There is no indication for a chest tube in CDH except for active air leak or anticipated/active bleeding. The ipsilateral lung is small and won't fill the pleural space—that's how God made this lung. ↗
▶ Ep 2 · 1:07:13
clinical A pneumothorax in CDH is a pneumothorax ex vacuo, not air under pressure. Putting in a chest tube on water seal suction will just distort the mediastinum and precipitate a pulmonary hypertensive crisis. ↗
▶ Ep 2 · 1:08:54
clinical The typical stable CDH baby will be crummy for about a day postoperatively, then get better and be extubated in 4-5 days and go home. ↗
▶ Ep 2 · 1:09:39
clinical CDH is a field defect affecting the whole foregut from pharynx to ligament of Treitz. Everything—esophagus, stomach, gastric emptying—has abnormal motility. ↗
▶ Ep 2 · 1:09:51
clinical If you do a GI series on CDH kids, the esophagus will be very dilated, ectatic, and abnormal-looking. Manometry and impedance manometry are abnormal. ↗
▶ Ep 2 · 1:10:09
opinion It's not really reflux in CDH—calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture. ↗
▶ Ep 2 · 1:10:09
quote This business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 2 · 1:10:28
clinical CDH kids generally do well with continuous feedings slowly condensed to bolus. It's unusual to need surgical intervention for foregut dysmotility. ↗
▶ Ep 2 · 1:10:36
guideline When surgery is needed for CDH foregut dysmotility, approach it as palliation: some sort of fundoplication (not Nissen—it's fully competent on an abnormal-motility esophagus), combined with gastrostomy and a real drainage procedure like Jaboulay-Finney, not Heineke-Mikulicz. ↗
▶ Ep 2 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis and now recommends lifelong proton pump inhibitors and regular scoping for all CDH patients. ↗
▶ Ep 2 · 1:13:46
clinical Dr. Stolar's 1989-1990 paper showed most CDH kids turn out OK unless the mother had an 8th grade education and the child is a boy. ↗
▶ Ep 2 · 1:13:58
clinical There is an incidence of attention deficit disorders and autism in CDH survivors, prompting early intervention for neuropsychiatric issues. ↗
▶ Ep 2 · 1:14:09
clinical Because CDH is a field defect, there's asymmetric chest growth leading to pectus-like distorted chest wall growth requiring Nuss-type operations in some patients. ↗
▶ Ep 2 · 1:14:20
clinical Some CDH girls as teenagers have no breast development on the side of the hernia, requiring Nuss operation and breast implant. ↗
▶ Ep 2 · 1:14:34
clinical CDH patients can develop non-idiopathic scoliosis (mostly in boys, not the typical idiopathic scoliosis in girls), requiring early bracing to minimize thoracolumbar scoliosis. ↗
▶ Ep 2 · 1:15:04
quote I send all my recurrences to Ponsky. ↗
▶ Ep 2 · 1:17:51
guideline For right-sided CDH, the most important consideration is to ask echocardiographers where the hepatic veins drain, because they often enter directly into the right atrium, not the suprahepatic cava. ↗
▶ Ep 2 · 1:18:36
clinical Hepatopulmonary fusion actually exists in right-sided CDH. The liver and lung are fused and cannot be separated surgically. Most of these patients don't survive and often have severe congenital heart disease and IVC discontinuation. ↗
▶ Ep 2 · 1:19:48
guideline For right-sided CDH, prep the baby for both thoracic and abdominal incisions because you often need to be on both sides. Start in the abdomen, but if the liver is in the way, make a counter-incision in the chest. ↗
▶ Ep 2 · 1:20:12
guideline Even with an open thoracotomy, you can put a scope in to see around a corner without ugly retractors. ↗

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 4 · 2:13
quote the most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach ↗
▶ Ep 4 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies ↗
▶ Ep 4 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 4 · 3:37
clinical CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart ↗
▶ Ep 4 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side ↗
▶ Ep 4 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation ↗
▶ Ep 4 · 4:39
clinical CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty ↗
▶ Ep 4 · 5:00
clinical CDH is a medical physiologic emergency but not a surgical emergency ↗
▶ Ep 4 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues ↗
▶ Ep 4 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best ↗
▶ Ep 4 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO ↗
▶ Ep 4 · 8:31
clinical In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value ↗
▶ Ep 4 · 8:42
clinical Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning ↗
▶ Ep 4 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis ↗
▶ Ep 4 · 10:13
quote if you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 4 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers ↗
▶ Ep 4 · 10:37
clinical Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable ↗
▶ Ep 4 · 12:06
opinion Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies ↗
▶ Ep 4 · 12:06
quote I think that's nonsense. ↗
▶ Ep 4 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth ↗
▶ Ep 4 · 14:45
clinical Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function ↗
▶ Ep 4 · 15:55
clinical Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood ↗
▶ Ep 4 · 17:06
clinical ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care ↗
▶ Ep 4 · 17:44
clinical The best way to assess end-organ function is urine output ↗
▶ Ep 4 · 18:21
guideline ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more ↗
▶ Ep 4 · 19:06
clinical All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin ↗
▶ Ep 4 · 20:25
clinical When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs ↗
▶ Ep 4 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today ↗
▶ Ep 4 · 21:56
clinical CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously ↗
▶ Ep 4 · 22:15
clinical Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies ↗
▶ Ep 4 · 22:53
clinical Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia ↗
▶ Ep 4 · 24:30
quote I often joke that when people say, how do you know when to set up an ECMO circuit with a diaphragmatic hernia, it's when they get out the oscillator. ↗
▶ Ep 4 · 24:30
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit ↗
▶ Ep 4 · 25:45
opinion Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH ↗
▶ Ep 4 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 4 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 4 · 26:07
opinion The best drug for CDH is oxygen ↗
▶ Ep 4 · 26:22
clinical ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor ↗
▶ Ep 4 · 27:40
clinical The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter ↗
▶ Ep 4 · 28:15
clinical For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit ↗
▶ Ep 4 · 28:45
clinical The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start? ↗
▶ Ep 4 · 30:27
clinical VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum ↗
▶ Ep 4 · 31:00
clinical VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO ↗
▶ Ep 4 · 31:25
quote there ain't nothing like VA bypass. ↗
▶ Ep 4 · 31:53
clinical VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage ↗
▶ Ep 4 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein ↗
▶ Ep 4 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen ↗
▶ Ep 4 · 33:23
clinical Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted ↗
▶ Ep 4 · 33:55
clinical Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage ↗
▶ Ep 4 · 34:47
clinical In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium ↗
▶ Ep 4 · 34:55
clinical ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence ↗
▶ Ep 4 · 35:10
clinical Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct ↗
▶ Ep 4 · 35:29
clinical At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70% ↗
▶ Ep 4 · 36:12
clinical Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet ↗
▶ Ep 4 · 36:34
clinical The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO ↗
▶ Ep 4 · 37:38
quote I leave town after 2 weeks. ↗
▶ Ep 4 · 38:18
clinical For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair ↗
▶ Ep 4 · 39:05
clinical Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest ↗
▶ Ep 4 · 39:39
quote This is not a space occupying lesion is not the problem here ↗
▶ Ep 4 · 40:40
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours ↗
▶ Ep 4 · 41:07
clinical If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off ↗
▶ Ep 4 · 41:51
clinical Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run ↗
▶ Ep 4 · 42:39
clinical When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube ↗
▶ Ep 4 · 44:11
clinical Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage ↗
▶ Ep 4 · 45:42
clinical For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days ↗
▶ Ep 4 · 46:07
clinical Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant ↗
▶ Ep 4 · 46:28
clinical Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine ↗
▶ Ep 4 · 46:47
clinical Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times ↗
▶ Ep 4 · 47:57
clinical Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn ↗
▶ Ep 4 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 4 · 48:32
clinical The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby ↗
▶ Ep 4 · 49:37
clinical In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions ↗
▶ Ep 4 · 50:21
opinion Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest ↗
▶ Ep 4 · 53:01
quote I was very disappointed at our own data because I thought the scope approach was gorgeous. ↗
▶ Ep 4 · 54:58
clinical For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect ↗
▶ Ep 4 · 55:31
clinical Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib ↗
▶ Ep 4 · 56:11
clinical The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair ↗
▶ Ep 4 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl ↗
▶ Ep 4 · 57:59
clinical For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch ↗
▶ Ep 4 · 58:43
clinical Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue ↗
▶ Ep 4 · 1:00:23
clinical For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly ↗
▶ Ep 4 · 1:01:35
clinical Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner ↗
▶ Ep 4 · 1:02:03
clinical For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin ↗
▶ Ep 4 · 1:04:16
clinical If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail ↗
▶ Ep 4 · 1:06:31
quote neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 4 · 1:06:47
clinical The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest ↗
▶ Ep 4 · 1:06:53
quote That's how God made this lung. ↗
▶ Ep 4 · 1:07:01
clinical The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo ↗
▶ Ep 4 · 1:07:18
clinical Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding ↗
▶ Ep 4 · 1:08:53
clinical Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days ↗
▶ Ep 4 · 1:09:34
clinical CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout ↗
▶ Ep 4 · 1:09:51
clinical All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying ↗
▶ Ep 4 · 1:10:09
opinion The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture ↗
▶ Ep 4 · 1:10:09
quote this business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 4 · 1:10:28
clinical CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation ↗
▶ Ep 4 · 1:10:40
opinion Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz) ↗
▶ Ep 4 · 1:12:11
clinical Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time ↗
▶ Ep 4 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance ↗
▶ Ep 4 · 1:13:57
clinical CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended ↗
▶ Ep 4 · 1:14:09
clinical As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall ↗
▶ Ep 4 · 1:14:29
clinical Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed ↗
▶ Ep 4 · 1:14:34
clinical CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this ↗
▶ Ep 4 · 1:15:16
clinical CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair ↗
▶ Ep 4 · 1:17:35
clinical Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right ↗
▶ Ep 4 · 1:17:51
clinical For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC ↗
▶ Ep 4 · 1:18:09
clinical If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen ↗
▶ Ep 4 · 1:18:29
clinical Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically ↗
▶ Ep 4 · 1:19:11
clinical Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation ↗
▶ Ep 4 · 1:19:48
clinical For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way ↗
▶ Ep 4 · 1:20:12
clinical For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart ↗
Charlie's statements about Congenital Diaphragmatic Hernia 201 statements

Open the Congenital Diaphragmatic Hernia collection →

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 3 · 2:13
quote The most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach. ↗
▶ Ep 3 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies managed by community obstetricians. ↗
▶ Ep 3 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 3 · 3:21
quote I expect parents to leave with a sense of cautious optimism, not doom and gloom. ↗
▶ Ep 3 · 3:37
clinical CDH diagnosis is usually made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart. ↗
▶ Ep 3 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side. ↗
▶ Ep 3 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation. ↗
▶ Ep 3 · 5:00
clinical CDH is a medical physiologic emergency, not a surgical emergency. ↗
▶ Ep 3 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section. ↗
▶ Ep 3 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best. ↗
▶ Ep 3 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability. ↗
▶ Ep 3 · 7:34
epidemiological Maybe 10-15% of babies diagnosed with CDH will benefit from ECMO. ↗
▶ Ep 3 · 8:31
clinical In single-center experiences, presence of liver in the chest is of no prognostic value for CDH. ↗
▶ Ep 3 · 8:42
clinical Lung-to-head ratio (LHR) is of limited prognostic value except when very low (less than 0.8). ↗
▶ Ep 3 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis in CDH. ↗
▶ Ep 3 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers. ↗
▶ Ep 3 · 10:13
quote If you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 3 · 10:37
clinical Steroids have tremendous value for preterm labor under 35 weeks but their role in near-term CDH babies (37-39 weeks) is arguable. ↗
▶ Ep 3 · 12:06
opinion Exit-to-ECMO for CDH is essentially moving the goalposts and deck chairs around on the Titanic for non-viable babies. ↗
▶ Ep 3 · 12:06
quote The short answer is I think that's nonsense. ↗
▶ Ep 3 · 12:36
quote What you're now doing is putting what in my view is almost certainly a non-viable baby on a heart lung machine and basically moving the goalposts and moving the deck chairs around on the Titanic. ↗
▶ Ep 3 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth. ↗
▶ Ep 3 · 17:11
quote ECMO is a drug delivery system for oxygen. So if the end organs are getting enough oxygen, then you're doing fine. ↗
▶ Ep 3 · 19:06
guideline All therapy for CDH should be guided by preductal oximetry, not postductal, because all babies have some degree of pulmonary hypertension with shunting. ↗
▶ Ep 3 · 19:32
clinical If preductal saturation is 90% (PaO2 of 65 torr), the brain is doing fine because this is fetal hemoglobin. ↗
▶ Ep 3 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today because they trash lungs in a heartbeat. ↗
▶ Ep 3 · 21:56
guideline CDH babies should not be paralyzed and should have minimal sedation to maintain spontaneous breathing. ↗
▶ Ep 3 · 22:15
clinical Most CDH babies don't tolerate conventional ventilator settings (rate 40, peak pressure 25-28, PEEP 5) and require unconventional high-rate (100 breaths/min) low-pressure ventilation. ↗
▶ Ep 3 · 24:38
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO. ↗
▶ Ep 3 · 24:50
quote When I see them getting out the oscillator, I'll go prime a circuit. That's just how I think about it. ↗
▶ Ep 3 · 25:45
clinical Nitric oxide is a waste of money for CDH babies; meta-analyses show it's terrific for premature babies with immature lung disease but of no value in CDH. ↗
▶ Ep 3 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 3 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 3 · 26:07
opinion The best drug for CDH is oxygen. ↗
▶ Ep 3 · 26:22
guideline ECMO should not be used in babies under 36 weeks gestational age initially, though this has been pushed down to 35 weeks, maybe 34 weeks, with intracranial hemorrhage rates taking off below 32 weeks. ↗
▶ Ep 3 · 27:40
clinical The smallest ECMO arterial perfusion cannula available is about 8 French, and resistance is related to both length and diameter, making adequate flow difficult in very small babies. ↗
▶ Ep 3 · 28:15
clinical For ECMO candidacy, the real risk for intracranial hemorrhage is the germinal matrix, which is usually OK by 35-36 weeks gestation, so it's gestational age that matters, not size. ↗
▶ Ep 3 · 29:10
guideline The broad principle for ECMO candidacy is whether you can get out of ECMO with reasonable confidence if you get in—don't start something you can't finish. ↗
▶ Ep 3 · 29:10
quote Don't start something you can't finish. ↗
▶ Ep 3 · 30:27
clinical VV ECMO is terrific if the heart works, but in CDH the heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum. ↗
▶ Ep 3 · 31:53
opinion VA bypass is essentially dialing in a PaO2, while VV ECMO is much more annoying with mixing, cannula position issues, and CDH babies are generally too unstable for VV. ↗
▶ Ep 3 · 31:53
quote VA bypass is basically dial in a PAO2. ↗
▶ Ep 3 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful to prevent driving the arterial cannula out the subclavian artery or the venous cannula into the innominate vein. ↗
▶ Ep 3 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a very well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen. ↗
▶ Ep 3 · 33:01
quote If you drive it out the subclavian artery, you're going to have a very well perfused hand, and you think your preductal sats are looking really good, but the baby's not seeing the oxygen. ↗
▶ Ep 3 · 34:19
clinical The first few hours on ECMO can be unstable; hyperkalemia cardiac arrest can occur if blood isn't washed, but you just perfuse through it and give calcium. ↗
▶ Ep 3 · 34:55
guideline ECMO flow should be slowly increased over 45 minutes to 1.5 hours to about 100-125 cc/kg/min (about 80% of cardiac output) to reduce intracranial hemorrhage incidence. ↗
▶ Ep 3 · 36:34
clinical The hyperoxia test—turning FIO2 up to 1.0 on the ventilator while on ECMO—gives courage to begin weaning if the PaO2 rises, showing the baby can use their lungs. ↗
▶ Ep 3 · 38:18
guideline For babies stuck on ECMO at 2 weeks, ensure they are maximally dried out (bone dry, eyes sucked into back of head, turned into a prune) before considering on-ECMO repair. ↗
▶ Ep 3 · 39:14
clinical The problem in CDH is not that bowel is in the chest; the problem is growth arrest of the lungs that happened at 14-15 weeks gestation. Getting bowel out of the chest is not miraculous. ↗
▶ Ep 3 · 39:20
quote The problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest. ↗
▶ Ep 3 · 40:37
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) make clot on ECMO. A platelet thrombus lasts 48-72 hours, giving a window to operate and get off ECMO before bleeding starts. ↗
▶ Ep 3 · 41:14
guideline Preferred approach is to wean ECMO down to 20 cc/kg/min, do the operation, accept 1 day of post-op edema, then have 2-3 days to get off ECMO before bleeding starts. ↗
▶ Ep 3 · 41:51
clinical If you take a baby off ECMO then operate, every patient gets stiff after surgery, pulmonary hypertension relapses, and you're talking about a second ECMO run. ↗
▶ Ep 3 · 42:39
guideline When operating on ECMO, load with Amicar preoperatively, do it as an abdominal operation, use a patch with low threshold to avoid tension, place a Jackson-Pratt drain under the patch, and place a chest tube. ↗
▶ Ep 3 · 44:14
opinion Futility on ECMO starts to rear its head after about 2-3 weeks. ↗
▶ Ep 3 · 45:42
clinical The typical stable CDH baby not requiring ECMO takes 3-4 days to wean to minimal ventilator settings (FIO2 0.4, conventional settings) before repair. ↗
▶ Ep 3 · 46:07
guideline Use the infant ventilator instead of an anesthesia machine intraoperatively because infant anesthesia machines have high dead space and are not very compliant. ↗
▶ Ep 3 · 46:47
guideline For repair timing, three variables matter: pre/post-ductal gradient on pulse ox, right ventricle dilation on echo, and RV pressure versus LV pressure (RV should be no more than systemic). ↗
▶ Ep 3 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 3 · 48:32
clinical The thoracoscopic approach for CDH is gorgeous with a sparkling view, but the recurrence rate is really high—about 25% in under a year in Dr. Stolar's series of 35 stable kids. ↗
▶ Ep 3 · 50:02
clinical The APSA outcomes committee meta-analysis came to a very similar conclusion about high thoracoscopic CDH recurrence rates. ↗
▶ Ep 3 · 55:02
guideline For open CDH repair, need a real subcostal incision (not a small two-finger incision), rotate the liver out of chest and abdomen, eviscerate bowel, and mobilize the posterior leaflet like unrolling a window shade down to rib. ↗
▶ Ep 3 · 56:06
clinical The medial part of CDH repair is hardest because sometimes the esophagus or aorta is hanging out with nothing to sew to. ↗
▶ Ep 3 · 56:28
guideline When there's no diaphragm to sew to medially, make an upside-down U-shaped incision on the pericardium and rotate that down to where the diaphragm would be to begin the repair. ↗
▶ Ep 3 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike Vicryl which saws tissue. ↗
▶ Ep 3 · 57:59
guideline Favor non-biologic material like 1mm Gore-Tex for patches, and anchor the patch to the ribs laterally by getting a needle around the rib. ↗
▶ Ep 3 · 58:43
guideline Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out taking a deep breath; over time it gets incorporated into fibrous tissue. ↗
▶ Ep 3 · 1:00:23
guideline For thoracoscopic CDH repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and put solid organs (spleen or left liver lobe) in last to plug the hole and keep bowel down. ↗
▶ Ep 3 · 1:04:16
guideline If you can see through the diaphragm tissue (it's nothing but pleura and peritoneum), resect it back to muscle for a fresh edge to sew together, or the plication will fail. ↗
▶ Ep 3 · 1:06:31
quote Neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 3 · 1:06:47
guideline There is no indication for a chest tube in CDH except for active air leak or anticipated/active bleeding. The ipsilateral lung is small and won't fill the pleural space—that's how God made this lung. ↗
▶ Ep 3 · 1:07:13
clinical A pneumothorax in CDH is a pneumothorax ex vacuo, not air under pressure. Putting in a chest tube on water seal suction will just distort the mediastinum and precipitate a pulmonary hypertensive crisis. ↗
▶ Ep 3 · 1:08:54
clinical The typical stable CDH baby will be crummy for about a day postoperatively, then get better and be extubated in 4-5 days and go home. ↗
▶ Ep 3 · 1:09:39
clinical CDH is a field defect affecting the whole foregut from pharynx to ligament of Treitz. Everything—esophagus, stomach, gastric emptying—has abnormal motility. ↗
▶ Ep 3 · 1:09:51
clinical If you do a GI series on CDH kids, the esophagus will be very dilated, ectatic, and abnormal-looking. Manometry and impedance manometry are abnormal. ↗
▶ Ep 3 · 1:10:09
quote This business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 3 · 1:10:09
opinion It's not really reflux in CDH—calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture. ↗
▶ Ep 3 · 1:10:28
clinical CDH kids generally do well with continuous feedings slowly condensed to bolus. It's unusual to need surgical intervention for foregut dysmotility. ↗
▶ Ep 3 · 1:10:36
guideline When surgery is needed for CDH foregut dysmotility, approach it as palliation: some sort of fundoplication (not Nissen—it's fully competent on an abnormal-motility esophagus), combined with gastrostomy and a real drainage procedure like Jaboulay-Finney, not Heineke-Mikulicz. ↗
▶ Ep 3 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis and now recommends lifelong proton pump inhibitors and regular scoping for all CDH patients. ↗
▶ Ep 3 · 1:13:46
clinical Dr. Stolar's 1989-1990 paper showed most CDH kids turn out OK unless the mother had an 8th grade education and the child is a boy. ↗
▶ Ep 3 · 1:13:58
clinical There is an incidence of attention deficit disorders and autism in CDH survivors, prompting early intervention for neuropsychiatric issues. ↗
▶ Ep 3 · 1:14:09
clinical Because CDH is a field defect, there's asymmetric chest growth leading to pectus-like distorted chest wall growth requiring Nuss-type operations in some patients. ↗
▶ Ep 3 · 1:14:20
clinical Some CDH girls as teenagers have no breast development on the side of the hernia, requiring Nuss operation and breast implant. ↗
▶ Ep 3 · 1:14:34
clinical CDH patients can develop non-idiopathic scoliosis (mostly in boys, not the typical idiopathic scoliosis in girls), requiring early bracing to minimize thoracolumbar scoliosis. ↗
▶ Ep 3 · 1:15:04
quote I send all my recurrences to Ponsky. ↗
▶ Ep 3 · 1:17:51
guideline For right-sided CDH, the most important consideration is to ask echocardiographers where the hepatic veins drain, because they often enter directly into the right atrium, not the suprahepatic cava. ↗
▶ Ep 3 · 1:18:36
clinical Hepatopulmonary fusion actually exists in right-sided CDH. The liver and lung are fused and cannot be separated surgically. Most of these patients don't survive and often have severe congenital heart disease and IVC discontinuation. ↗
▶ Ep 3 · 1:19:48
guideline For right-sided CDH, prep the baby for both thoracic and abdominal incisions because you often need to be on both sides. Start in the abdomen, but if the liver is in the way, make a counter-incision in the chest. ↗
▶ Ep 3 · 1:20:12
guideline Even with an open thoracotomy, you can put a scope in to see around a corner without ugly retractors. ↗

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 8 · 2:13
quote the most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach ↗
▶ Ep 8 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies ↗
▶ Ep 8 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 8 · 3:37
clinical CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart ↗
▶ Ep 8 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side ↗
▶ Ep 8 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation ↗
▶ Ep 8 · 4:39
clinical CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty ↗
▶ Ep 8 · 5:00
clinical CDH is a medical physiologic emergency but not a surgical emergency ↗
▶ Ep 8 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues ↗
▶ Ep 8 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best ↗
▶ Ep 8 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO ↗
▶ Ep 8 · 8:31
clinical In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value ↗
▶ Ep 8 · 8:42
clinical Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning ↗
▶ Ep 8 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis ↗
▶ Ep 8 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers ↗
▶ Ep 8 · 10:13
quote if you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 8 · 10:37
clinical Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable ↗
▶ Ep 8 · 12:06
quote I think that's nonsense. ↗
▶ Ep 8 · 12:06
opinion Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies ↗
▶ Ep 8 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth ↗
▶ Ep 8 · 14:45
clinical Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function ↗
▶ Ep 8 · 15:55
clinical Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood ↗
▶ Ep 8 · 17:06
clinical ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care ↗
▶ Ep 8 · 17:44
clinical The best way to assess end-organ function is urine output ↗
▶ Ep 8 · 18:21
guideline ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more ↗
▶ Ep 8 · 19:06
clinical All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin ↗
▶ Ep 8 · 20:25
clinical When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs ↗
▶ Ep 8 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today ↗
▶ Ep 8 · 21:56
clinical CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously ↗
▶ Ep 8 · 22:15
clinical Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies ↗
▶ Ep 8 · 22:53
clinical Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia ↗
▶ Ep 8 · 24:30
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit ↗
▶ Ep 8 · 24:30
quote I often joke that when people say, how do you know when to set up an ECMO circuit with a diaphragmatic hernia, it's when they get out the oscillator. ↗
▶ Ep 8 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 8 · 25:45
opinion Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH ↗
▶ Ep 8 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 8 · 26:07
opinion The best drug for CDH is oxygen ↗
▶ Ep 8 · 26:22
clinical ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor ↗
▶ Ep 8 · 27:40
clinical The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter ↗
▶ Ep 8 · 28:15
clinical For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit ↗
▶ Ep 8 · 28:45
clinical The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start? ↗
▶ Ep 8 · 30:27
clinical VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum ↗
▶ Ep 8 · 31:00
clinical VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO ↗
▶ Ep 8 · 31:25
quote there ain't nothing like VA bypass. ↗
▶ Ep 8 · 31:53
clinical VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage ↗
▶ Ep 8 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein ↗
▶ Ep 8 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen ↗
▶ Ep 8 · 33:23
clinical Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted ↗
▶ Ep 8 · 33:55
clinical Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage ↗
▶ Ep 8 · 34:47
clinical In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium ↗
▶ Ep 8 · 34:55
clinical ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence ↗
▶ Ep 8 · 35:10
clinical Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct ↗
▶ Ep 8 · 35:29
clinical At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70% ↗
▶ Ep 8 · 36:12
clinical Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet ↗
▶ Ep 8 · 36:34
clinical The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO ↗
▶ Ep 8 · 37:38
quote I leave town after 2 weeks. ↗
▶ Ep 8 · 38:18
clinical For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair ↗
▶ Ep 8 · 39:05
clinical Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest ↗
▶ Ep 8 · 39:39
quote This is not a space occupying lesion is not the problem here ↗
▶ Ep 8 · 40:40
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours ↗
▶ Ep 8 · 41:07
clinical If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off ↗
▶ Ep 8 · 41:51
clinical Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run ↗
▶ Ep 8 · 42:39
clinical When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube ↗
▶ Ep 8 · 44:11
clinical Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage ↗
▶ Ep 8 · 45:42
clinical For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days ↗
▶ Ep 8 · 46:07
clinical Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant ↗
▶ Ep 8 · 46:28
clinical Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine ↗
▶ Ep 8 · 46:47
clinical Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times ↗
▶ Ep 8 · 47:57
clinical Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn ↗
▶ Ep 8 · 48:32
clinical The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby ↗
▶ Ep 8 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 8 · 49:37
clinical In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions ↗
▶ Ep 8 · 50:21
opinion Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest ↗
▶ Ep 8 · 53:01
quote I was very disappointed at our own data because I thought the scope approach was gorgeous. ↗
▶ Ep 8 · 54:58
clinical For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect ↗
▶ Ep 8 · 55:31
clinical Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib ↗
▶ Ep 8 · 56:11
clinical The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair ↗
▶ Ep 8 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl ↗
▶ Ep 8 · 57:59
clinical For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch ↗
▶ Ep 8 · 58:43
clinical Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue ↗
▶ Ep 8 · 1:00:23
clinical For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly ↗
▶ Ep 8 · 1:01:35
clinical Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner ↗
▶ Ep 8 · 1:02:03
clinical For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin ↗
▶ Ep 8 · 1:04:16
clinical If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail ↗
▶ Ep 8 · 1:06:31
quote neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 8 · 1:06:47
clinical The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest ↗
▶ Ep 8 · 1:06:53
quote That's how God made this lung. ↗
▶ Ep 8 · 1:07:01
clinical The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo ↗
▶ Ep 8 · 1:07:18
clinical Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding ↗
▶ Ep 8 · 1:08:53
clinical Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days ↗
▶ Ep 8 · 1:09:34
clinical CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout ↗
▶ Ep 8 · 1:09:51
clinical All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying ↗
▶ Ep 8 · 1:10:09
opinion The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture ↗
▶ Ep 8 · 1:10:09
quote this business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 8 · 1:10:28
clinical CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation ↗
▶ Ep 8 · 1:10:40
opinion Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz) ↗
▶ Ep 8 · 1:12:11
clinical Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time ↗
▶ Ep 8 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance ↗
▶ Ep 8 · 1:13:57
clinical CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended ↗
▶ Ep 8 · 1:14:09
clinical As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall ↗
▶ Ep 8 · 1:14:29
clinical Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed ↗
▶ Ep 8 · 1:14:34
clinical CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this ↗
▶ Ep 8 · 1:15:16
clinical CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair ↗
▶ Ep 8 · 1:17:35
clinical Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right ↗
▶ Ep 8 · 1:17:51
clinical For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC ↗
▶ Ep 8 · 1:18:09
clinical If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen ↗
▶ Ep 8 · 1:18:29
clinical Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically ↗
▶ Ep 8 · 1:19:11
clinical Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation ↗
▶ Ep 8 · 1:19:48
clinical For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way ↗
▶ Ep 8 · 1:20:12
clinical For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart ↗
Charlie's statements about Congenital Diaphragmatic Hernia 201 statements

Open the Congenital Diaphragmatic Hernia collection →

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 3 · 2:13
quote The most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach. ↗
▶ Ep 3 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies managed by community obstetricians. ↗
▶ Ep 3 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 3 · 3:21
quote I expect parents to leave with a sense of cautious optimism, not doom and gloom. ↗
▶ Ep 3 · 3:37
clinical CDH diagnosis is usually made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart. ↗
▶ Ep 3 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side. ↗
▶ Ep 3 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation. ↗
▶ Ep 3 · 5:00
clinical CDH is a medical physiologic emergency, not a surgical emergency. ↗
▶ Ep 3 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section. ↗
▶ Ep 3 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best. ↗
▶ Ep 3 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability. ↗
▶ Ep 3 · 7:34
epidemiological Maybe 10-15% of babies diagnosed with CDH will benefit from ECMO. ↗
▶ Ep 3 · 8:31
clinical In single-center experiences, presence of liver in the chest is of no prognostic value for CDH. ↗
▶ Ep 3 · 8:42
clinical Lung-to-head ratio (LHR) is of limited prognostic value except when very low (less than 0.8). ↗
▶ Ep 3 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis in CDH. ↗
▶ Ep 3 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers. ↗
▶ Ep 3 · 10:13
quote If you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 3 · 10:37
clinical Steroids have tremendous value for preterm labor under 35 weeks but their role in near-term CDH babies (37-39 weeks) is arguable. ↗
▶ Ep 3 · 12:06
opinion Exit-to-ECMO for CDH is essentially moving the goalposts and deck chairs around on the Titanic for non-viable babies. ↗
▶ Ep 3 · 12:06
quote The short answer is I think that's nonsense. ↗
▶ Ep 3 · 12:36
quote What you're now doing is putting what in my view is almost certainly a non-viable baby on a heart lung machine and basically moving the goalposts and moving the deck chairs around on the Titanic. ↗
▶ Ep 3 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth. ↗
▶ Ep 3 · 17:11
quote ECMO is a drug delivery system for oxygen. So if the end organs are getting enough oxygen, then you're doing fine. ↗
▶ Ep 3 · 19:06
guideline All therapy for CDH should be guided by preductal oximetry, not postductal, because all babies have some degree of pulmonary hypertension with shunting. ↗
▶ Ep 3 · 19:32
clinical If preductal saturation is 90% (PaO2 of 65 torr), the brain is doing fine because this is fetal hemoglobin. ↗
▶ Ep 3 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today because they trash lungs in a heartbeat. ↗
▶ Ep 3 · 21:56
guideline CDH babies should not be paralyzed and should have minimal sedation to maintain spontaneous breathing. ↗
▶ Ep 3 · 22:15
clinical Most CDH babies don't tolerate conventional ventilator settings (rate 40, peak pressure 25-28, PEEP 5) and require unconventional high-rate (100 breaths/min) low-pressure ventilation. ↗
▶ Ep 3 · 24:38
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO. ↗
▶ Ep 3 · 24:50
quote When I see them getting out the oscillator, I'll go prime a circuit. That's just how I think about it. ↗
▶ Ep 3 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 3 · 25:45
clinical Nitric oxide is a waste of money for CDH babies; meta-analyses show it's terrific for premature babies with immature lung disease but of no value in CDH. ↗
▶ Ep 3 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 3 · 26:07
opinion The best drug for CDH is oxygen. ↗
▶ Ep 3 · 26:22
guideline ECMO should not be used in babies under 36 weeks gestational age initially, though this has been pushed down to 35 weeks, maybe 34 weeks, with intracranial hemorrhage rates taking off below 32 weeks. ↗
▶ Ep 3 · 27:40
clinical The smallest ECMO arterial perfusion cannula available is about 8 French, and resistance is related to both length and diameter, making adequate flow difficult in very small babies. ↗
▶ Ep 3 · 28:15
clinical For ECMO candidacy, the real risk for intracranial hemorrhage is the germinal matrix, which is usually OK by 35-36 weeks gestation, so it's gestational age that matters, not size. ↗
▶ Ep 3 · 29:10
quote Don't start something you can't finish. ↗
▶ Ep 3 · 29:10
guideline The broad principle for ECMO candidacy is whether you can get out of ECMO with reasonable confidence if you get in—don't start something you can't finish. ↗
▶ Ep 3 · 30:27
clinical VV ECMO is terrific if the heart works, but in CDH the heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum. ↗
▶ Ep 3 · 31:53
quote VA bypass is basically dial in a PAO2. ↗
▶ Ep 3 · 31:53
opinion VA bypass is essentially dialing in a PaO2, while VV ECMO is much more annoying with mixing, cannula position issues, and CDH babies are generally too unstable for VV. ↗
▶ Ep 3 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful to prevent driving the arterial cannula out the subclavian artery or the venous cannula into the innominate vein. ↗
▶ Ep 3 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a very well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen. ↗
▶ Ep 3 · 33:01
quote If you drive it out the subclavian artery, you're going to have a very well perfused hand, and you think your preductal sats are looking really good, but the baby's not seeing the oxygen. ↗
▶ Ep 3 · 34:19
clinical The first few hours on ECMO can be unstable; hyperkalemia cardiac arrest can occur if blood isn't washed, but you just perfuse through it and give calcium. ↗
▶ Ep 3 · 34:55
guideline ECMO flow should be slowly increased over 45 minutes to 1.5 hours to about 100-125 cc/kg/min (about 80% of cardiac output) to reduce intracranial hemorrhage incidence. ↗
▶ Ep 3 · 36:34
clinical The hyperoxia test—turning FIO2 up to 1.0 on the ventilator while on ECMO—gives courage to begin weaning if the PaO2 rises, showing the baby can use their lungs. ↗
▶ Ep 3 · 38:18
guideline For babies stuck on ECMO at 2 weeks, ensure they are maximally dried out (bone dry, eyes sucked into back of head, turned into a prune) before considering on-ECMO repair. ↗
▶ Ep 3 · 39:14
clinical The problem in CDH is not that bowel is in the chest; the problem is growth arrest of the lungs that happened at 14-15 weeks gestation. Getting bowel out of the chest is not miraculous. ↗
▶ Ep 3 · 39:20
quote The problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest. ↗
▶ Ep 3 · 40:37
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) make clot on ECMO. A platelet thrombus lasts 48-72 hours, giving a window to operate and get off ECMO before bleeding starts. ↗
▶ Ep 3 · 41:14
guideline Preferred approach is to wean ECMO down to 20 cc/kg/min, do the operation, accept 1 day of post-op edema, then have 2-3 days to get off ECMO before bleeding starts. ↗
▶ Ep 3 · 41:51
clinical If you take a baby off ECMO then operate, every patient gets stiff after surgery, pulmonary hypertension relapses, and you're talking about a second ECMO run. ↗
▶ Ep 3 · 42:39
guideline When operating on ECMO, load with Amicar preoperatively, do it as an abdominal operation, use a patch with low threshold to avoid tension, place a Jackson-Pratt drain under the patch, and place a chest tube. ↗
▶ Ep 3 · 44:14
opinion Futility on ECMO starts to rear its head after about 2-3 weeks. ↗
▶ Ep 3 · 45:42
clinical The typical stable CDH baby not requiring ECMO takes 3-4 days to wean to minimal ventilator settings (FIO2 0.4, conventional settings) before repair. ↗
▶ Ep 3 · 46:07
guideline Use the infant ventilator instead of an anesthesia machine intraoperatively because infant anesthesia machines have high dead space and are not very compliant. ↗
▶ Ep 3 · 46:47
guideline For repair timing, three variables matter: pre/post-ductal gradient on pulse ox, right ventricle dilation on echo, and RV pressure versus LV pressure (RV should be no more than systemic). ↗
▶ Ep 3 · 48:32
clinical The thoracoscopic approach for CDH is gorgeous with a sparkling view, but the recurrence rate is really high—about 25% in under a year in Dr. Stolar's series of 35 stable kids. ↗
▶ Ep 3 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 3 · 50:02
clinical The APSA outcomes committee meta-analysis came to a very similar conclusion about high thoracoscopic CDH recurrence rates. ↗
▶ Ep 3 · 55:02
guideline For open CDH repair, need a real subcostal incision (not a small two-finger incision), rotate the liver out of chest and abdomen, eviscerate bowel, and mobilize the posterior leaflet like unrolling a window shade down to rib. ↗
▶ Ep 3 · 56:06
clinical The medial part of CDH repair is hardest because sometimes the esophagus or aorta is hanging out with nothing to sew to. ↗
▶ Ep 3 · 56:28
guideline When there's no diaphragm to sew to medially, make an upside-down U-shaped incision on the pericardium and rotate that down to where the diaphragm would be to begin the repair. ↗
▶ Ep 3 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike Vicryl which saws tissue. ↗
▶ Ep 3 · 57:59
guideline Favor non-biologic material like 1mm Gore-Tex for patches, and anchor the patch to the ribs laterally by getting a needle around the rib. ↗
▶ Ep 3 · 58:43
guideline Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out taking a deep breath; over time it gets incorporated into fibrous tissue. ↗
▶ Ep 3 · 1:00:23
guideline For thoracoscopic CDH repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and put solid organs (spleen or left liver lobe) in last to plug the hole and keep bowel down. ↗
▶ Ep 3 · 1:04:16
guideline If you can see through the diaphragm tissue (it's nothing but pleura and peritoneum), resect it back to muscle for a fresh edge to sew together, or the plication will fail. ↗
▶ Ep 3 · 1:06:31
quote Neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 3 · 1:06:47
guideline There is no indication for a chest tube in CDH except for active air leak or anticipated/active bleeding. The ipsilateral lung is small and won't fill the pleural space—that's how God made this lung. ↗
▶ Ep 3 · 1:07:13
clinical A pneumothorax in CDH is a pneumothorax ex vacuo, not air under pressure. Putting in a chest tube on water seal suction will just distort the mediastinum and precipitate a pulmonary hypertensive crisis. ↗
▶ Ep 3 · 1:08:54
clinical The typical stable CDH baby will be crummy for about a day postoperatively, then get better and be extubated in 4-5 days and go home. ↗
▶ Ep 3 · 1:09:39
clinical CDH is a field defect affecting the whole foregut from pharynx to ligament of Treitz. Everything—esophagus, stomach, gastric emptying—has abnormal motility. ↗
▶ Ep 3 · 1:09:51
clinical If you do a GI series on CDH kids, the esophagus will be very dilated, ectatic, and abnormal-looking. Manometry and impedance manometry are abnormal. ↗
▶ Ep 3 · 1:10:09
opinion It's not really reflux in CDH—calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture. ↗
▶ Ep 3 · 1:10:09
quote This business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 3 · 1:10:28
clinical CDH kids generally do well with continuous feedings slowly condensed to bolus. It's unusual to need surgical intervention for foregut dysmotility. ↗
▶ Ep 3 · 1:10:36
guideline When surgery is needed for CDH foregut dysmotility, approach it as palliation: some sort of fundoplication (not Nissen—it's fully competent on an abnormal-motility esophagus), combined with gastrostomy and a real drainage procedure like Jaboulay-Finney, not Heineke-Mikulicz. ↗
▶ Ep 3 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis and now recommends lifelong proton pump inhibitors and regular scoping for all CDH patients. ↗
▶ Ep 3 · 1:13:46
clinical Dr. Stolar's 1989-1990 paper showed most CDH kids turn out OK unless the mother had an 8th grade education and the child is a boy. ↗
▶ Ep 3 · 1:13:58
clinical There is an incidence of attention deficit disorders and autism in CDH survivors, prompting early intervention for neuropsychiatric issues. ↗
▶ Ep 3 · 1:14:09
clinical Because CDH is a field defect, there's asymmetric chest growth leading to pectus-like distorted chest wall growth requiring Nuss-type operations in some patients. ↗
▶ Ep 3 · 1:14:20
clinical Some CDH girls as teenagers have no breast development on the side of the hernia, requiring Nuss operation and breast implant. ↗
▶ Ep 3 · 1:14:34
clinical CDH patients can develop non-idiopathic scoliosis (mostly in boys, not the typical idiopathic scoliosis in girls), requiring early bracing to minimize thoracolumbar scoliosis. ↗
▶ Ep 3 · 1:15:04
quote I send all my recurrences to Ponsky. ↗
▶ Ep 3 · 1:17:51
guideline For right-sided CDH, the most important consideration is to ask echocardiographers where the hepatic veins drain, because they often enter directly into the right atrium, not the suprahepatic cava. ↗
▶ Ep 3 · 1:18:36
clinical Hepatopulmonary fusion actually exists in right-sided CDH. The liver and lung are fused and cannot be separated surgically. Most of these patients don't survive and often have severe congenital heart disease and IVC discontinuation. ↗
▶ Ep 3 · 1:19:48
guideline For right-sided CDH, prep the baby for both thoracic and abdominal incisions because you often need to be on both sides. Start in the abdomen, but if the liver is in the way, make a counter-incision in the chest. ↗
▶ Ep 3 · 1:20:12
guideline Even with an open thoracotomy, you can put a scope in to see around a corner without ugly retractors. ↗

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 8 · 2:13
quote the most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach ↗
▶ Ep 8 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies ↗
▶ Ep 8 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 8 · 3:37
clinical CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart ↗
▶ Ep 8 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side ↗
▶ Ep 8 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation ↗
▶ Ep 8 · 4:39
clinical CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty ↗
▶ Ep 8 · 5:00
clinical CDH is a medical physiologic emergency but not a surgical emergency ↗
▶ Ep 8 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues ↗
▶ Ep 8 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best ↗
▶ Ep 8 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO ↗
▶ Ep 8 · 8:31
clinical In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value ↗
▶ Ep 8 · 8:42
clinical Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning ↗
▶ Ep 8 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis ↗
▶ Ep 8 · 10:13
quote if you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 8 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers ↗
▶ Ep 8 · 10:37
clinical Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable ↗
▶ Ep 8 · 12:06
quote I think that's nonsense. ↗
▶ Ep 8 · 12:06
opinion Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies ↗
▶ Ep 8 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth ↗
▶ Ep 8 · 14:45
clinical Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function ↗
▶ Ep 8 · 15:55
clinical Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood ↗
▶ Ep 8 · 17:06
clinical ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care ↗
▶ Ep 8 · 17:44
clinical The best way to assess end-organ function is urine output ↗
▶ Ep 8 · 18:21
guideline ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more ↗
▶ Ep 8 · 19:06
clinical All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin ↗
▶ Ep 8 · 20:25
clinical When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs ↗
▶ Ep 8 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today ↗
▶ Ep 8 · 21:56
clinical CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously ↗
▶ Ep 8 · 22:15
clinical Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies ↗
▶ Ep 8 · 22:53
clinical Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia ↗
▶ Ep 8 · 24:30
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit ↗
▶ Ep 8 · 24:30
quote I often joke that when people say, how do you know when to set up an ECMO circuit with a diaphragmatic hernia, it's when they get out the oscillator. ↗
▶ Ep 8 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 8 · 25:45
opinion Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH ↗
▶ Ep 8 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 8 · 26:07
opinion The best drug for CDH is oxygen ↗
▶ Ep 8 · 26:22
clinical ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor ↗
▶ Ep 8 · 27:40
clinical The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter ↗
▶ Ep 8 · 28:15
clinical For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit ↗
▶ Ep 8 · 28:45
clinical The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start? ↗
▶ Ep 8 · 30:27
clinical VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum ↗
▶ Ep 8 · 31:00
clinical VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO ↗
▶ Ep 8 · 31:25
quote there ain't nothing like VA bypass. ↗
▶ Ep 8 · 31:53
clinical VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage ↗
▶ Ep 8 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein ↗
▶ Ep 8 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen ↗
▶ Ep 8 · 33:23
clinical Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted ↗
▶ Ep 8 · 33:55
clinical Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage ↗
▶ Ep 8 · 34:47
clinical In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium ↗
▶ Ep 8 · 34:55
clinical ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence ↗
▶ Ep 8 · 35:10
clinical Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct ↗
▶ Ep 8 · 35:29
clinical At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70% ↗
▶ Ep 8 · 36:12
clinical Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet ↗
▶ Ep 8 · 36:34
clinical The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO ↗
▶ Ep 8 · 37:38
quote I leave town after 2 weeks. ↗
▶ Ep 8 · 38:18
clinical For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair ↗
▶ Ep 8 · 39:05
clinical Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest ↗
▶ Ep 8 · 39:39
quote This is not a space occupying lesion is not the problem here ↗
▶ Ep 8 · 40:40
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours ↗
▶ Ep 8 · 41:07
clinical If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off ↗
▶ Ep 8 · 41:51
clinical Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run ↗
▶ Ep 8 · 42:39
clinical When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube ↗
▶ Ep 8 · 44:11
clinical Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage ↗
▶ Ep 8 · 45:42
clinical For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days ↗
▶ Ep 8 · 46:07
clinical Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant ↗
▶ Ep 8 · 46:28
clinical Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine ↗
▶ Ep 8 · 46:47
clinical Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times ↗
▶ Ep 8 · 47:57
clinical Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn ↗
▶ Ep 8 · 48:32
clinical The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby ↗
▶ Ep 8 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 8 · 49:37
clinical In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions ↗
▶ Ep 8 · 50:21
opinion Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest ↗
▶ Ep 8 · 53:01
quote I was very disappointed at our own data because I thought the scope approach was gorgeous. ↗
▶ Ep 8 · 54:58
clinical For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect ↗
▶ Ep 8 · 55:31
clinical Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib ↗
▶ Ep 8 · 56:11
clinical The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair ↗
▶ Ep 8 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl ↗
▶ Ep 8 · 57:59
clinical For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch ↗
▶ Ep 8 · 58:43
clinical Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue ↗
▶ Ep 8 · 1:00:23
clinical For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly ↗
▶ Ep 8 · 1:01:35
clinical Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner ↗
▶ Ep 8 · 1:02:03
clinical For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin ↗
▶ Ep 8 · 1:04:16
clinical If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail ↗
▶ Ep 8 · 1:06:31
quote neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 8 · 1:06:47
clinical The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest ↗
▶ Ep 8 · 1:06:53
quote That's how God made this lung. ↗
▶ Ep 8 · 1:07:01
clinical The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo ↗
▶ Ep 8 · 1:07:18
clinical Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding ↗
▶ Ep 8 · 1:08:53
clinical Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days ↗
▶ Ep 8 · 1:09:34
clinical CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout ↗
▶ Ep 8 · 1:09:51
clinical All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying ↗
▶ Ep 8 · 1:10:09
opinion The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture ↗
▶ Ep 8 · 1:10:09
quote this business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 8 · 1:10:28
clinical CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation ↗
▶ Ep 8 · 1:10:40
opinion Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz) ↗
▶ Ep 8 · 1:12:11
clinical Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time ↗
▶ Ep 8 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance ↗
▶ Ep 8 · 1:13:57
clinical CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended ↗
▶ Ep 8 · 1:14:09
clinical As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall ↗
▶ Ep 8 · 1:14:29
clinical Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed ↗
▶ Ep 8 · 1:14:34
clinical CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this ↗
▶ Ep 8 · 1:15:16
clinical CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair ↗
▶ Ep 8 · 1:17:35
clinical Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right ↗
▶ Ep 8 · 1:17:51
clinical For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC ↗
▶ Ep 8 · 1:18:09
clinical If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen ↗
▶ Ep 8 · 1:18:29
clinical Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically ↗
▶ Ep 8 · 1:19:11
clinical Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation ↗
▶ Ep 8 · 1:19:48
clinical For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way ↗
▶ Ep 8 · 1:20:12
clinical For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart ↗
Charlie's statements about Neonatal Surgery Essentials 110 statements

Open the Neonatal Surgery Essentials collection →

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 2 · 2:13
quote the most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach ↗
▶ Ep 2 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies ↗
▶ Ep 2 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 2 · 3:37
clinical CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart ↗
▶ Ep 2 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side ↗
▶ Ep 2 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation ↗
▶ Ep 2 · 4:39
clinical CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty ↗
▶ Ep 2 · 5:00
clinical CDH is a medical physiologic emergency but not a surgical emergency ↗
▶ Ep 2 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues ↗
▶ Ep 2 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best ↗
▶ Ep 2 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO ↗
▶ Ep 2 · 8:31
clinical In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value ↗
▶ Ep 2 · 8:42
clinical Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning ↗
▶ Ep 2 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis ↗
▶ Ep 2 · 10:13
quote if you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 2 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers ↗
▶ Ep 2 · 10:37
clinical Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable ↗
▶ Ep 2 · 12:06
quote I think that's nonsense. ↗
▶ Ep 2 · 12:06
opinion Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies ↗
▶ Ep 2 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth ↗
▶ Ep 2 · 14:45
clinical Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function ↗
▶ Ep 2 · 15:55
clinical Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood ↗
▶ Ep 2 · 17:06
clinical ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care ↗
▶ Ep 2 · 17:44
clinical The best way to assess end-organ function is urine output ↗
▶ Ep 2 · 18:21
guideline ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more ↗
▶ Ep 2 · 19:06
clinical All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin ↗
▶ Ep 2 · 20:25
clinical When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs ↗
▶ Ep 2 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today ↗
▶ Ep 2 · 21:56
clinical CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously ↗
▶ Ep 2 · 22:15
clinical Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies ↗
▶ Ep 2 · 22:53
clinical Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia ↗
▶ Ep 2 · 24:30
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit ↗
▶ Ep 2 · 24:30
quote I often joke that when people say, how do you know when to set up an ECMO circuit with a diaphragmatic hernia, it's when they get out the oscillator. ↗
▶ Ep 2 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 2 · 25:45
opinion Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH ↗
▶ Ep 2 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 2 · 26:07
opinion The best drug for CDH is oxygen ↗
▶ Ep 2 · 26:22
clinical ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor ↗
▶ Ep 2 · 27:40
clinical The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter ↗
▶ Ep 2 · 28:15
clinical For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit ↗
▶ Ep 2 · 28:45
clinical The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start? ↗
▶ Ep 2 · 30:27
clinical VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum ↗
▶ Ep 2 · 31:00
clinical VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO ↗
▶ Ep 2 · 31:25
quote there ain't nothing like VA bypass. ↗
▶ Ep 2 · 31:53
clinical VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage ↗
▶ Ep 2 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein ↗
▶ Ep 2 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen ↗
▶ Ep 2 · 33:23
clinical Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted ↗
▶ Ep 2 · 33:55
clinical Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage ↗
▶ Ep 2 · 34:47
clinical In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium ↗
▶ Ep 2 · 34:55
clinical ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence ↗
▶ Ep 2 · 35:10
clinical Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct ↗
▶ Ep 2 · 35:29
clinical At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70% ↗
▶ Ep 2 · 36:12
clinical Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet ↗
▶ Ep 2 · 36:34
clinical The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO ↗
▶ Ep 2 · 37:38
quote I leave town after 2 weeks. ↗
▶ Ep 2 · 38:18
clinical For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair ↗
▶ Ep 2 · 39:05
clinical Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest ↗
▶ Ep 2 · 39:39
quote This is not a space occupying lesion is not the problem here ↗
▶ Ep 2 · 40:40
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours ↗
▶ Ep 2 · 41:07
clinical If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off ↗
▶ Ep 2 · 41:51
clinical Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run ↗
▶ Ep 2 · 42:39
clinical When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube ↗
▶ Ep 2 · 44:11
clinical Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage ↗
▶ Ep 2 · 45:42
clinical For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days ↗
▶ Ep 2 · 46:07
clinical Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant ↗
▶ Ep 2 · 46:28
clinical Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine ↗
▶ Ep 2 · 46:47
clinical Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times ↗
▶ Ep 2 · 47:57
clinical Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn ↗
▶ Ep 2 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 2 · 48:32
clinical The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby ↗
▶ Ep 2 · 49:37
clinical In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions ↗
▶ Ep 2 · 50:21
opinion Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest ↗
▶ Ep 2 · 53:01
quote I was very disappointed at our own data because I thought the scope approach was gorgeous. ↗
▶ Ep 2 · 54:58
clinical For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect ↗
▶ Ep 2 · 55:31
clinical Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib ↗
▶ Ep 2 · 56:11
clinical The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair ↗
▶ Ep 2 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl ↗
▶ Ep 2 · 57:59
clinical For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch ↗
▶ Ep 2 · 58:43
clinical Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue ↗
▶ Ep 2 · 1:00:23
clinical For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly ↗
▶ Ep 2 · 1:01:35
clinical Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner ↗
▶ Ep 2 · 1:02:03
clinical For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin ↗
▶ Ep 2 · 1:04:16
clinical If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail ↗
▶ Ep 2 · 1:06:31
quote neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 2 · 1:06:47
clinical The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest ↗
▶ Ep 2 · 1:06:53
quote That's how God made this lung. ↗
▶ Ep 2 · 1:07:01
clinical The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo ↗
▶ Ep 2 · 1:07:18
clinical Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding ↗
▶ Ep 2 · 1:08:53
clinical Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days ↗
▶ Ep 2 · 1:09:34
clinical CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout ↗
▶ Ep 2 · 1:09:51
clinical All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying ↗
▶ Ep 2 · 1:10:09
opinion The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture ↗
▶ Ep 2 · 1:10:09
quote this business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 2 · 1:10:28
clinical CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation ↗
▶ Ep 2 · 1:10:40
opinion Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz) ↗
▶ Ep 2 · 1:12:11
clinical Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time ↗
▶ Ep 2 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance ↗
▶ Ep 2 · 1:13:57
clinical CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended ↗
▶ Ep 2 · 1:14:09
clinical As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall ↗
▶ Ep 2 · 1:14:29
clinical Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed ↗
▶ Ep 2 · 1:14:34
clinical CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this ↗
▶ Ep 2 · 1:15:16
clinical CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair ↗
▶ Ep 2 · 1:17:35
clinical Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right ↗
▶ Ep 2 · 1:17:51
clinical For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC ↗
▶ Ep 2 · 1:18:09
clinical If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen ↗
▶ Ep 2 · 1:18:29
clinical Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically ↗
▶ Ep 2 · 1:19:11
clinical Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation ↗
▶ Ep 2 · 1:19:48
clinical For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way ↗
▶ Ep 2 · 1:20:12
clinical For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart ↗
Charlie's statements about Pulmonary Hypoplasia 203 statements

Open the Pulmonary Hypoplasia collection →

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 4 · 2:13
quote The most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach. ↗
▶ Ep 4 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies managed by community obstetricians. ↗
▶ Ep 4 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 4 · 3:21
quote I expect parents to leave with a sense of cautious optimism, not doom and gloom. ↗
▶ Ep 4 · 3:37
clinical CDH diagnosis is usually made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart. ↗
▶ Ep 4 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side. ↗
▶ Ep 4 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation. ↗
▶ Ep 4 · 5:00
clinical CDH is a medical physiologic emergency, not a surgical emergency. ↗
▶ Ep 4 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section. ↗
▶ Ep 4 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best. ↗
▶ Ep 4 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability. ↗
▶ Ep 4 · 7:34
epidemiological Maybe 10-15% of babies diagnosed with CDH will benefit from ECMO. ↗
▶ Ep 4 · 8:31
clinical In single-center experiences, presence of liver in the chest is of no prognostic value for CDH. ↗
▶ Ep 4 · 8:42
clinical Lung-to-head ratio (LHR) is of limited prognostic value except when very low (less than 0.8). ↗
▶ Ep 4 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis in CDH. ↗
▶ Ep 4 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers. ↗
▶ Ep 4 · 10:13
quote If you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 4 · 10:37
clinical Steroids have tremendous value for preterm labor under 35 weeks but their role in near-term CDH babies (37-39 weeks) is arguable. ↗
▶ Ep 4 · 12:06
opinion Exit-to-ECMO for CDH is essentially moving the goalposts and deck chairs around on the Titanic for non-viable babies. ↗
▶ Ep 4 · 12:06
quote The short answer is I think that's nonsense. ↗
▶ Ep 4 · 12:36
quote What you're now doing is putting what in my view is almost certainly a non-viable baby on a heart lung machine and basically moving the goalposts and moving the deck chairs around on the Titanic. ↗
▶ Ep 4 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth. ↗
▶ Ep 4 · 17:11
quote ECMO is a drug delivery system for oxygen. So if the end organs are getting enough oxygen, then you're doing fine. ↗
▶ Ep 4 · 19:06
guideline All therapy for CDH should be guided by preductal oximetry, not postductal, because all babies have some degree of pulmonary hypertension with shunting. ↗
▶ Ep 4 · 19:32
clinical If preductal saturation is 90% (PaO2 of 65 torr), the brain is doing fine because this is fetal hemoglobin. ↗
▶ Ep 4 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today because they trash lungs in a heartbeat. ↗
▶ Ep 4 · 21:38
quote If you ever wanted to find out if somebody tried to invent a neonatal ventilator today, they would throw it out as a lethal device because they will trash in the lungs in a heartbeat. ↗
▶ Ep 4 · 21:56
guideline CDH babies should not be paralyzed and should have minimal sedation to maintain spontaneous breathing. ↗
▶ Ep 4 · 22:15
clinical Most CDH babies don't tolerate conventional ventilator settings (rate 40, peak pressure 25-28, PEEP 5) and require unconventional high-rate (100 breaths/min) low-pressure ventilation. ↗
▶ Ep 4 · 24:38
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO. ↗
▶ Ep 4 · 24:50
quote When I see them getting out the oscillator, I'll go prime a circuit. That's just how I think about it. ↗
▶ Ep 4 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 4 · 25:45
clinical Nitric oxide is a waste of money for CDH babies; meta-analyses show it's terrific for premature babies with immature lung disease but of no value in CDH. ↗
▶ Ep 4 · 26:07
opinion The best drug for CDH is oxygen. ↗
▶ Ep 4 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 4 · 26:22
guideline ECMO should not be used in babies under 36 weeks gestational age initially, though this has been pushed down to 35 weeks, maybe 34 weeks, with intracranial hemorrhage rates taking off below 32 weeks. ↗
▶ Ep 4 · 27:40
clinical The smallest ECMO arterial perfusion cannula available is about 8 French, and resistance is related to both length and diameter, making adequate flow difficult in very small babies. ↗
▶ Ep 4 · 28:15
clinical For ECMO candidacy, the real risk for intracranial hemorrhage is the germinal matrix, which is usually OK by 35-36 weeks gestation, so it's gestational age that matters, not size. ↗
▶ Ep 4 · 29:10
guideline The broad principle for ECMO candidacy is whether you can get out of ECMO with reasonable confidence if you get in—don't start something you can't finish. ↗
▶ Ep 4 · 29:10
quote Don't start something you can't finish. ↗
▶ Ep 4 · 30:27
clinical VV ECMO is terrific if the heart works, but in CDH the heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum. ↗
▶ Ep 4 · 31:25
quote There ain't nothing like VA bypass. ↗
▶ Ep 4 · 31:53
opinion VA bypass is essentially dialing in a PaO2, while VV ECMO is much more annoying with mixing, cannula position issues, and CDH babies are generally too unstable for VV. ↗
▶ Ep 4 · 31:53
quote VA bypass is basically dial in a PAO2. ↗
▶ Ep 4 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful to prevent driving the arterial cannula out the subclavian artery or the venous cannula into the innominate vein. ↗
▶ Ep 4 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a very well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen. ↗
▶ Ep 4 · 33:01
quote If you drive it out the subclavian artery, you're going to have a very well perfused hand, and you think your preductal sats are looking really good, but the baby's not seeing the oxygen. ↗
▶ Ep 4 · 34:19
clinical The first few hours on ECMO can be unstable; hyperkalemia cardiac arrest can occur if blood isn't washed, but you just perfuse through it and give calcium. ↗
▶ Ep 4 · 34:55
guideline ECMO flow should be slowly increased over 45 minutes to 1.5 hours to about 100-125 cc/kg/min (about 80% of cardiac output) to reduce intracranial hemorrhage incidence. ↗
▶ Ep 4 · 36:34
clinical The hyperoxia test—turning FIO2 up to 1.0 on the ventilator while on ECMO—gives courage to begin weaning if the PaO2 rises, showing the baby can use their lungs. ↗
▶ Ep 4 · 38:18
guideline For babies stuck on ECMO at 2 weeks, ensure they are maximally dried out (bone dry, eyes sucked into back of head, turned into a prune) before considering on-ECMO repair. ↗
▶ Ep 4 · 39:14
clinical The problem in CDH is not that bowel is in the chest; the problem is growth arrest of the lungs that happened at 14-15 weeks gestation. Getting bowel out of the chest is not miraculous. ↗
▶ Ep 4 · 39:20
quote The problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest. ↗
▶ Ep 4 · 40:37
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) make clot on ECMO. A platelet thrombus lasts 48-72 hours, giving a window to operate and get off ECMO before bleeding starts. ↗
▶ Ep 4 · 41:14
guideline Preferred approach is to wean ECMO down to 20 cc/kg/min, do the operation, accept 1 day of post-op edema, then have 2-3 days to get off ECMO before bleeding starts. ↗
▶ Ep 4 · 41:51
clinical If you take a baby off ECMO then operate, every patient gets stiff after surgery, pulmonary hypertension relapses, and you're talking about a second ECMO run. ↗
▶ Ep 4 · 42:39
guideline When operating on ECMO, load with Amicar preoperatively, do it as an abdominal operation, use a patch with low threshold to avoid tension, place a Jackson-Pratt drain under the patch, and place a chest tube. ↗
▶ Ep 4 · 44:14
opinion Futility on ECMO starts to rear its head after about 2-3 weeks. ↗
▶ Ep 4 · 45:42
clinical The typical stable CDH baby not requiring ECMO takes 3-4 days to wean to minimal ventilator settings (FIO2 0.4, conventional settings) before repair. ↗
▶ Ep 4 · 46:07
guideline Use the infant ventilator instead of an anesthesia machine intraoperatively because infant anesthesia machines have high dead space and are not very compliant. ↗
▶ Ep 4 · 46:47
guideline For repair timing, three variables matter: pre/post-ductal gradient on pulse ox, right ventricle dilation on echo, and RV pressure versus LV pressure (RV should be no more than systemic). ↗
▶ Ep 4 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 4 · 48:32
clinical The thoracoscopic approach for CDH is gorgeous with a sparkling view, but the recurrence rate is really high—about 25% in under a year in Dr. Stolar's series of 35 stable kids. ↗
▶ Ep 4 · 50:02
clinical The APSA outcomes committee meta-analysis came to a very similar conclusion about high thoracoscopic CDH recurrence rates. ↗
▶ Ep 4 · 55:02
guideline For open CDH repair, need a real subcostal incision (not a small two-finger incision), rotate the liver out of chest and abdomen, eviscerate bowel, and mobilize the posterior leaflet like unrolling a window shade down to rib. ↗
▶ Ep 4 · 56:06
clinical The medial part of CDH repair is hardest because sometimes the esophagus or aorta is hanging out with nothing to sew to. ↗
▶ Ep 4 · 56:28
guideline When there's no diaphragm to sew to medially, make an upside-down U-shaped incision on the pericardium and rotate that down to where the diaphragm would be to begin the repair. ↗
▶ Ep 4 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike Vicryl which saws tissue. ↗
▶ Ep 4 · 57:59
guideline Favor non-biologic material like 1mm Gore-Tex for patches, and anchor the patch to the ribs laterally by getting a needle around the rib. ↗
▶ Ep 4 · 58:43
guideline Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out taking a deep breath; over time it gets incorporated into fibrous tissue. ↗
▶ Ep 4 · 1:00:23
guideline For thoracoscopic CDH repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and put solid organs (spleen or left liver lobe) in last to plug the hole and keep bowel down. ↗
▶ Ep 4 · 1:04:16
guideline If you can see through the diaphragm tissue (it's nothing but pleura and peritoneum), resect it back to muscle for a fresh edge to sew together, or the plication will fail. ↗
▶ Ep 4 · 1:06:31
quote Neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 4 · 1:06:47
guideline There is no indication for a chest tube in CDH except for active air leak or anticipated/active bleeding. The ipsilateral lung is small and won't fill the pleural space—that's how God made this lung. ↗
▶ Ep 4 · 1:07:13
clinical A pneumothorax in CDH is a pneumothorax ex vacuo, not air under pressure. Putting in a chest tube on water seal suction will just distort the mediastinum and precipitate a pulmonary hypertensive crisis. ↗
▶ Ep 4 · 1:08:54
clinical The typical stable CDH baby will be crummy for about a day postoperatively, then get better and be extubated in 4-5 days and go home. ↗
▶ Ep 4 · 1:09:39
clinical CDH is a field defect affecting the whole foregut from pharynx to ligament of Treitz. Everything—esophagus, stomach, gastric emptying—has abnormal motility. ↗
▶ Ep 4 · 1:09:51
clinical If you do a GI series on CDH kids, the esophagus will be very dilated, ectatic, and abnormal-looking. Manometry and impedance manometry are abnormal. ↗
▶ Ep 4 · 1:10:09
quote This business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 4 · 1:10:09
opinion It's not really reflux in CDH—calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture. ↗
▶ Ep 4 · 1:10:28
clinical CDH kids generally do well with continuous feedings slowly condensed to bolus. It's unusual to need surgical intervention for foregut dysmotility. ↗
▶ Ep 4 · 1:10:36
guideline When surgery is needed for CDH foregut dysmotility, approach it as palliation: some sort of fundoplication (not Nissen—it's fully competent on an abnormal-motility esophagus), combined with gastrostomy and a real drainage procedure like Jaboulay-Finney, not Heineke-Mikulicz. ↗
▶ Ep 4 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis and now recommends lifelong proton pump inhibitors and regular scoping for all CDH patients. ↗
▶ Ep 4 · 1:13:46
clinical Dr. Stolar's 1989-1990 paper showed most CDH kids turn out OK unless the mother had an 8th grade education and the child is a boy. ↗
▶ Ep 4 · 1:13:58
clinical There is an incidence of attention deficit disorders and autism in CDH survivors, prompting early intervention for neuropsychiatric issues. ↗
▶ Ep 4 · 1:14:09
clinical Because CDH is a field defect, there's asymmetric chest growth leading to pectus-like distorted chest wall growth requiring Nuss-type operations in some patients. ↗
▶ Ep 4 · 1:14:20
clinical Some CDH girls as teenagers have no breast development on the side of the hernia, requiring Nuss operation and breast implant. ↗
▶ Ep 4 · 1:14:34
clinical CDH patients can develop non-idiopathic scoliosis (mostly in boys, not the typical idiopathic scoliosis in girls), requiring early bracing to minimize thoracolumbar scoliosis. ↗
▶ Ep 4 · 1:15:04
quote I send all my recurrences to Ponsky. ↗
▶ Ep 4 · 1:17:51
guideline For right-sided CDH, the most important consideration is to ask echocardiographers where the hepatic veins drain, because they often enter directly into the right atrium, not the suprahepatic cava. ↗
▶ Ep 4 · 1:18:36
clinical Hepatopulmonary fusion actually exists in right-sided CDH. The liver and lung are fused and cannot be separated surgically. Most of these patients don't survive and often have severe congenital heart disease and IVC discontinuation. ↗
▶ Ep 4 · 1:19:48
guideline For right-sided CDH, prep the baby for both thoracic and abdominal incisions because you often need to be on both sides. Start in the abdomen, but if the liver is in the way, make a counter-incision in the chest. ↗
▶ Ep 4 · 1:20:12
guideline Even with an open thoracotomy, you can put a scope in to see around a corner without ugly retractors. ↗

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 5 · 2:13
quote the most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach ↗
▶ Ep 5 · 2:45
epidemiological CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies ↗
▶ Ep 5 · 3:11
quote The discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends. ↗
▶ Ep 5 · 3:37
clinical CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart ↗
▶ Ep 5 · 4:14
clinical CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side ↗
▶ Ep 5 · 4:23
clinical At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation ↗
▶ Ep 5 · 4:39
clinical CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty ↗
▶ Ep 5 · 5:00
clinical CDH is a medical physiologic emergency but not a surgical emergency ↗
▶ Ep 5 · 5:24
guideline The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues ↗
▶ Ep 5 · 6:35
opinion Antenatal interventions for CDH are no better than investigational and experimental at best ↗
▶ Ep 5 · 7:23
guideline Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO ↗
▶ Ep 5 · 8:31
clinical In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value ↗
▶ Ep 5 · 8:42
clinical Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning ↗
▶ Ep 5 · 9:07
clinical Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis ↗
▶ Ep 5 · 10:13
epidemiological If shown 100 children with CDH, 80-85% will survive to become teenagers ↗
▶ Ep 5 · 10:13
quote if you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them. ↗
▶ Ep 5 · 10:37
clinical Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable ↗
▶ Ep 5 · 12:06
quote I think that's nonsense. ↗
▶ Ep 5 · 12:06
opinion Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies ↗
▶ Ep 5 · 13:00
clinical We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth ↗
▶ Ep 5 · 14:45
clinical Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function ↗
▶ Ep 5 · 15:55
clinical Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood ↗
▶ Ep 5 · 17:06
clinical ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care ↗
▶ Ep 5 · 17:44
clinical The best way to assess end-organ function is urine output ↗
▶ Ep 5 · 18:21
guideline ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more ↗
▶ Ep 5 · 19:06
clinical All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin ↗
▶ Ep 5 · 20:25
clinical When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs ↗
▶ Ep 5 · 21:38
opinion Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today ↗
▶ Ep 5 · 21:56
clinical CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously ↗
▶ Ep 5 · 22:15
clinical Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies ↗
▶ Ep 5 · 22:53
clinical Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia ↗
▶ Ep 5 · 24:30
quote I often joke that when people say, how do you know when to set up an ECMO circuit with a diaphragmatic hernia, it's when they get out the oscillator. ↗
▶ Ep 5 · 24:30
clinical High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit ↗
▶ Ep 5 · 25:45
opinion Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH ↗
▶ Ep 5 · 25:45
quote Nitric oxide is a waste of money. ↗
▶ Ep 5 · 26:07
opinion The best drug for CDH is oxygen ↗
▶ Ep 5 · 26:07
quote The best drug for diaphragmatic hernia is oxygen. ↗
▶ Ep 5 · 26:22
clinical ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor ↗
▶ Ep 5 · 27:40
clinical The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter ↗
▶ Ep 5 · 28:15
clinical For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit ↗
▶ Ep 5 · 28:45
clinical The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start? ↗
▶ Ep 5 · 30:27
clinical VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum ↗
▶ Ep 5 · 31:00
clinical VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO ↗
▶ Ep 5 · 31:25
quote there ain't nothing like VA bypass. ↗
▶ Ep 5 · 31:53
clinical VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage ↗
▶ Ep 5 · 32:17
clinical Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein ↗
▶ Ep 5 · 33:01
clinical If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen ↗
▶ Ep 5 · 33:23
clinical Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted ↗
▶ Ep 5 · 33:55
clinical Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage ↗
▶ Ep 5 · 34:47
clinical In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium ↗
▶ Ep 5 · 34:55
clinical ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence ↗
▶ Ep 5 · 35:10
clinical Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct ↗
▶ Ep 5 · 35:29
clinical At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70% ↗
▶ Ep 5 · 36:12
clinical Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet ↗
▶ Ep 5 · 36:34
clinical The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO ↗
▶ Ep 5 · 37:38
quote I leave town after 2 weeks. ↗
▶ Ep 5 · 38:18
clinical For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair ↗
▶ Ep 5 · 39:05
clinical Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest ↗
▶ Ep 5 · 39:39
quote This is not a space occupying lesion is not the problem here ↗
▶ Ep 5 · 40:40
clinical Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours ↗
▶ Ep 5 · 41:07
clinical If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off ↗
▶ Ep 5 · 41:51
clinical Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run ↗
▶ Ep 5 · 42:39
clinical When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube ↗
▶ Ep 5 · 44:11
clinical Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage ↗
▶ Ep 5 · 45:42
clinical For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days ↗
▶ Ep 5 · 46:07
clinical Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant ↗
▶ Ep 5 · 46:28
clinical Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine ↗
▶ Ep 5 · 46:47
clinical Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times ↗
▶ Ep 5 · 47:57
clinical Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn ↗
▶ Ep 5 · 48:32
clinical The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby ↗
▶ Ep 5 · 48:32
quote The thoracoscopic approach is gorgeous. It is just a gorgeous view. ↗
▶ Ep 5 · 49:37
clinical In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions ↗
▶ Ep 5 · 50:21
opinion Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest ↗
▶ Ep 5 · 53:01
quote I was very disappointed at our own data because I thought the scope approach was gorgeous. ↗
▶ Ep 5 · 54:58
clinical For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect ↗
▶ Ep 5 · 55:31
clinical Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib ↗
▶ Ep 5 · 56:11
clinical The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair ↗
▶ Ep 5 · 57:16
opinion Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl ↗
▶ Ep 5 · 57:59
clinical For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch ↗
▶ Ep 5 · 58:43
clinical Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue ↗
▶ Ep 5 · 1:00:23
clinical For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly ↗
▶ Ep 5 · 1:01:35
clinical Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner ↗
▶ Ep 5 · 1:02:03
clinical For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin ↗
▶ Ep 5 · 1:04:16
clinical If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail ↗
▶ Ep 5 · 1:06:31
quote neonatal nurses, they pee around their isolate to mark their territory. ↗
▶ Ep 5 · 1:06:47
clinical The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest ↗
▶ Ep 5 · 1:06:53
quote That's how God made this lung. ↗
▶ Ep 5 · 1:07:01
clinical The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo ↗
▶ Ep 5 · 1:07:18
clinical Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding ↗
▶ Ep 5 · 1:08:53
clinical Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days ↗
▶ Ep 5 · 1:09:34
clinical CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout ↗
▶ Ep 5 · 1:09:51
clinical All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying ↗
▶ Ep 5 · 1:10:09
quote this business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture. ↗
▶ Ep 5 · 1:10:09
opinion The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture ↗
▶ Ep 5 · 1:10:28
clinical CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation ↗
▶ Ep 5 · 1:10:40
opinion Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz) ↗
▶ Ep 5 · 1:12:11
clinical Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time ↗
▶ Ep 5 · 1:13:18
clinical Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance ↗
▶ Ep 5 · 1:13:57
clinical CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended ↗
▶ Ep 5 · 1:14:09
clinical As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall ↗
▶ Ep 5 · 1:14:29
clinical Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed ↗
▶ Ep 5 · 1:14:34
clinical CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this ↗
▶ Ep 5 · 1:15:16
clinical CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair ↗
▶ Ep 5 · 1:17:35
clinical Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right ↗
▶ Ep 5 · 1:17:51
clinical For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC ↗
▶ Ep 5 · 1:18:09
clinical If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen ↗
▶ Ep 5 · 1:18:29
clinical Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically ↗
▶ Ep 5 · 1:19:11
clinical Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation ↗
▶ Ep 5 · 1:19:48
clinical For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way ↗
▶ Ep 5 · 1:20:12
clinical For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart ↗

Summaries Charlie gave as host · 6 summaries

Recaps of other experts' statements, not Charlie's own clinical position.

Summaries Charlie gave as host · Congenital Diaphragmatic Hernia 2 summaries

Open the Congenital Diaphragmatic Hernia collection →

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 3 · 21:38
host summary Charlie Stolar summarizing a resource: If you ever wanted to find out if somebody tried to invent a neonatal ventilator today, they would throw it out as a lethal device because they will trash in the lungs in a heartbeat. ↗
▶ Ep 3 · 31:25
host summary Charlie Stolar summarizing a resource: There ain't nothing like VA bypass. ↗
Summaries Charlie gave as host · Congenital Diaphragmatic Hernia 2 summaries

Open the Congenital Diaphragmatic Hernia collection →

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 3 · 21:38
host summary Charlie Stolar summarizing a resource: If you ever wanted to find out if somebody tried to invent a neonatal ventilator today, they would throw it out as a lethal device because they will trash in the lungs in a heartbeat. ↗
▶ Ep 3 · 31:25
host summary Charlie Stolar summarizing a resource: There ain't nothing like VA bypass. ↗
Summaries Charlie gave as host · Congenital Diaphragmatic Hernia 2 summaries

Open the Congenital Diaphragmatic Hernia collection →

Congenital Diaphragmatic Hernia with Dr. Charlie Stolar

▶ Ep 2 · 21:38
host summary Charlie Stolar summarizing a resource: If you ever wanted to find out if somebody tried to invent a neonatal ventilator today, they would throw it out as a lethal device because they will trash in the lungs in a heartbeat. ↗
▶ Ep 2 · 31:25
host summary Charlie Stolar summarizing a resource: There ain't nothing like VA bypass. ↗