The 2016 CDH protocol change places infants in a quiet NICU area for the first 72 hours with immediate intubation on high frequency oscillator and decreased mean airway pressure
clinicalPrimary Children's Hospital ECMO program was established in 2003, with first CDH protocol implemented in 2007↗
▶Ep 16 · 0:50
clinicalThe 2016 CDH protocol change places infants in a quiet NICU area for the first 72 hours with immediate intubation on high frequency oscillator and decreased mean airway pressure↗
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quotefor the 1st 72 hours, we're going to put the baby in a corner↗
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clinicalThe protocol minimizes stimulation by using transport-capable beds to avoid moving the infant between beds↗
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clinicalEcho is not performed within the first 24 hours if a prenatal echo already exists↗
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clinicalOxygen is weaned according to preductal saturations only, with no routine postductal saturation monitoring↗
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clinicalOxygen resuscitation starts at FIO2 of 0.4 instead of 1.0↗
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clinicalInhaled nitric oxide and other vasodilators or pressor agents are used only for clinically significant hypoperfusion↗
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clinicalMedian mean airway pressure decreased from 13 to 11 after protocol implementation↗
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clinicalHigher mean airway pressures compromise gas exchange and lung vascularization, potentially increasing pulmonary hypertension↗
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quotewe feel like that that actually increased pressure is compromising gas exchange in the child as well as the vascularization within the lungs, which could lead to increasing pulmonary hypertension or exacerbation of it↗
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clinicalThe protocol is applied to all prenatally diagnosed CDH cases regardless of severity↗
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clinicalECMO utilization rate decreased from 37% to 13% after protocol implementation↗
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clinicalOverall survival increased from 74% to 89%, a statistically significant change↗
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clinicalSurvival was significantly improved for liver-down CDH cases↗
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clinicalSurvival increased for liver-up CDH cases but was not statistically significant↗
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clinicalSurvival without ECMO use increased after protocol implementation↗
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quoteI think ECMO is a great adjuvant in taking care of these very sick kids, but it is not without consequence↗
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clinicalSince 2016, 97% of CDH cases received prenatal MRI compared to 24% before the fetal center was established↗
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clinicalIn the study period since 2016, there were 53 isolated left CDH cases after exclusions↗
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clinicalAmong infants with MRI total fetal lung volume observed-to-expected less than 15%, ECMO utilization was 38% rather than the expected 100%↗
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clinicalECMO criteria include PaO2 never rising above 50 and inability to get CO2 levels below 100↗
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clinicalThe MRI less than 15% group had 50% survival↗
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clinicalThe CDH protocol is implemented uniformly by all neonatologists in the closed NICU unit, not by select individual providers↗
▶Ep 16 · 9:00
opinionThe hardest aspect of implementing the protocol was changing the culture around practices like routine early echocardiography, immediate transport, and postductal saturation monitoring↗
▶Ep 16 · 9:00
quotethe hardest aspects of implementing the protocol was actually changing the culture↗
