Update Course Rewind: When & How to Operate CDH Patients on ECMO 2024

The 13 French VV cannula is too big for some neonates, leading institutions to choose VA instead.

Better VV cannulas are coming out that may change practice patterns.

Michigan's SPHERE protocol prenatally selected severe CDH babies and had ECMO on standby in the delivery room.

SPHERE protocol criteria: within two hours post-delivery, if pH did not meet 7, PCO2 wasn't less than 100, and preductal sats weren't above 80, comfort measures only were offered; if criteria were met, ECMO was offered.

In the SPHERE protocol comparison, the two groups (comfort care vs ECMO) had equivalent survival.

Half of the patients offered comfort measures in SPHERE could have been survivors.

Half of the patients offered ECMO in SPHERE did not survive.

If you make the decision to choose ECMO versus comfort care beforehand using early criteria, you're going to be wrong 50% of the time.

Dr. Stark believes that if parents have good prenatal counseling and are all in, you should pursue ECMO for every unilateral isolated CDH.

Dr. Stark clarified she is not referring to cases involving genetic or cardiac syndromes, which she considers an entirely different scenario.

Early ECMO intervention is often preferred in severe CDH.

Veno-arterial ECMO is still widely used in CDH, though veno-venous ECMO may increase with improved cannulas.

Predicting outcomes in severe CDH remains imprecise despite protocols like SPHERE.

Many providers advocate for universally offering ECMO in cases of isolated unilateral CDH, approaching each infant as a potential survivor until proven otherwise.