Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC)
Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO.
Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC).
Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5–15 CDH repairs were reported annually per institution; 26–50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III–IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4–5 weeks.
Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions.
Level of evidence
V (expert opinion).
KeywordsCongenital diaphragmatic hernia Extracorporeal membrane oxygenation ECMO CDH Pediatric surgery
This research did not receive any specific Grant from funding agencies in the public, commercial, not-for-profit sectors.
Compliance with ethical standards
Conflict of interest
Dr. Cairo reports that she has no conflict of interest. Dr. Arbuthnot reports that she has no conflicts of interest. Dr. Boomer has no conflicts of interest to report. Dr. Dingeldein has no relevant conflicts of interest to report. Dr. Feliz has no conflicts of interest to report. Dr. Gadepalli reports that he has no conflicts of interest. Dr. Newton reports that he has no conflicts of interest. Dr. Ricca Jr has no conflicts of interest to report. Dr. Vogel reports no conflicts of interest relevant to the present study. Senior author, Dr. Rothstein, reports that he has no conflicts of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards or the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
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