T. Jancelewicz1, M. E. Brindle2, P. A. Lally3, K. P. Lally3, M. T. Harting3 1University Of Tennessee Health Science Center,Department Of Pediatric Surgery,Memphis, TN, USA 2University Of Calgary,Department Of Surgery,Calgary, AB, Canada 3University Of Texas McGovern Medical School,Department Of Pediatric Surgery,Houston, TX, USA
Introduction: Proper clinical management during the first hours of life for patients with congenital diaphragmatic hernia (CDH) is essential to avoid lung injury and optimize outcomes. However, the variability of neonatal CDH management strategies between centers is unknown. Our objective was to identify North American centers who have an established CDH clinical practice guideline (CPG), obtain/review these CPGs, and assess the degree of variability in general perinatal and neonatal management.
Methods: Members of the CDH Study Group (CDHSG) and Pediatric Surgery Research Collaborative (PedSRC) were solicited via email to submit their CDH CPG. Standardized variables were created for CPG elements, and CPGs were screened by surgeons, with a 10% blinded second audit to ensure consistent abstraction. Review, descriptive analysis, and measures of variation were performed of perinatal and neonatal CPG components (delivery, resuscitation, vascular access, and sedation).
Results: Sixty-eight centers were solicited with 40 responses (59%). Of these, 29 (73%) had a CDH CPG and 11 (28%) did not; 27 CPGs were obtained for review. Estimated concordance between screeners was 95.0%. Just 5 CPGs (19%) had specified CDH delivery team members. Several key components of CDH resuscitation and general management were included in many CPGs (Table 1). One CPG recommended delayed umbilical cord clamping. An umbilical or right radial arterial line was recommended in 23 CPGs (85%). Initial venous access was mentioned in 21 (78%), with 95% of these recommending the umbilical vein. Sedative medications were addressed in 18 CPGs (67%).
Conclusion: General perinatal management of infants with CDH is frequently addressed in North American CPGs, with variable inclusion of specific elements. There is relative consistency seen with certain elements of management. These data identify important targets for a consensus approach to CDH patient management, and progression toward multi-institutional CDH management standardization in NA.
