Pulmonary support on Day 30 as a predictor of morbidity and mortality in congenital diaphragmatic hernia,☆☆

https://doi.org/10.1016/j.jpedsurg.2013.03.012Get rights and content

Abstract

Purpose

Congenital diaphragmatic hernia (CDH) is associated with significant in-hospital mortality, morbidity and length-of-stay (LOS). We hypothesized that the degree of pulmonary support on hospital day-30 may predict in-hospital mortality, LOS, and discharge oxygen needs and could be useful for risk prediction and counseling.

Methods

862 patients in the CDH Study Group registry with a LOS  30 days were analyzed (2007–2010). Pulmonary support was defined as (1) room-air (n = 320) (2) noninvasive supplementation (n = 244) (3) mechanical ventilation (n = 279) and (4) extracorporeal membrane oxygenation (ECMO, n = 19). Cox Proportional hazards and logistic regression models were used to determine the case-mix adjusted association of oxygen requirements on day-30 with mortality and oxygen requirements at discharge.

Results

On multivariate analysis, use of ventilator (HR 5.1, p = .003) or ECMO (HR 19.6, p < .001) was a significant predictor of in-patient mortality. Need for non-invasive supplementation or ventilator on day-30 was associated with a respective 22-fold (p < .001) and 43-fold (p < .001) increased odds of oxygen use at discharge compared to those on room-air.

Conclusions

Pulmonary support on Day-30 is a strong predictor of length of stay, oxygen requirements at discharge and in-patient mortality and may be used as a simple prognostic indicator for family counseling, discharge planning, and identification of high-risk infants.

Section snippets

Methods

We performed a retrospective cohort study of all patients in the CDH Study Group registry who had a hospital length of stay (LOS) ≥ 30 days during 2007–2010. IRB Approval was obtained from Boston Children's Hospital (IRB-P00002412). Thirty-three patients were missing 30-day pulmonary support status and therefore excluded. The primary outcome was mortality before hospital discharge. Secondary outcomes included need for a prolonged hospital stay (defined as a hospital stay longer than 60 days) and

Unadjusted analysis

862 CDH patients in the CDH study group registry had a LOS  30 days and had information regarding their need for pulmonary support. There were 320 patients on room air on hospital day 30 and 542 (62.9%) required some form of pulmonary support. Of those who required oxygen, 244 (45.0%) required only nasal cannula or CPAP, 279 (51.5%) needed some form of mechanical ventilation, and 19 (3.5%) were on ECMO support (Fig. 1). 30-day pulmonary support was associated with significant differences among

Discussion

We hypothesized that the degree of pulmonary support at 30 days could be used as a simple prognostic indicator for both late mortality and pulmonary morbidity in high-risk patients. We found that pulmonary support status at 30 days is the strongest independent predictor of both late mortality and pulmonary morbidity in survivors at discharge. This single factor can correctly predict over 85% of all subsequent inpatient deaths, and is a stronger independent predictor of mortality and discharge

Acknowledgments

This work was supported in part by Agency for Healthcare Research and Quality (AHRQ) Grant number T32HS019485 (RC), and National Institute of Child Health and Human Development (NICHD) Grant number K24HD060786 (JAF). The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

References (24)

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Author Contributions: All authors contributed to the study design, data collection, study analysis and the drafting of this article.

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Funding/Disclosure: None of the authors have commercial associations to disclose.

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