Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

The impact of a care bundle with an emphasis on hemodynamic assessment on the short-term outcomes in neonates with congenital diaphragmatic hernia

Journal of Perinatology volume 44, pages 348–353 (2024)Cite this article

Subjects

Abstract

Objective

To evaluate the short-term outcomes of implementing a care bundle emphasizing frequent hemodynamic assessments by echocardiography in neonates with congenital diaphragmatic hernia (CDH).

Study design

This was a retrospective cohort study of infants with CDH admitted to a quaternary perinatal unit from January 2013 to March 2021. The primary composite outcome was defined as mortality or use of extracorporeal membrane oxygenation or need for respiratory support at discharge.

Results

We identified 37 and 20 CDH infants in Epoch I and II, respectively. More patch repairs (50% vs. 21.9%, p = 0.035) and echocardiograms (6[4–8] vs. 1[0–5], p = 0.003) were performed in Epoch II. While there were no differences in the primary outcome, there was a reduction in mortality in Epoch II (0% vs. 27%, p = 0.01).

Conclusion

With the implementation of a CDH care bundle with an emphasis on hemodynamic assessment, we demonstrated a significant reduction in mortality.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

Data availability

The database for this research article is not available because of identifiable patient particulars in a relatively small number of patients.

References

  1. Paoletti M, Raffler G, Gaffi MS, Antounians L, Lauriti G, Zani A. Prevalence and risk factors for congenital diaphragmatic hernia: a global view. J Pediatr Surg. 2020;55:2297–307.

    PubMed  Google Scholar 

  2. Mohseni-Bod H, Bohn D. Pulmonary hypertension in congenital diaphragmatic hernia. Semin Pediatr Surg. 2007;16:126–33.

    PubMed  Google Scholar 

  3. Thibeault DW, Haney B. Lung volume, pulmonary vasculature, and factors affecting survival in congenital diaphragmatic hernia. Pediatrics. 1998;101:289–95.

    CAS  PubMed  Google Scholar 

  4. Patel N, Kipfmueller F. Cardiac dysfunction in congenital diaphragmatic hernia: pathophysiology, clinical assessment, and management. Semin Pediatr Surg. 2017;26:154–8.

    PubMed  Google Scholar 

  5. Dillon PW, Cilley RE, Mauger D, Zachary C, Meier A. The relationship of pulmonary artery pressure and survival in congenital diaphragmatic hernia. J Pediatr Surg. 2004;39:307–12.

    PubMed  Google Scholar 

  6. Baird R, MacNab YC, Skarsgard ED. Mortality prediction in congenital diaphragmatic hernia. J Pediatr Surg. 2008;43:783–7.

    PubMed  Google Scholar 

  7. Safavi A, Synnes AR, O’Brien K, Chiang M, Skarsgard ED, Chiu PP. Multi-institutional follow-up of patients with congenital diaphragmatic hernia reveals severe disability and variations in practice. J Pediatr Surg. 2012;47:836–41.

    PubMed  Google Scholar 

  8. Tissot C, Singh Y. Neonatal functional echocardiography. Curr Opin Pediatr. 2020;32:235–44.

    PubMed  Google Scholar 

  9. El-Khuffash AF, McNamara PJ. Neonatologist-performed functional echocardiography in the neonatal intensive care unit. Semin Fetal Neonatal Med. 2011;16:50–60.

    PubMed  Google Scholar 

  10. McCrary AW, Barker PCA, Torok RD, Spears TG, Li JS, Hornik CP, et al. Agreement of an echocardiogram-based diagnosis of pulmonary hypertension in infants at risk for bronchopulmonary dysplasia among masked reviewers. J Perinatol. 2019;39:248–55.

    PubMed  Google Scholar 

  11. Moenkemeyer F, Patel N. Right ventricular diastolic function measured by tissue doppler imaging predicts early outcome in congenital diaphragmatic hernia. Pediatr Crit Care Med. 2014;15:49–55.

    PubMed  Google Scholar 

  12. Lusk LA, Wai KC, Moon-Grady AJ, Steurer MA, Keller RL. Persistence of pulmonary hypertension by echocardiography predicts short-term outcomes in congenital diaphragmatic hernia. J Pediatr. 2015;166:251–6.e1.

    PubMed  Google Scholar 

  13. Reiss I, Schaible T, van den Hout L, Capolupo I, Allegaert K, van Heijst A, et al. Standardized postnatal management of infants with congenital diaphragmatic hernia in Europe: the CDH EURO Consortium consensus. Neonatology. 2010;98:354–64.

    CAS  PubMed  Google Scholar 

  14. Puligandla PS, Skarsgard ED, Offringa M, Adatia I, Baird R, Bailey M, et al. Diagnosis and management of congenital diaphragmatic hernia: a clinical practice guideline. Cmaj. 2018;190:E103–e12.

    PubMed  PubMed Central  Google Scholar 

  15. Yadav K, Hebert A, Lavie-Nevo K, Kuan MTY, Castaldo M, Osiovich H, et al. Targeted neonatal echocardiography for patent ductus arteriosus in neonates reduces the surgical ligation rate without affecting healthcare outcomes. Transl Pediatr. 2023;12:137–45.

    PubMed  PubMed Central  Google Scholar 

  16. Ting JY, Resende M, More K, Nicholls D, Weisz DE, El-Khuffash A, et al. Predictors of respiratory instability in neonates undergoing patient ductus arteriosus ligation after the introduction of targeted milrinone treatment. J Thorac Cardiovasc Surg. 2016;152:498–504.

    PubMed  Google Scholar 

  17. El-Khuffash A, Herbozo C, Jain A, Lapointe A, McNamara PJ. Targeted neonatal echocardiography (TnECHO) service in a Canadian neonatal intensive care unit: a 4-year experience. J Perinatol. 2013;33:687–90.

    CAS  PubMed  Google Scholar 

  18. Alammary D, Narvey M, Soni R, Elsayed Y, Louis D. Targeted neonatal echocardiography service in neonatal intensive care in Manitoba, Canada. J Perinatol. 2022;42:655–9.

    PubMed  Google Scholar 

  19. Richardson DK, Corcoran JD, Escobar GJ, Lee SK. SNAP-II and SNAPPE-II: simplified newborn illness severity and mortality risk scores. J Pediatr. 2001;138:92–100.

    CAS  PubMed  Google Scholar 

  20. Kipfmueller F, Schroeder L, Melaku T, Geipel A, Berg C, Gembruch U, et al. Prediction of ECMO and mortality in neonates with congenital diaphragmatic hernia using the SNAP-II Score. Klin Padiatr. 2019;231:297–303.

    PubMed  Google Scholar 

  21. The Canadian Neonatal Network. The Canadian Neonatal Network Abstractor’s Mannual 2023 [updated March 8, 2023. Available from: https://www.canadianneonatalnetwork.org/portal/Portals/0/CNN%20Manuals/CNN%20Manual_20230308.pdf.

  22. Harting MT, Lally KP. The congenital diaphragmatic hernia study group registry update. Semin Fetal Neonatal Med. 2014;19:370–5.

    PubMed  Google Scholar 

  23. Puligandla PS, Skarsgard ED. The canadian pediatric surgery network congenital diaphragmatic hernia evidence review project: developing national guidelines for care. Paediatr Child Health. 2016;21:183–6.

    PubMed  PubMed Central  Google Scholar 

  24. Ferguson DM, Gupta VS, Lally PA, Luco M, Tsao K, Lally KP, et al. Early, postnatal pulmonary hypertension severity predicts inpatient outcomes in congenital diaphragmatic hernia. Neonatology. 2021;118:147–54.

    PubMed  Google Scholar 

  25. Patel N, Massolo AC, Kraemer US, Kipfmueller F. The heart in congenital diaphragmatic hernia: Knowns, unknowns, and future priorities. Front Pediatr. 2022;10:890422.

    PubMed  PubMed Central  Google Scholar 

  26. Brindle ME, Brar M, Skarsgard ED. Patch repair is an independent predictor of morbidity and mortality in congenital diaphragmatic hernia. Pediatr Surg Int. 2011;27:969–74.

    CAS  PubMed  Google Scholar 

  27. van den Hout L, Sluiter I, Gischler S, De Klein A, Rottier R, Ijsselstijn H, et al. Can we improve outcome of congenital diaphragmatic hernia? Pediatr Surg Int. 2009;25:733–43.

    PubMed  PubMed Central  Google Scholar 

  28. LaRusso K, Puligandla PS, Anna GS. The canadian congenital diaphragmatic hernia collaborative mobile app: a national guideline implementation strategy. Am J Perinatol. 2020;37:S66–S70.

    PubMed  Google Scholar 

  29. Al Kharusi A, Al-Maawali A, Traynor M, Adreak N, Ting J, Skarsgard ED. High frequency jet ventilation for congenital diaphragmatic hernia. J Pediatr Surg. 2023;58:799–802.

    PubMed  Google Scholar 

  30. Papadhima I, Louis D, Purna J, Deshpande P, Diambomba Y, Lee S, et al. Targeted neonatal echocardiography (TNE) consult service in a large tertiary perinatal center in Canada. J Perinatol. 2018;38:1039–45.

    PubMed  Google Scholar 

  31. Deeney S, Howley LW, Hodges M, Liechty KW, Marwan AI, Gien J, et al. Impact of objective echocardiographic criteria for timing of congenital diaphragmatic hernia repair. J Pediatr. 2018;192:99–104.e4.

    PubMed  Google Scholar 

  32. Snoek KG, Reiss IKM, Greenough A, Capolupo I, Urlesberger B, Wessel L, et al. Standardized postnatal management of infants with congenital diaphragmatic hernia in Europe: the CDH EURO Consortium Consensus - 2015 Update. Neonatology. 2016;110:66–74.

    PubMed  Google Scholar 

  33. Soni R, Soni N, Chakkarapani A, Gupta S, Yajamanyam PK, Ali SKM, et al. The utility of serial echocardiography parameters in management of newborns with Congenital Diaphragmatic Hernia (CDH) and predictors of mortality. Pediatr Cardiol. 2023;44:354–66.

    PubMed  Google Scholar 

  34. Aggarwal S, Shanti C, Agarwal P, Lelli J, Natarajan G. Echocardiographic measures of ventricular-vascular interactions in congenital diaphragmatic hernia. Early Hum Dev. 2022;165:105534.

    CAS  PubMed  Google Scholar 

  35. Dingeldein M. Congenital diaphragmatic hernia: management & outcomes. Adv Pediatr. 2018;65:241–7.

    PubMed  Google Scholar 

  36. McNamara PJ, Giesinger RE, Lakshminrusimha S. Dopamine and neonatal pulmonary hypertension - pressing need for a better pressor? J Pediatr. 2022;246:242–50.

    CAS  PubMed  Google Scholar 

  37. Jain A, McNamara PJ. Persistent pulmonary hypertension of the newborn: Advances in diagnosis and treatment. Semin Fetal Neonatal Med. 2015;20:262–71.

    PubMed  Google Scholar 

  38. Giesinger RE, McNamara PJ. Hemodynamic instability in the critically ill neonate: an approach to cardiovascular support based on disease pathophysiology. Semin Perinatol. 2016;40:174–88.

    PubMed  Google Scholar 

  39. Mohamed A, Nasef N, Shah V, McNamara PJ. Vasopressin as a rescue therapy for refractory pulmonary hypertension in neonates: case series. Pediatr Crit Care Med. 2014;15:148–54.

    PubMed  Google Scholar 

  40. Qasim A, Jain SK. Milrinone use in persistent pulmonary hypertension of the newborn. NeoReviews. 2020;21:e165–e78.

    PubMed  Google Scholar 

  41. Kamath BD, Fashaw L, Kinsella JP. Adrenal insufficiency in newborns with congenital diaphragmatic hernia. J Pediatr. 2010;156:495–7.e1.

    PubMed  PubMed Central  Google Scholar 

  42. Lakshminrusimha S, Keszler M, Kirpalani H, Van Meurs K, Chess P, Ambalavanan N, et al. Milrinone in congenital diaphragmatic hernia – a randomized pilot trial: study protocol, review of literature and survey of current practices. Matern Health, Neonatol Perinatol. 2017;3:27.

    PubMed  Google Scholar 

  43. Skarsgard ED. Preoperative management of congenital diaphragmatic hernia. Curr Treat Options Pediatr. 2022;8:232–45.

    Google Scholar 

  44. Hollinger LE, Harting MT, Lally KP. Long-term follow-up of congenital diaphragmatic hernia. Semin Pediatr Surg. 2017;26:178–84.

    PubMed  Google Scholar 

Download references

Acknowledgements

We thank Dr. Alfonso Solimano for his contribution to the implementation of the TnEcho protocol.

Author information

Authors and Affiliations

  1. Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada

    Mimi T. Y. Kuan, Krishan Yadav, Michael Castaldo, Natalie H. Chan, Martin Hosking & Joseph Y. Ting

  2. Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada

    Jason Tan

  3. Department of Pediatric and Newborn Medicine, UCSF and Benioff Children’s Hospital, San Francisco, CA, USA

    Natalie H. Chan

  4. Department of Anesthesiology, University of British Columbia, Vancouver, BC, Canada

    Michael Traynor

  5. Department of Surgery, University of British Columbia, Vancouver, BC, Canada

    Erik Skarsgard

  6. Department of Pediatrics, University of Alberta, Edmonton, AB, Canada

    Joseph Y. Ting

Authors
  1. Mimi T. Y. Kuan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Krishan Yadav
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael Castaldo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jason Tan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Natalie H. Chan
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michael Traynor
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Martin Hosking
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Erik Skarsgard
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Joseph Y. Ting
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MTYK, KY, ES and JYT conceptualized and designed the study. MTYK, KY and JT collected the data. All authors analyzed and interpreted the data. MK and JYT drafted the initial manuscript. All authors critically reviewed and revised the manuscript for important intellectual content.

Corresponding author

Correspondence to Joseph Y. Ting.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kuan, M.T.Y., Yadav, K., Castaldo, M. et al. The impact of a care bundle with an emphasis on hemodynamic assessment on the short-term outcomes in neonates with congenital diaphragmatic hernia. J Perinatol 44, 348–353 (2024). https://doi.org/10.1038/s41372-023-01807-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41372-023-01807-0

Search

Advanced search

Quick links