Stability prior to surgery in Congenital Diaphragmatic Hernia: Is it necessary?

AbstractBackground Delaying surgery for infants with CDH until they achieve clinical stability is common practice. Stability, however, is inconsistently defined, and many infants fail to reach pre-established criteria. We sought to determine if infants undergoing surgery without meeting pre-established criteria could achieve meaningful survival. Methods All infants in the CAPSNet database were analyzed (2005-2010). Patients undergoing operative repair were divided into two groups based on whether they met strict (FiO2 < 0.40, conventional ventilation, preductal saturation > 92%, no inotropes or vasodilators), or lenient (FiO2 < 0.60, conventional ventilation, preductal saturation > 88%, no vasodilators) criteria. Univariate analyses were performed comparing characteristics of those who survived after surgery (N = 273) with those who did not (N = 21). Results 294 patients (85%) survived to surgery. Predictors of post-operative survival included prenatal liver position (p = 0.003), preoperative oxygen requirements (p = 0.008), preoperative inotropes (p < 0.0001), and non-conventional ventilation (p = 0.004). Infants meeting strict criteria had increased survival (99%; p < 0.0001). Infants meeting lenient criteria constituted 70% of survivors. Nearly one-third of survivors met neither strict nor lenient criteria. Conclusions Infants with CDH can achieve good survival even when criteria for pre-operative stability are not met. We suggest that all infants should be repaired even if lenient criteria for ventilatory, inotrope, or vasodilator requirements are not achieved.