# Congenital Diaphragmatic Hernia Management — GCMD Library living collection Updated: n/a · 9 episodes · 117 cited statements ## Episodes ### Prenatal Intervention - [Fetoscopic endoluminal tracheal occlusion for congenital diaphragmatic hernia](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835) — podcast · 4:30 · [machine version](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835.md) - [Fetoscopic Tracheal Occlusion for Congenital Diaphragmatic Hernia: Procedural Walkthrough](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845) — podcast · 4:30 · [machine version](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845.md) - [Severe CDH case with FETO: unexpected anatomic findings and clinical outcome](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836) — podcast · 3:51 · [machine version](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836.md) - [FETO procedure for late-diagnosed severe CDH with liver herniation](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837) — podcast · 4:55 · [machine version](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837.md) ### Postnatal Management - [Timing and anticoagulation strategies for CDH repair on ECMO](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869) — podcast · 4:55 · [machine version](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869.md) - [ECMO timing and technique for severe congenital diaphragmatic hernia in neonates](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872) — podcast · 4:43 · [machine version](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872.md) - [Postnatal Lung Growth and Nutrition in Congenital Diaphragmatic Hernia Outcomes](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850) — podcast · 5:30 · [machine version](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850.md) ### Outcomes and Protocols - [Protocol changes improve CDH survival rates at Cincinnati Children's Hospital](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849) — podcast · 5:22 · [machine version](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849.md) - [Hirschsprung Dilations, Gastroschisis Management, and CDH Volume Outcomes](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865) — podcast · 4:23 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865.md) ## Chapters - [0:01](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=1) Introduction and FETO Overview (Ep 1) - [0:59](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=59) Anatomic Navigation and Scope Manipulation (Ep 1) - [2:34](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=154) Balloon Positioning and Deployment (Ep 1) - [3:58](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=238) Summary and Closing (Ep 1) - [0:00](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=0) Case presentation and initial prenatal diagnosis (Ep 3) - [1:02](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=62) FETO procedure and response assessment (Ep 3) - [1:45](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=105) Delivery and unexpected postnatal findings (Ep 3) - [2:48](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=168) Clinical course and outcome (Ep 3) - [0:01](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=1) Introduction and FETO procedure overview (Ep 4) - [0:31](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=31) Case presentation and initial diagnosis (Ep 4) - [1:52](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=112) FETO intervention and response (Ep 4) - [2:57](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=177) Delivery and postnatal management (Ep 4) - [4:09](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=249) Imaging findings and case summary (Ep 4) - [0:01](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=1) Introduction to FETO Procedure and Mechanism (Ep 2) - [1:03](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=63) Initial Navigation: Identifying Anatomical Landmarks (Ep 2) - [1:58](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=118) Advancing Through the Vocal Cords into the Trachea (Ep 2) - [2:46](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=166) Balloon Positioning, Inflation, and Deployment (Ep 2) - [3:58](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=238) Procedure Summary and Conclusion (Ep 2) - [0:00](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=0) Introduction and Protocol Timeline (Ep 8) - [0:40](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=40) ECMO and Surgical Timing Changes (Ep 8) - [1:24](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=84) Respiratory and Cardiovascular Management (Ep 8) - [2:10](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=130) Nutrition and Sedation Protocols (Ep 8) - [3:08](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=188) Quality Improvement Outcomes (Ep 8) - [0:00](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=0) CDH Epidemiology and Prognosis (Ep 7) - [1:09](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=69) Postnatal Lung Imaging with MRI (Ep 7) - [2:35](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=155) Lung Growth and Nutrition (Ep 7) - [3:52](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=232) Pulmonary Vascular Density as Outcome Predictor (Ep 7) - [5:03](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=303) Summary and Clinical Implications (Ep 7) - [0:00](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=0) Postoperative Dilations in Hirschsprung Disease (Ep 9) - [1:47](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=107) Gastroschisis Management: Timing, Antibiotics, and Closure (Ep 9) - [2:56](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=176) CDH Outcomes by Hospital Volume (Ep 9) - [0:00](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=0) Clinical scenario and bivalirudin introduction (Ep 5) - [1:32](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=92) Bivalirudin pharmacology and monitoring (Ep 5) - [2:23](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=143) Timing of CDH repair on ECMO (Ep 5) - [4:21](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=261) Summary and conclusions (Ep 5) - [0:00](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=0) Introduction and clinical scenario setup (Ep 6) - [0:53](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=53) ECMO modality selection: VA versus VV (Ep 6) - [2:35](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=155) SEER protocol and comfort care decision-making (Ep 6) - [3:49](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=229) Summary and conclusions (Ep 6) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - The clinical scenario involves a full-term neonate with known left-sided very severe CDH, no cardiac or genetic anomalies, delivered about an hour ago and intubated per institutional protocols. — Rebecca Stark (clinical) [Ep 6 · 0:55](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=55) - Initial vitals show preductal saturations in the 70s, heart rate 150, blood pressure 35/25 on 100% FIO2, with first gas showing pH 6.8, PaCO2 130, and PaO2 28. — Rebecca Stark (clinical) [Ep 6 · 1:09](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=69) - The majority of centers still do VA ECMO primarily for CDH babies. — Rebecca Stark (epidemiological) [Ep 6 · 1:49](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=109) - Both VA and VV ECMO are totally reasonable answers for this clinical scenario. — Rebecca Stark (opinion) [Ep 6 · 1:54](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=114) - There are lots of benefits to VV ECMO and lots of benefits to VA ECMO. — Rebecca Stark (opinion) [Ep 6 · 1:45](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=105) - Based on prenatal imaging showing high risk for needing ECMO, the time to intervene is probably earlier rather than later. — Rebecca Stark (opinion) [Ep 6 · 2:00](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=120) - VV cannula availability and concerns with certain VV cannulas have played a role in ECMO modality selection. (opinion) [Ep 6 · 2:08](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=128) - If an institution does VV ECMO but cannot cannulate because the 13 French cannula is too big, they would probably do VA instead. — Rebecca Stark (clinical) [Ep 6 · 2:24](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=144) - Better VV cannulas are coming out, which may change the numbers of centers using VV ECMO. — Rebecca Stark (opinion) [Ep 6 · 2:24](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=144) - Michigan's SEER protocol prenatally selected severe CDH cases and educated parents they would go on this pathway. — Rebecca Stark (guideline) [Ep 6 · 2:41](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=161) - In the SEER protocol, ECMO was on standby in the delivery room, and babies were intubated and resuscitated within 2 hours. — Rebecca Stark (guideline) [Ep 6 · 2:57](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=177) - In the SEER protocol, if pH did not reach 7, PCO2 was not less than 100, and preductal sats were not above 80 within 2 hours, comfort measures only were offered. — Rebecca Stark (guideline) [Ep 6 · 3:04](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=184) - The two groups in the SEER protocol (ECMO versus comfort care) had equivalent survival. — Rebecca Stark (epidemiological) [Ep 6 · 3:16](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=196) - Half of the patients offered comfort measures in the SEER protocol could have been survivors. — Rebecca Stark (epidemiological) [Ep 6 · 3:20](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=200) - If you make the decision to choose ECMO versus comfort care beforehand using protocols like SEER, you will be wrong 50% of the time. — Rebecca Stark (opinion) [Ep 6 · 3:30](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=210) - With good prenatal counseling and parents who are all in, ECMO should be pursued for every unilateral isolated CDH. — Rebecca Stark (opinion) [Ep 6 · 3:38](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=218) - Cases involving genetic or cardiac syndromes are an entirely different scenario from isolated CDH and are not included in the recommendation for universal ECMO. — Rebecca Stark (opinion) [Ep 6 · 3:49](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=229) - FETO is a percutaneous intervention on the mother using one trocar placed through the maternal abdominal wall into the uterus. — Beth Rymeski (clinical) [Ep 1 · 0:33](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=33) - A standard fetoscope with a side channel is used, and the balloon is worked through the side channel. — Beth Rymeski (clinical) [Ep 1 · 0:36](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=36) - The tongue is an easy landmark to identify during FETO because it is bumpy. — Beth Rymeski (clinical) [Ep 1 · 1:21](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=81) - Fluid is hooked up to the scope and can be intermittently turned on and off to push tissue away from the scope to allow easier advancement. — Beth Rymeski (clinical) [Ep 1 · 1:29](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=89) - If the baby's head is not perfectly aligned with the scope, twisting and turning is required to navigate through the mouth. — Beth Rymeski (clinical) [Ep 1 · 1:39](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=99) - The epiglottis is sought as a landmark to guide navigation toward the trachea. — Beth Rymeski (clinical) [Ep 1 · 1:58](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=118) - Excessive torquing of the membranes should be avoided because the scope goes through the abdominal wall and uterine wall, and excessive turning can cause membrane damage. — Beth Rymeski (clinical) [Ep 1 · 2:23](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=143) - The scope should always be advanced until the carina is visualized, which confirms location in the trachea and not the esophagus. — Beth Rymeski (clinical) [Ep 1 · 2:36](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=156) - The balloon should not be driven into one side of the trachea; it must be inflated in the main trachea. — Beth Rymeski (clinical) [Ep 1 · 2:56](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=176) - The scope is backed up during balloon inflation to allow visualization of the balloon as it inflates. — Beth Rymeski (clinical) [Ep 1 · 3:03](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=183) - The patient was a 33-year-old G3P2 diagnosed with CDH on routine 20-week ultrasound — Beth Rymeski (clinical) [Ep 3 · 0:29](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=29) - The left lung was so small they couldn't measure it (less than 1 mL) — Beth Rymeski (clinical) [Ep 3 · 0:42](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=42) - The O/E (observed to expected lung to head ratio) by ultrasound was 14% — Beth Rymeski (clinical) [Ep 3 · 0:49](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=49) - While the balloon was in place, the lungs showed some growth but it was shy of 20%, making this a non-responder — Beth Rymeski (clinical) [Ep 3 · 1:15](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=75) - Post-FETO imaging showed left lung volume just over 2 mL (increased from less than 1 mL) and some interval growth in the right lung, but overall still really poor numbers — Beth Rymeski (clinical) [Ep 3 · 1:32](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=92) - The baby was immediately put on ECMO in the delivery room — Beth Rymeski (clinical) [Ep 3 · 1:58](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=118) - The baby had only 6 pairs of ribs at birth, missing a lot of ribs — Beth Rymeski (clinical) [Ep 3 · 2:09](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=129) - The baby had spinal kyphosis — Beth Rymeski (clinical) [Ep 3 · 2:17](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=137) - The baby had no anus (anorectal malformation) — Beth Rymeski (clinical) [Ep 3 · 2:17](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=137) - The cardiac anatomy was determined to be a right dominant double aortic arch with narrowing on the right and atresia on the left, after considerable discussion about what the anatomy actually was — Beth Rymeski (clinical) [Ep 3 · 2:29](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=149) - The baby remained on ECMO for several weeks — Beth Rymeski (clinical) [Ep 3 · 2:48](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=168) - Multiple attempts were made to wean off ECMO, achieving partial weaning but never getting below a certain threshold — Beth Rymeski (clinical) [Ep 3 · 2:52](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=172) - After discussion with the family, they decided to withdraw support and the baby passed at around 3 weeks of life, never making it off ECMO — Beth Rymeski (clinical) [Ep 3 · 3:06](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=186) - Radiology reviewed the prenatal imaging retrospectively knowing the postnatal findings and still could not identify the abnormalities that were found after birth — Beth Rymeski (clinical) [Ep 3 · 3:14](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=194) - The case was a late diagnosis at 28 weeks in a patient planning home birth with a midwife who had not had prior imaging — Beth Vermesy (clinical) [Ep 4 · 0:34](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=34) - The left lobe of the liver touching the apex of the left chest indicates the entire hemi liver has herniated into that side of the chest — Beth Vermesy (clinical) [Ep 4 · 0:50](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=50) - The fluid-filled stomach had completely herniated into the right chest because the liver was taking up the entire left side — Beth Vermesy (clinical) [Ep 4 · 1:13](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=73) - Initial calculated lung volume on the left was just over 1 mL at 28 weeks — Beth Vermesy (clinical) [Ep 4 · 1:27](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=87) - The O/E (observed to expected lung to head ratio) on ultrasound was 19% — Beth Vermesy (clinical) [Ep 4 · 1:37](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=97) - The cutoff for severe CDH O/E on ultrasound is 25% — Beth Vermesy (guideline) [Ep 4 · 1:44](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=104) - Patient was discharged on post-op day 1 but returned on post-op day 3 for preterm contractions requiring magnesium, then discharged on Procardia and vaginal progesterone — Beth Vermesy (clinical) [Ep 4 · 1:59](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=119) - Post-removal MRI showed the right-sided stomach now midline, right lung nicely expanded, and left lung pushed the liver slightly away from the apex — Beth Vermesy (clinical) [Ep 4 · 2:20](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=140) - Left lung volume increased from 1 mL to 23 mL, representing a 42% increase between balloon placement and removal — Beth Vermesy (clinical) [Ep 4 · 2:45](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=165) - Intubation support and surfactant administration were performed during C-section since it was less than a week after balloon removal — Beth Vermesy (clinical) [Ep 4 · 3:05](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=185) - Male infant delivered with birth weight 2.6 kg and Apgars of 6 and 7 — Beth Vermesy (clinical) [Ep 4 · 3:16](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=196) - Initial ventilation was on Vyvent (APRV setting), then transitioned to oscillator with low-dose fentanyl for blood pressure support, then back to Vyvent settings — Beth Vermesy (clinical) [Ep 4 · 3:25](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=205) - Extubation occurred at 26 days of life, which is considered pretty good for severe CDH — Beth Vermesy (clinical) [Ep 4 · 3:43](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=223) - One month after extubation, the infant developed hemoptysis with extensive workup revealing subglottic edema and narrowing that ultimately resolved — Beth Vermesy (clinical) [Ep 4 · 3:47](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=227) - Discharge occurred on day of life 94 (approximately 3 months old), which is considered pretty good — Beth Vermesy (clinical) [Ep 4 · 4:02](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=242) - Tracheal dilation is a very common finding in babies who had tracheal occlusion because the trachea was stretched out during pregnancy — Beth Vermesy (clinical) [Ep 4 · 4:15](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=255) - Tracheal dilation is not felt to be clinically impactful in the long run based on follow-up data from Europe — Beth Vermesy (clinical) [Ep 4 · 4:24](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=264) - FETO is a percutaneous intervention performed on the mother using one trocar placed through the maternal abdominal wall into the uterus. — Beth Rymeski (clinical) [Ep 2 · 0:33](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=33) - A standard fetoscope with a side channel is used, and the balloon is worked through the side channel. — Beth Rymeski (clinical) [Ep 2 · 0:36](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=36) - The tongue is an easy landmark to identify during FETO because it is bumpy in appearance. — Beth Rymeski (clinical) [Ep 2 · 1:21](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=81) - Fluid is hooked up to the scope and can be intermittently turned on and off to push tissue away from the scope to allow easier advancement. — Beth Rymeski (clinical) [Ep 2 · 1:29](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=89) - If the baby's head is not perfectly aligned with the scope, twisting and turning of the scope is required to navigate through the mouth. — Beth Rymeski (clinical) [Ep 2 · 1:39](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=99) - The epiglottis is a key landmark to identify when navigating to the trachea. — Beth Rymeski (clinical) [Ep 2 · 1:58](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=118) - Excessive torquing of the scope should be avoided because it can cause membrane damage, as the scope passes through the abdominal wall and uterine wall. — Beth Rymeski (clinical) [Ep 2 · 2:23](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=143) - The scope should always be advanced until the carina is visualized, which confirms tracheal position and indicates location within the trachea. — Beth Rymeski (clinical) [Ep 2 · 2:36](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=156) - The balloon should not be driven into one side of the trachea; it must inflate in the main trachea. — Beth Rymeski (clinical) [Ep 2 · 2:56](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=176) - The scope is backed up during balloon inflation to allow visualization of the balloon as it inflates. — Beth Rymeski (clinical) [Ep 2 · 3:03](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=183) - The balloon contains a small metal ball that is visible on imaging. — Beth Rymeski (clinical) [Ep 2 · 3:29](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=209) - The protocol changes initially focused on delivery room and ECMO utilization, then ventilator management, then went system by system through EEN, cardiac, and neuro. — Paul Kingma (clinical) [Ep 8 · 0:27](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=27) - Under the old protocol, if CDH babies were off ECMO, surgical repair was performed when echo demonstrated improved pulmonary hypertension, which could be anywhere from a few days to 56 days (the most delayed repair Dr. Kingma had). — Paul Kingma (clinical) [Ep 8 · 0:46](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=46) - Under the old protocol, if CDH babies were on ECMO, repair time was variable—sometimes early, sometimes during the ECMO course, sometimes after ECMO. (clinical) [Ep 8 · 1:00](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=60) - The new protocol repairs all ECMO kids within the first 12 to 24 hours of going on ECMO. — Paul Kingma (clinical) [Ep 8 · 1:09](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=69) - The new protocol repairs all non-ECMO kids somewhere between day 4 and 8, provided they're stable, which is the vast majority of the kids. — Paul Kingma (clinical) [Ep 8 · 1:16](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=76) - Dr. Kingma's philosophy is that if you protect the lungs, all the rest will fall in line and improve. — Paul Kingma (opinion) [Ep 8 · 1:35](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=95) - The new respiratory protocol never goes above a peak pressure of 22. — Paul Kingma (clinical) [Ep 8 · 1:39](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=99) - The new respiratory protocol has a very standardized escalation and weaning protocol followed almost 100% of the time. — Paul Kingma (clinical) [Ep 8 · 1:42](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=102) - From a cardiovascular standpoint, the old approach was to play it by ear; now every baby gets started on hydrocortisone for blood pressure support. — Paul Kingma (clinical) [Ep 8 · 1:51](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=111) - There is now a standardized protocol for which pressors are used. — Paul Kingma (clinical) [Ep 8 · 2:01](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=121) - INO is only started if there's evidence of a need. — Paul Kingma (clinical) [Ep 8 · 2:05](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=125) - The All Children's philosophy is that if you start NG feeds in babies prior to their ability to take oral feeds because of respiratory trouble, they will lose the developmental connection of oral feeding leads to a full belly. — Paul Kingma (clinical) [Ep 8 · 2:20](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=140) - Under the new nutrition protocol, CDH babies are not fed until they can feed by mouth; prior to that, they're on TPN. — Paul Kingma (clinical) [Ep 8 · 2:34](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=154) - Now every baby gets started on a sedation drip automatically to capture them early. — Paul Kingma (clinical) [Ep 8 · 2:48](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=168) - Even though Cincinnati Children's is starting at a higher level of sedation than before and starting automatically on a drip versus PRN, overall use of sedation has plummeted since starting this approach. — Paul Kingma (clinical) [Ep 8 · 2:56](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=176) - The QI project compared the patient population before and after protocol implementation; the new cohort appears to have a little bit more severe and a little bit more mild cases, with the population skewed out to the extremes. — Paul Kingma (epidemiological) [Ep 8 · 3:16](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=196) - Survival increased from around 70% to around 80% when Cincinnati Children's started implementing these protocol changes. — Paul Kingma (epidemiological) [Ep 8 · 3:41](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=221) - Time on mechanical ventilation dropped from a median of 19 days to a median of 9 days, almost a 50% decline. — Paul Kingma (epidemiological) [Ep 8 · 3:53](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=233) - Even though the philosophy is to get CDH babies on ECMO sooner if they need it, that philosophy hasn't caused an increase in the number of ECMO babies. — Paul Kingma (epidemiological) [Ep 8 · 4:19](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=259) - There are lots of problems that CDH babies have that need to be improved beyond survival, time on the ventilator, and length of stay. — Paul Kingma (opinion) [Ep 8 · 4:41](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=281) - CDH occurs in approximately 1 in 3,000 births, with referral centers seeing 20 to 30 babies per year. — Paul Kingma (epidemiological) [Ep 7 · 0:21](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=21) - Overall survival for infants born with CDH remains static at about 70% over the past two decades despite intensive care efforts. — Paul Kingma (epidemiological) [Ep 7 · 0:59](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=59) - CDH is often identified on initial ultrasound at roughly 20 weeks of pregnancy, when other anomalies may also be identified that can greatly impact outcome. — Paul Kingma (clinical) [Ep 7 · 0:38](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=38) - Very little imaging has been done to study what happens to CDH lungs after birth, specifically whether and how the lungs grow postnatally. — Paul Kingma (clinical) [Ep 7 · 1:36](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=96) - Ultra-short echoT MRI allows determination of postnatal lung volumes, lung density, and lung mass. — Paul Kingma (clinical) [Ep 7 · 2:23](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=143) - In a cohort of 13 CDH babies at Cincinnati Children's, postnatal lungs do grow: total lung volume, right lung volume, and left lung volume all increase. — Paul Kingma (clinical) [Ep 7 · 2:35](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=155) - The non-CDH (right) lung grows better than the CDH (left) lung, with the left lung growing approximately 2 mL per week slower than the right lung. — Paul Kingma (clinical) [Ep 7 · 2:53](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=173) - Relative growth of the left (CDH) lung increases in babies with better weight gain. — Paul Kingma (clinical) [Ep 7 · 3:08](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=188) - Maximizing calories and protein intake to maximize growth is important because growth is associated with better growth of the more severely hypoplastic lung. — Paul Kingma (clinical) [Ep 7 · 3:22](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=202) - Babies who gained weight better had more growth of their left (CDH) lung mass, but weight gain did not impact the mass of the right lung. — Paul Kingma (clinical) [Ep 7 · 3:38](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=218) - 2D time-of-flight MRI can detect blood vessels in the lungs down to a size of 0.7 millimeters, allowing quantitation of vascular volume divided by lung volume to calculate vascular density. — Paul Kingma (clinical) [Ep 7 · 4:02](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=242) - CDH pulmonary vascular density correlates very strongly with outcomes in babies with CDH. — Paul Kingma (clinical) [Ep 7 · 4:27](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=267) - Lower vascular density is associated with longer time spent on the ventilator. — Paul Kingma (clinical) [Ep 7 · 4:36](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=276) - Babies discharged on room air had significantly higher vascular density than those discharged on oxygen or mechanical ventilation. — Paul Kingma (clinical) [Ep 7 · 4:44](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=284) - Bivalirudin is used as the sole anticoagulant drip for ECMO in CDH cases at the speaker's institution (clinical) [Ep 5 · 1:06](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=66) - Most places still use heparin for ECMO anticoagulation, but the practice is shifting quickly toward bivalirudin (opinion) [Ep 5 · 1:20](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=80) - Bivalirudin levels can be monitored with a dilute thrombin time, which any lab can create (clinical) [Ep 5 · 1:55](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=115) - Dilute thrombin time is 5 times more specific and sensitive than PTT for monitoring bivalirudin (clinical) [Ep 5 · 1:59](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=119) - Bivalirudin has a very short half-life of approximately 20 minutes, allowing immediate on/off effects (clinical) [Ep 5 · 2:11](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=131) - Bivalirudin has much less variability between patients in anticoagulation effectiveness compared to heparin (clinical) [Ep 5 · 2:15](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=135) - Switching to early CDH repair on ECMO is challenging for lower-volume institutions (1-2 cases per year) and requires whole team buy-in (opinion) [Ep 5 · 2:28](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=148) - Building a team for early ECMO repair requires showing data and involving anesthesiologists and neonatologists who run the pump (clinical) [Ep 5 · 2:53](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=173) - Early CDH repair on ECMO results in very little edema and is very similar to doing a repair off ECMO (clinical) [Ep 5 · 3:25](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=205) - It is impossible to be 100% certain which babies will require late repair because they cannot come off ECMO, and late repair is the worst time to operate (opinion) [Ep 5 · 3:45](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=225) - Early CDH repair on ECMO promotes good lung growth (clinical) [Ep 5 · 3:55](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=235) - Cannula position is important, and left-sided heart disease is a big contributor to overall cardiac function in CDH cases (clinical) [Ep 5 · 3:58](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=238) - Out of 90 centers contributing to the CDH study group, almost 80% are performing early repair on ECMO (epidemiological) [Ep 5 · 4:12](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=252) - The data on early ECMO repair for CDH has shifted significantly over the last 3 years (epidemiological) [Ep 5 · 4:20](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=260) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - In the SEER protocol, if babies could achieve the resuscitation targets, they were offered ECMO. — Em Gootee summarizing the discussion [Ep 6 · 3:12](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=192) - Half of the patients offered ECMO in the SEER protocol did not survive. — Em Gootee summarizing the discussion [Ep 6 · 3:26](https://library.globalcastmd.com/watch/ecmo-timing-and-technique-for-severe-congenital-diaphragmatic-hernia-in-neonates-16872?t=206) - The goal of FETO is to trap fluid in the lungs to allow the lungs to expand and grow. — Jill Knareth summarizes what Dr. Beth Romesky said [Ep 1 · 0:47](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=47) - FETO helps prevent pulmonary hypoplasia, which is a big factor in poor outcomes for CDH babies. — Jill Knareth summarizes what Dr. Beth Romesky said [Ep 1 · 0:53](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=53) - The balloon is filled with water, around 0.65 to 0.8 mL, depending on the size of the trachea. — Jill Knareth summarizes what Dr. Beth Romesky said [Ep 1 · 3:08](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=188) - After deployment, the scope is advanced one more time to confirm the balloon is below the vocal cords. — Jill Knareth summarizes what Dr. Beth Romesky said [Ep 1 · 3:40](https://library.globalcastmd.com/watch/fetoscopic-endoluminal-tracheal-occlusion-for-congenital-diaphragmatic-hernia-16835?t=220) - FETO uses a fetoscope to insert a balloon into the fetal trachea to temporarily block it, trapping fluid in the lungs to allow expansion and growth — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 0:18](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=18) - The PPLV (percent predicted lung volume) on MRI was 7% — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 0:52](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=52) - The balloon was placed early at 27 weeks and 4 days gestation — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 1:02](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=62) - Dr. Romeski stated this patient was the ideal case for FETO, with not a single hospitalization stay during the procedure period — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 1:04](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=64) - The balloon was removed at 34 weeks gestation — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 1:12](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=72) - A non-responder is a fetus with CDH who received FETO but did not show any improvement in lung growth — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 1:23](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=83) - The remainder of the pregnancy was uneventful — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 1:45](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=105) - The patient went into labor at 37 weeks and 3 days and had a vaginal delivery — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 1:47](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=107) - The Apgar scores for the baby were 2 and 1 — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 1:51](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=111) - The baby had several unexpected findings after delivery despite extensive prenatal imaging — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 2:03](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=123) - Anorectal malformations are rarely diagnosed prenatally — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 2:21](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=141) - Genetic testing showed only a few variations of unclear significance — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 2:43](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=163) - The team was not confident they could repair the cardiac defect, especially for a baby who couldn't come off ECMO due to limited lung volume — Jill Knepprath summarizes what Dr. Beth Romeske said [Ep 3 · 2:58](https://library.globalcastmd.com/watch/severe-cdh-case-with-feto-unexpected-anatomic-findings-and-clinical-outcome-16836?t=178) - FETO uses a fetoscope to insert a balloon into the fetal trachea to temporarily block it, trapping fluid in the lungs to allow expansion and growth — Jill Knepprath summarizes what Dr. Beth Vermesy said [Ep 4 · 0:21](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=21) - Liver herniation is especially harmful for fetal lung development because the liver is a large solid organ, unlike the bowels — Jill Knepprath summarizes what Dr. Beth Vermesy said [Ep 4 · 1:06](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=66) - FETO was performed at 29 weeks and 3 days gestation — Jill Knepprath summarizes what Dr. Beth Vermesy said [Ep 4 · 1:52](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=112) - Elective balloon removal is typically done by week 34 — Jill Knepprath summarizes what Dr. Beth Vermesy said [Ep 4 · 2:13](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=133) - Balloon removal was performed at 34 weeks and 3 days — Jill Knepprath summarizes what Dr. Beth Vermesy said [Ep 4 · 2:13](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=133) - Mother presented in labor six days after balloon removal at 35 weeks and 2 days — Jill Knepprath summarizes what Dr. Beth Vermesy said [Ep 4 · 2:57](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=177) - C-section was performed due to breech presentation — Jill Knepprath summarizes what Dr. Beth Vermesy said [Ep 4 · 3:01](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=181) - Muscle flap repair was performed on day of life 9 — Jill Knepprath summarizes what Dr. Beth Vermesy said [Ep 4 · 3:38](https://library.globalcastmd.com/watch/feto-procedure-for-late-diagnosed-severe-cdh-with-liver-herniation-16837?t=218) - The goal of FETO is to trap fluid in the lungs to allow the lungs to expand and grow. — Jill Knepprath summarizes what Dr. Beth Rymeski said [Ep 2 · 0:47](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=47) - FETO helps prevent pulmonary hypoplasia, which is a big factor in poor outcomes for CDH babies. — Jill Knepprath summarizes what Dr. Beth Rymeski said [Ep 2 · 0:53](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=53) - The balloon is filled with water, typically 0.65 to 0.8 mL, depending on the size of the trachea. — Jill Knepprath summarizes what Dr. Beth Rymeski said [Ep 2 · 3:08](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=188) - After balloon deployment, the vocal cords are visualized and the scope is advanced one more time to confirm the balloon is positioned below the cords. — Jill Knepprath summarizes what Dr. Beth Rymeski said [Ep 2 · 3:40](https://library.globalcastmd.com/watch/fetoscopic-tracheal-occlusion-for-congenital-diaphragmatic-hernia-procedural-wal-16845?t=220) - Protocol changes at Cincinnati Children's began in August 2023 and were implemented in spring of 2024. — Jill Knepprath summarizing the discussion [Ep 8 · 0:20](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=20) - Previously, Cincinnati Children's limited ventilator pressures to 25 to 26 and MAPs to less than 16 to 17. — Jill Knepprath summarizing the discussion [Ep 8 · 1:26](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=86) - In the past, Cincinnati Children's used to feed CDH babies once they had return of bowel function after repair. — Jill Knepprath summarizing the discussion [Ep 8 · 2:12](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=132) - Regarding sedation, Cincinnati Children's used to give babies as-needed sedation. — Jill Knepprath summarizing the discussion [Ep 8 · 2:44](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=164) - The new cohort had 36 babies compared to 99 in the previous cohort. — Jill Knepprath summarizing the discussion [Ep 8 · 3:31](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=211) - The new cohort saw an increase in the use of feto from 14% to 22%. — Jill Knepprath summarizing the discussion [Ep 8 · 3:31](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=211) - Survival for ECMO patients increased from 39% to 55%. — Jill Knepprath summarizing the discussion [Ep 8 · 4:10](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=250) - ECMO use was around the same in the old and new cohort at around 41% versus 45%. — Jill Knepprath summarizing the discussion [Ep 8 · 4:29](https://library.globalcastmd.com/watch/protocol-changes-improve-cdh-survival-rates-at-cincinnati-children-s-hospital-16849?t=269) - Fetal imaging findings such as fetal lung volumes, liver herniation, and lung to head ratio contribute to CDH prognosis. — Jill Knepprath summarizes what Dr. Paul Kingma said [Ep 7 · 1:09](https://library.globalcastmd.com/watch/postnatal-lung-growth-and-nutrition-in-congenital-diaphragmatic-hernia-outcomes-16850?t=69) - The prospective study by Beotti et al. took place 2021 to 2023 and included 33 patients under six months old who underwent endorectal pull-through surgeries. — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 9 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=63) - Patients were assigned to a new non-dilation protocol group or a traditional dilation group. — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 9 · 1:14](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=74) - The primary outcomes examined were anastomotic complications, enterocolitis, and constipation. — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 9 · 1:20](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=80) - There was no significant difference in anastomotic complications between the two groups. — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 9 · 1:27](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=87) - The non-dilation group had less enterocolitis and less constipation compared to the traditional dilation group. — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 9 · 1:27](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=87) - Choosing not to do postoperative anal dilations may be a good alternative with benefits like lower constipation and enterocolitis. — Lizzy Lee summarizes what Dr. Alex Halpern said [Ep 9 · 1:36](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=96) - For gastroschisis, delivery after 37 weeks is optimal. — Alex Halpern summarizing a resource [Ep 9 · 2:18](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=138) - Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until closure in gastroschisis. — Alex Halpern summarizing a resource [Ep 9 · 2:21](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=141) - Studies support primary fascial repair for gastroschisis as long as hemodynamics and abdominal domain permit. — Alex Halpern summarizing a resource [Ep 9 · 2:28](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=148) - Sutureless repair for gastroschisis is safe and effective and does not delay feeding or increase length of stay. — Alex Halpern summarizing a resource [Ep 9 · 2:28](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=148) - There is a need for high quality randomized controlled trials to help provide evidence-based care for gastroschisis infants. — Alex Halpern summarizing a resource [Ep 9 · 2:42](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=162) - The CDH study by Pier et al. is a retrospective study done in Texas using a state hospital database examining outcomes by center volume. — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 9 · 3:16](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=196) - The CDH study identified 1,314 patients: 728 from high volume centers, 9 from mid-volume centers, and 79 from low volume centers. — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 9 · 3:32](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=212) - High volume centers had significantly lower mortality rates for CDH patients even though they treated significantly sicker patients. — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 9 · 3:46](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=226) - High volume centers had significantly shorter length of stay for CDH patients. — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 9 · 3:46](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=226) - High volume centers had better outcomes for patients with CDH. — Cecilia Gigena summarizes what Dr. Alex Halpern said [Ep 9 · 4:00](https://library.globalcastmd.com/watch/hirschsprung-dilations-gastroschisis-management-and-cdh-volume-outcomes-16865?t=240) - Bivalirudin is a direct thrombin inhibitor used to prevent blood clots, especially during cardiac and vascular procedures — The host summarizing the discussion [Ep 5 · 1:32](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=92) - With bivalirudin, surgery can be performed after 8 hours of ECMO initiation as long as anticoagulation levels are stable — The host summarizing the discussion [Ep 5 · 3:17](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=197) - Some groups perform risk stratification after ECMO initiation: high-risk babies get early repair, lower-risk babies are weaned off ECMO before repair — The host summarizing the discussion [Ep 5 · 3:32](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=212) - It is not possible to reliably predict which babies can come off ECMO without repair — The host summarizing the discussion [Ep 5 · 4:05](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=245) - Early repair places patients in a much better position to come off ECMO urgently if needed — The host summarizing the discussion [Ep 5 · 4:05](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=245) - CDH repair can be safely performed on ECMO with minimal to no bleeding complications when meticulous operative techniques are used — The host summarizing the discussion [Ep 5 · 4:23](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=263) - The optimal window for early CDH repair on ECMO is between 8 to 24 hours — The host summarizing the discussion [Ep 5 · 4:32](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=272) - Bivalirudin is a safe anticoagulant for CDH repair on ECMO — The host summarizing the discussion [Ep 5 · 4:38](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=278) - A smaller consistent surgical team can enhance outcomes for CDH repair on ECMO — The host summarizing the discussion [Ep 5 · 4:42](https://library.globalcastmd.com/watch/timing-and-anticoagulation-strategies-for-cdh-repair-on-ecmo-16869?t=282) --- Educational content from recorded physician discussions — not medical advice. 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