The Timing of CDH Repair on ECMO impacts on surgical bleeding

Infographic · Nov 2023 · 1 min read

In brief

Retrospective study of 146 infants found that early CDH repair within 48 hours of ECMO cannulation resulted in significantly less surgical bleeding compared to delayed repair (5% vs 36%). Elevated blood urea nitrogen was identified as a strong risk factor for bleeding in delayed repairs.

Early CDH repair (within 48h of ECMO) reduces surgical bleeding risk from 36% to 5% compared to delayed repair (OR 11.7, p<0.001).
Elevated BUN at time of repair strongly predicts surgical bleeding (median 63 vs 9 mg/dL in bleeders vs non-bleeders, p<0.0001).
Early repair shortens ECMO duration by 5 days (median 13 vs 18 days, p=0.005) without affecting survival rates.
Azotemia is a key modifiable risk factor—delaying repair allows renal dysfunction to worsen, increasing hemorrhagic complications.
Surgical bleeding requiring reoperation occurs 7× more often with delayed repair, challenging the practice of waiting for stabilization.

Written by the GCMD Library team from the infographic.

The infographic uses a teal and yellow color scheme with a split layout comparing two patient groups. The left side (red text) represents early repair patients, the right side (green text) represents late repair patients, with comparative statistics displayed in large numbers. A small illustration of a clinician reviewing an x-ray appears in the upper right corner.

New infographic by Cecilia Gigena

"Timing of CDH Repair on ECMO impacts on surgical bleeding"

Authors: C. Jason Smithers, Jill M. Zalieckas, Samuel E. Rice–Townsend, Ali Kamran, David Zurakowski, Terry L. Buchmiller

Full article: https://gcmd.co/3sJ5Ihj

Background

The optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion.

Methods

A retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression.

Results

102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48–39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20–85) vs. those who did not (median 9 mg/dL, IQR 7–13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737).

Conclusion

We demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO.

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