Update Course Rewind: When & How to Operate CDH Patients on ECMO 2024 Part 2

What's the optimal timing for surgical repair in a newborn with a very severe congenital diaphragmatic hernia on ECMO? And is it time to move beyond Heparin? Hello pediatric surgery family. I'm Menghoti from Cincinnati Children's Hospital Medical Center. Today, pediatric surgeons, Dr. Rebecca Stark and Steven Lee will discuss the timing and techniques from performing ECMO in severe congenital diaphragmatic hernia, or CDH cases. Here's our clinical scenario. Full-term neonate, known diagnosis of a left-sided very severe CDH, no known cardiac anomalies, no genetic anomalies, delivered about an hour ago, intubated and resuscitated per your institutional protocols. Predductal stats are in the 70s. Heart rate is 150, blood pressure is 35 over 25. The patient is on 100% FIO2, and this is your first gas results, pH is 6.8, PACO2 is 130 and PAO2 is 28. You've placed the baby on VA ECMO, and what anticoagulant are you going to be using? What do you think? We use Bival. You never have to worry about HIT. You never have to worry about falling AT3. Bival is pretty much a no-brainer and we use predominantly as the sole anticoagulant drip for most. My gosh. I love that you're saying that. I think most places still use heparin, but I think this is one of those times when the needle is like really moving quickly because everything is better about it and I think people once you try it will switch pretty quickly. Bivalrudin is a direct thrombin inhibitor used to prevent blood clots, especially during cardiac and vascular procedures. This is a protocol that came out really early on and people started adopting pretty quickly. This paper highlights how Dr. Stark and Lee's institution historically used Bival or Bivalirudin for LVADs, and developed a method to closely monitor its levels. You can do it with a dilute thrombin time, any lab can create this. It's five times more specific and sensitive as PTT and so it's something that we can share and it's a great way to monitor the Bival levels as you go through. Here are two key points about Bival to remember. It's a very short half-life, so it's really easy to turn on and off. You see immediate effects, it's like a 20 minute half-life. And there is much less variability between patients in terms of how effective it is at anticoagulation. Same CDH case. Patients on ECMO manage with Bival. When do you proceed with surgical repair? I think in this room we have experts from major institutions and there are many institutions that are lower volume where neonatologists are very involved with the care and switching to an early repair if you're only putting one or two children on ECMO per year for CDH is a challenge and you need a whole buy. So Dr. Lee asks, how do you get this buy in? What kind of protocols you use and how do you ease this transition? Well, I think you show a lot of data and then you really build the team. So we have anesthesiologists who do our repairs on ECMO. You need to get buy in from the neonatologist who's running the pump to be with you in the operating room so they can help you manage those levels at the same time. And you get people to agree to operate on weekends sometimes because if you use Bival, you you don't have to wait for the circuit to kind of equilibrate. It it's very fast. You can operate after 8 hours of putting them on Bival, as long as your levels are stable, which happens really soon. And it's a much easier surgical repair. There's very little edema. It's very similar to doing a repair off ECMO. There are groups that actually perform risk stratification after initiating ECMO. If the baby is high risk, they proceed with earlier repair, whereas if the baby is lower risk, they attempt to wean off ECMO before performing the repair. The problem is you can't be 100% certain which babies will end up with a late repair because they can't come off ECMO and that's really the worst time to operate. This is one of the papers that really popularized this. These are all the advantages. You get good lung growth. The cannular position thing is really important. Left-sided heart disease is a big contributor to overall cardiac function. You can't predict which babies can come off without repair reliably. And you're in a much better position to come off ECMO if you need to, urgently. Out of the 90 centers that contribute to the CDH study group, almost 80% of centers are doing early repair on ECMO and it's pretty impressive. The data has shifted just over the last three years. In summary, CDH repair can be safely performed on ECMO with minimal to no bleeding complications when meticulous operative techniques are used. Early repair offers physiological benefits with the optimal window often between 8 to 24 hours. Bival is a safe anticoagulant for CDH repair on ECMO, and a smaller consistent surgical team can enhance outcomes. Thank you for watching this video. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.