ECMO timing and technique for severe congenital diaphragmatic hernia in neonates

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.

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.

There are lots of benefits to VV ECMO and lots of benefits to VA ECMO.

The majority of centers still do VA ECMO primarily for CDH babies.

Both VA and VV ECMO are totally reasonable answers for this clinical scenario.

Based on prenatal imaging showing high risk for needing ECMO, the time to intervene is probably earlier rather than later.

VV cannula availability and concerns with certain VV cannulas have played a role in ECMO modality selection.

If an institution does VV ECMO but cannot cannulate because the 13 French cannula is too big, they would probably do VA instead.

Better VV cannulas are coming out, which may change the numbers of centers using VV ECMO.

Michigan's SEER protocol prenatally selected severe CDH cases and educated parents they would go on this pathway.

In the SEER protocol, ECMO was on standby in the delivery room, and babies were intubated and resuscitated within 2 hours.

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.

The two groups in the SEER protocol (ECMO versus comfort care) had equivalent survival.

Half of the patients offered comfort measures in the SEER protocol could have been survivors.

If you make the decision to choose ECMO versus comfort care beforehand using protocols like SEER, you will be wrong 50% of the time.

With good prenatal counseling and parents who are all in, ECMO should be pursued for every unilateral isolated CDH.

Cases involving genetic or cardiac syndromes are an entirely different scenario from isolated CDH and are not included in the recommendation for universal ECMO.