Protocol changes improve CDH survival rates at Cincinnati Children's Hospital

The protocol changes initially focused on delivery room and ECMO utilization, then ventilator management, then went system by system through EEN, cardiac, and neuro.

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).

Under the old protocol, if CDH babies were on ECMO, repair time was variable—sometimes early, sometimes during the ECMO course, sometimes after ECMO.

The new protocol repairs all ECMO kids within the first 12 to 24 hours of going on ECMO.

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.

Dr. Kingma's philosophy is that if you protect the lungs, all the rest will fall in line and improve.

The new respiratory protocol never goes above a peak pressure of 22.

The new respiratory protocol has a very standardized escalation and weaning protocol followed almost 100% of the time.

From a cardiovascular standpoint, the old approach was to play it by ear; now every baby gets started on hydrocortisone for blood pressure support.

There is now a standardized protocol for which pressors are used.

INO is only started if there's evidence of a need.

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.

Under the new nutrition protocol, CDH babies are not fed until they can feed by mouth; prior to that, they're on TPN.

Now every baby gets started on a sedation drip automatically to capture them early.

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.

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.

Survival increased from around 70% to around 80% when Cincinnati Children's started implementing these protocol changes.

Time on mechanical ventilation dropped from a median of 19 days to a median of 9 days, almost a 50% decline.

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.

There are lots of problems that CDH babies have that need to be improved beyond survival, time on the ventilator, and length of stay.