Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC)

Purpose: Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO.

Methods: Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC).

Results: Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5-15 CDH repairs were reported annually per institution; 26-50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III-IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4-5 weeks.

Conclusions: Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions.

Level of evidence: V (expert opinion).