Riak Stratification And Follow Up Of Infants With Congenital Diaphragmatic Hernia

Objective:This study aims to identify risk factors of survival,establish new predictive models,and assess the growth and development of infants with congenital diaphragmatic hernia（CDH）.Methods:A retrospective analysis of 225 patients with CDH treated in the Pediatric Surgery Department of Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine from 2001 to 2018 were performed.Data collected included:gestational age at diagnosis,the presence of hernia sac,size of the defect,outcomes,body weights,heights,and so on.We made follow up through outpatient,telephone,and questionnaires.Results:（1）Logistic regression analysis demonstrated that birth weight,Apgar score at 1 minute,side of the defect,site of liver and Pa CO₂were predictive of mortality for CDH（all P<0.05）.Then the new predictive equation was created using those factors:Probability of survival=e ^Logit（P）/(1+e ^Logit（P）),where Logit（P）=0.001（birth weight）+0.540（Apgar score at 1 minute）+1.599（side of hernia）-0.049（Pa CO₂）+2.642（site of liver）-10.397.Area under the receiver operator curve for survival for the new predictive equation was 0.912,which was better than other predictive equations.（2）Compared with nonsurvivors,survivors had later gestational age at diagnosis in prenatally diagnosed CDH.Survival rate at discharge increased significantly when gestational age at diagnosis increased（p=0.0002）.Area under the receiver operator curve for survival for gestational age at diagnosis was 0.736,O/E LHR 0.741 and liver herniation 0.758.Then the new predictive equation about probability of survival in prenatally diagnosed CDH was created using those three factors:POSP（probability of survival in prenatally diagnosed CDH）=e ^x/（1+e ^x）,where X=0.134（gestational age at diagnosis）+0.060（O/E LHR）-2.399（site of liver）-4.571.Area under the receiver operator curve for survival for the POSP was 0.884（95%CI:0.832-0.937,P<0.0001）.Compared with those diagnosed with CDH before 25 gestational weeks,patients diagnosed with CDH after 25 gestational weeks had a higher value of O/E LHR,smaller size of diaphragmatic defect,less need of patch repair,and higher survival rate.（3）Compared with patients without hernia sac,those patients with hernia sac had significantly higher birth weight,higher Apgar score at 1 and 5 minutes,higher O/E LHR,higher p H,lower Pa CO₂,lower need of patch repair during surgery,shorter duration of mechanical ventilation,shorter length of hospital stay and higher survival rate（all P<0.05）.（4）Eighty-seven children received follow-up.Nine patients（10.3%）were found with growth retardation（GR）.Compared with patients without GR,those patients with GR had the significantly lower birth weight,longer duration of mechanical ventilation,longer length of hospital stay,and higher rate of pulmonary morbidities（all P<0.05）.Conclusions:（1）Birth weight,Apgar score at 1 minute,side of the defect,site of liver and Pa CO₂on admission arterial blood gas analysis are the independent predictors of the mortality of CDH.The new predictive model based on these factors could be useful in clinical assessment.（2）Gestational age at diagnosis is an independent predictor of CDH prognosis.Patients with later gestational age at diagnosis had a smaller size of the diaphragmatic defect and the better development lungs.（3）The existence of the hernia sac indeed indicated a more favorable presentation and a better prognosis for infants with CDH.（4）GR was present in some CDH survivors.The risk factors of GR are birth weight,duration of mechanical ventilation and the pulmonary morbidities.