Congenital Diaphragmatic Hernia : Optimising outcomes through a consistent care bundle approach

St Michael9s NICU (StMH) provides pre and postoperative care for all newborns with an ante/postnatal diagnosis of congenital diaphragmatic hernia (CDH) in South-West England. A consistent care bundle is followed for antenatal diagnoses: delivery at StMH, sedation and muscle relaxation at birth, elective intubation, high frequency oscillatory ventilation (HFOV), inotropic support, pulmonary vasodilators and delayed surgery. ECMO is only considered for reversible pulmonary hypertension when conventional management fails. Objectives To review clinical management and evaluate survival/morbidity in infants with CDH over a 12 year period. Methods A retrospective case note review of all CDH cases managed at StMH(1998–2010). A review of the South-West Congenital Anomaly Register. Results 79 cases were identified, including 45 identified antenatally. 16 (20%) had additional major malformations/genetic syndromes; 2 lethal. Overall survival was 60/79(76%). The anomaly register identified 4 additional CDH deaths in local hospitals for this population. 100% of infants delivered at StMH received the full care bundle (91% received HFOV). No cases received ECMO. 10/79(12.6%) had pneumothoraces. 13/60(21%) of survivors required additional oxygen at 28 days of life and 3/60(5%) were discharged on oxygen. Domiciliary oxygen was not required for any infant delivered at StMH (where the complete care bundle was followed). Conclusion Our survival rate compares favourably with recent large published series and is not significantly biased by ‘hidden mortality’ in the South-West Region. Pneumothorax and chronic lung disease rates are significantly lower than recently published studies using HFOV. Our consistent approach delivers favourable survival rates with a low pulmonary morbidity burden in survivors.