Continuous Multimodal Monitoring of Neonates with a Congenital Diaphragmatic Hernia

Abstract

Introduction: Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm characterised by herniation of abdominal organs into the thoracic cavity during prenatal development. This herniation is usually accompanied by pulmonary hypertension (PH) and cardiac dysfunction (CD). Although several parameters are known to predict the clinical outcomes in CDH, most of these parameters do not monitor the degree of PH and CD and cannot be continuously measured. This retrospective observational trial aimed to monitor the degree of PH and CD in CDH using the oxygen saturation index (OSI), peripheral oxygen saturation (SpO2), heart rate (HR), heart rate variability (HRV), arterial blood pressure (ABP) and derivatives of these parameters.

Methods: the study population consisted of neonates admitted to the paediatric intensive care unit between 2019 and 2022 for treatment of CDH. The degree of PH and CD was determined for each cardiac ultrasound (CUS) performed. A 15-minute window of vital parameters, mechanical ventilator, and electrocardiogram data before each CUS was extracted to calculate the predictors. After preprocessing the data and meeting the statistical assumptions, both univariable and multivariable logistic mixed effects models were fitted and validated.

Results: in total, 136 CUS of 57 patients were included in the study. Of the univariable linear mixed-effects models, the median values of HR, pulse pressure (PP), preductal SpO2, dSpO2, OSI and the interquartile range (IQR) of HR were statistically significant predictors of PH. For the prediction of CD, this was the case for the power of HRV in the very low frequency band (HRV-VLF) and for the median values of HR, mean arterial pressure (MAP) and OSI. The multivariable model for the prediction of PH contained the median values of of dSpO2, HR, PP and OSI and the standard deviation of the normal-to-normal beat intervals (SDNN). The multivariable model for the prediction of CD included the median of dSpO2, HRV-VLF, SDNN and the IQR of the systolic arterial pressure (SAP) as predictors.

Conclusions: the most promising predictors are the median values of preductal SpO2, dSpO2 and OSI for the prediction of PH. For the prediction of CD, HRV-VLF and the median values of HR, OSI and dSpO2 were the most promising predictors. Despite limited predictive performance of the regression models, this study contributes to the improvement of monitoring of patients with CDH, which can lead to more timely interventions and eventually improved outcomes within this patient population.