Beyond readiness: impact of preoperative risk factors on outcomes in neonates with congenital diaphragmatic hernia

Abstract Background Congenital diaphragmatic hernia (CDH) remains a life-threatening condition with high neonatal mortality. Identifying reliable preoperative prognostic indicators is essential for optimizing surgical timing and improving outcomes. Methods This retrospective observational study included all neonates diagnosed with CDH admitted to a neonatal intensive care unit without extracorporeal membrane oxygenation facilities between January 2018 and December 2023. Preoperative vasoactive-inotropic score (VIS), presence and severity of persistent pulmonary hypertension of the newborn (PPHN), and blood gas parameters were analyzed in relation to surgical readiness—defined according to the 2015 CDH EURO Consortium Consensus guidelines—and short-term survival outcomes. Results Thirty-one neonates were analyzed; PPHN was present in 83.9% and severe in 30.8%. Only 20% of surgical patients met full readiness criteria. Compared with the non-readiness group, these infants had significantly lower preoperative FiO₂ requirements (median 30% [IQR 25.5–37.5] vs. 80% [IQR 32.5–100], p = 0.028) and lactate levels (median 1.5 mmol/L [IQR 1.5–1.75] vs. 1.52 mmol/L [IQR 2.5–4.95], p = 0.002). Mortality was lower in the readiness group (20% vs. 65%), although not statistically significant ( p = 0.096). VIS, presence/severity of PPHN, and other blood gas parameters were not significantly associated with survival (all p > 0.05). Conclusion In neonates with CDH, fulfilling surgical readiness criteria—particularly lower preoperative FiO₂ and lactate levels—appears to be associated with improved survival, whereas VIS, PPHN, and blood gas parameters alone may not reliably predict outcomes. These findings highlight the importance of comprehensive preoperative optimization over reliance on single physiological markers.