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Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient
Desmond Bohn The Department of Critical Care Medicine, The Hospital for Sick Children, Toronto
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Paediatric BMT and Critical Care
Sepsis Respiratory Airway obstruction Pneumonia/pneumonitis Pulmonary haemorrhage Interstitial pneumonitis ARDS Neurological Seizures Intracranial haemorrhage
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Paediatric BMT and Critical Care
Hepatic failure Venocclusive disease GVHD Renal failure Drug nephrotoxicity Cardiac failure Drug toxicity
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ICU outcomes in paediatric BMT patients
Diaz de Heredia C Bone Marrow Transplantation 1999; 24: 31/176 patients admitted to ICU post BMT - 18% n BMT BMT allogenic autologous ARF Septic shock 5 3 2 Neurological disorders 5 5 Heart failure 2 2 Others 4 2 2 26 patients underwent mechanical ventilation - survival 46%
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BAL in ventilated and non-ventilated in children after BMT
Ben-Ari J Bone Marrow Transplantation 2001; 27:191 non-ventilated ventilated
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Diffuse alveolar hemorrhage in pediatric BMT patients
Heggen J Pediatrics 2002; 109:965
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Diffuse alveolar hemorrhage in pediatric BMT patients
Heggen J Pediatrics 2002; 109:965
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Diffuse alveolar haemorrhage in BMT patients
Presents with cough and tachypneoa No underlying infective aetiology Pulmonary haemorrhage on BAL Usually occurs following engraftment Incidence % Characterised by thrombocytopoenia but normal coagulation Treated with high dose steroids and PEEP High mortality
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Markers of oxygenation defect
PaO2/FiO2 < 200 = ARDS Oxygenation Index MAP x FiO2 x 100 >15 = severe ARDS PaO2
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Lung recruitment in ARDS
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Goals: 1. Avoid Overdistention 2. Avoid Underinflation
3. Keep the lung open 4. Reduce FiO2 Froese AB, Crit Care Med 1997; 25:906
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Responses of baboons to prolonged hyperoxia
Fracica PJ J Appl Physiol 1991; 71:2352 normal lethal toxicity - FiO2 1.0 for 110 h alveolus PMN interstitial matrix PMN alveolus PMN interstitial matrix alveolus alveolus
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Pulmonary oxygen toxicity
Davis WB N Engl J Med 1983; 309:878 FiO2 0.9 for 17 hrs in healthy humans
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THE ACUTE RESPIRATORY DISTRESS SYNDROME NETWORK
VOLUME MAY 4, NUMBER 18 VENTILATION WITH LOWER TIDAL VOLUMES AS COMPARED WITH TRADITIONAL TIDAL VOLUMES FOR ACUTE LUNG INJURY AND THE ACUTE RESPIRATORY DISTRESS SYNDROME THE ACUTE RESPIRATORY DISTRESS SYNDROME NETWORK
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Surfactant proteins B & C
Surfactant in ARDS Willson D Crit Care Med 1999; 27:188 Infasurf Surfactant proteins B & C 42 children with ARDS
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Nitric oxide in ARDS Dobyns EL J Pediatr 1999;134:406 Control iNO 60
10 50 5 * 4 hours 12 hrs 40 * Change in P/F ratio from baseline 30 Change in OI from baseline -5 20 -10 * * 10 -15 -20 4 hours 12 hrs
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Nitric oxide in ARDS n=40 n=177 n=30 Michael JR
Am J Respir Crit Care Med 1999; 157:1372 Dellinger RP Crit Care Med 1998; 26:15 Troncy E Am J Respir Crit Care Med 1997; 157:1483
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Nitric oxide in ARDS 5 RCTs in adults
3 case series and 2 RCTs in pediatrics Physiological endpoints - improved oxygenation & reduction in PAP % of patients are “responders” No data suggests any improvement in outcome
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Steroids in ARDS Meduri GU JAMA 1998; 280:159 MODS Score Outcome
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Effect of prone position on survival in ARDS
Gattinoni L N Engl J Med 2001; 345:568
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Effect of prone position on survival in ARDS
Gattinoni L N Engl J Med 2001; 345:568
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RCT of prone vs supine ventilation in ARDS/ALI
Gattinoni L N Engl J Med 2001; 345:568 304 patients randomised in 3 yrs Mortality (%) Supine Prone Intention to treat End of study 25 21 ICU discharge Prone vs supine protocol End of study 27 22 ICU discharge *Patients with P/F <
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HFOV in Paediatric ARDS
Arnold J. Crit Care Med 1994; 22:1530 CMV HFOV No. of patients 29 29 Duration of CMV 80 ± ± 240 FiO ± ± 0.15 PEEP 21 ± 5 22 ± 3 OI 29 ± ± 10
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MAP >5 cmH2O above CMV setting (25-30 cmH2O)
Algorithm for the use of HFOV MAP >5 cmH2O above CMV setting (25-30 cmH2O) High FiO2 (>0.8) Maintain MAP for mins Attempt to decrease FiO2 yes no Decrease FiO2 in increments to <0.6 Increase the MAP in increments of 2 cmH2O Response usually at cmH20
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Oxygen delivery/consumption
DO2 = Q x CaO2 . As DO2 decreases VO2 maintained by increased extraction Oxygen extraction ratio = (CaO2 - CvO2)/CaO2 VO2 = Q x (CaO2 - CvO2) .
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Published outcomes in paediatric BMT patients admitted to ICU
Number of Number Survival BMTs ventilated ventilated patients Lamas (23%) Hagen (37%) Jacobe (41%) Keenan (16%) Rossi (44%) Warwick (40%) Diaz de Heredia (46%) Hayes (15%) Nichols (9%) Bojko (12%) Todd (11%)
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AHRF: an integrated approach
Pressure control ventilation (PIP <35 cmH2O) Negative fluid balance (furosimide) HFOV Prone position ventilation iNO ppm ?ECMO
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Prognosis of paediatric BMT patients requiring ventilation
Rossi R Crit Care Med 1999; 27:1181 n = 41
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Prognosis of paediatric BMT patients requiring PPV
Rossi R Crit Care Med 1999; 27:1181
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Ventilation in paediatric BMT patients
Hagen SA Pediatric Crit Care Med 2003; 4:206
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Ventilation in paediatric BMT patients
Hagen SA Pediatric Crit Care Med 2003; 4:206
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Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient
Acute respiratory failure requiring PPV in the BMT patient is associated with a high mortality Therapy should be focused on minimising ventilation induced lung injury Ventilation strategies that improve oxygenation may not improve O2 delivery The development of hepato-renal failure is almost universally fatal
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