ARF BMT Bohn

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<ul><li>1.Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn The Department of Critical Care Medicine, The Hospital for Sick Children, Toronto</li></ul> <p>2. Paediatric BMT and Critical Care Sepsis Respiratory Airway obstruction Pneumonia/pneumonitis Pulmonary haemorrhage Interstitial pneumonitis ARDS Neurological Seizures Intracranial haemorrhage 3. Hepatic failure Venocclusive disease GVHD Renal failure Drug nephrotoxicity Cardiac failure Drug toxicity Paediatric BMT and Critical Care 4. ICU outcomes in paediatric BMT patients 31/176 patients admitted to ICU post BMT - 18% ARF 15 10 5 Septic shock 5 3 2 Neurological disorders 5 5 Heart failure 2 2 Others 4 2 2 n BMT BMT allogenic autologous Diaz de Heredia CBone Marrow Transplantation 1999; 24:163-168 26 patients underwent mechanical ventilation - survival 46% 5. BAL in ventilated and non-ventilated in children after BMT Ben-Ari JBone Marrow Transplantation2001; 27:191 non-ventilated ventilated 6. Diffuse alveolar hemorrhage in pediatric BMT patients Heggen JPediatrics2002; 109:965 7. Diffuse alveolar hemorrhage in pediatric BMT patients Heggen JPediatrics2002; 109:965 8. Diffuse alveolar haemorrhage in BMT patients </p> <ul><li>Presents with cough and tachypneoa </li></ul> <ul><li>No underlying infective aetiology </li></ul> <ul><li>Pulmonary haemorrhage on BAL </li></ul> <ul><li>Usually occurs following engraftment </li></ul> <ul><li>Incidence 5 - 10% </li></ul> <ul><li>Characterised by thrombocytopoenia but normal coagulation </li></ul> <ul><li>Treated with high dose steroids and PEEP </li></ul> <ul><li>High mortality </li></ul> <p>9. 10. OxygenationIndex PaO 2 /FiO 2 MAP x FiO 2x 100 PaO 2 &lt; 200 = ARDS &gt;15 = severe ARDS Markers of oxygenation defect 11. Lung recruitment in ARDS 12. Froese AB, Crit Care Med 1997; 25:906 Goals: 1. Avoid Overdistention 2. Avoid Underinflation 3. Keep the lung open 4. Reduce FiO 2 13. Responses of baboons to prolonged hyperoxia Fracica PJJ Appl Physiol1991; 71:2352interstitial matrix alveolus PMN PMN PMN interstitial matrixalveolus normal lethal toxicity - FiO 21.0 for 110 h alveolus alveolus 14. Pulmonary oxygen toxicity Davis WBN Engl J Med1983; 309:878 FiO 20.9 for 17 hrs in healthy humans 15. VENTILATION WITH LOWER TIDAL VOLUMES AS COMPARED WITH TRADITIONAL TIDAL VOLUMES FOR ACUTE LUNG INJURY AND THE ACUTE RESPIRATORY DISTRESS SYNDROMETHE ACUTE RESPIRATORY DISTRESS SYNDROME NETWORK VOLUME 342MAY 4, 2000NUMBER 18 16. 17. Infasurf Surfactant proteins B &amp; C 42 children with ARDS Willson DCrit Care Med1999; 27:188 Surfactant in ARDS 18. Nitric oxide in ARDS Dobyns ELJ Pediatr 1999;134:406 60 50 40 30 20 10 0 10 5 0 -5 -10 -20 -15 4 hours 12 hrs Change in P/F ratio from baseline Change in OI from baseline * * * * 4 hours 12 hrs Control iNO 19. Nitric oxide in ARDS Dellinger RPCrit Care Med1998; 26:15 Michael JRAm J Respir Crit Care Med 1999; 157:1372 n=177 n=40 n=30 Troncy E Am J Respir Crit Care Med 1997; 157:1483 20. Nitric oxide in ARDS 5 RCTs in adults 3 case series and 2 RCTs in pediatrics Physiological endpoints - improved oxygenation &amp; reduction in PAP40 - 60% of patients are responders No data suggests any improvement in outcome 21. Steroids in ARDS MODS Score Outcome Meduri GUJAMA 1998; 280:159 22. 23. Effect of prone position on survival in ARDS Gattinoni LN Engl J Med2001;345:568 24. Effect of prone position on survival in ARDS Gattinoni LN Engl J Med2001;345:568 25. 304 patients randomised in 3 yrs Intention to treat End of study 25 21 ICU discharge 48 50.7 Prone vs supine protocol End of study 27 22 ICU discharge 49.3 52.2 *Patients with P/F 5 cmH 2 O above CMV setting (25-30 cmH 2 O) High FiO 2(&gt;0.8) Maintain MAP for 10-15 mins Attempt to decrease FiO 2 yes Decrease FiO 2in increments to</p>