ventilation/non-dialytic therapies in the paediatric bmt patient desmond bohn the department of...
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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
RespiratoryAirway obstructionPneumonia/pneumonitisPulmonary haemorrhageInterstitial pneumonitisARDS
NeurologicalSeizuresIntracranial haemorrhage
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Hepatic failureVenocclusive diseaseGVHD
Renal failureDrug nephrotoxicity
Cardiac failureDrug toxicity
Paediatric BMT and Critical Care
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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 BMTallogenic autologous
Diaz de Heredia C Bone Marrow Transplantation 1999; 24:163-168
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 5 - 10%
•Characterised by thrombocytopoenia but normal coagulation
•Treated with high dose steroids and PEEP
•High mortality
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Oxygenation Index
PaO2/FiO2
MAP x FiO2 x 100
PaO2
< 200 = ARDS
>15 = severe ARDS
Markers of oxygenation defect
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Lung recruitment in ARDS
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Froese AB, Crit Care Med 1997; 25:906Froese AB, Crit Care Med 1997; 25:906
Goals:Goals:1. Avoid Overdistention1. Avoid Overdistention2. Avoid Underinflation2. Avoid Underinflation3. Keep the lung open3. Keep the lung open4. Reduce FiO4. Reduce FiO22
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Responses of baboons to prolonged hyperoxiaFracica PJ J Appl Physiol 1991; 71:2352
interstitial matrix
alveolus
PMN
PMN
PMNinterstitial matrix
alveolus
normal lethal toxicity - FiO2 1.0 for 110 h
alveolus
alveolus
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Pulmonary oxygen toxicityDavis WB N Engl J Med 1983; 309:878
FiO2 0.9 for 17 hrs in healthy humans
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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
VOLUME 342 MAY 4, 2000 NUMBER 18
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Ventilation with low versus traditional tidalvolumes in ARDS
ARDS Network N Engl J Med 2000; 342:1301
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Infasurf
Surfactant proteins B & C
42 children with ARDS
Willson D Crit Care Med 1999; 27:188
Surfactant in ARDS
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Nitric oxide in ARDSDobyns EL J Pediatr 1999;134:406
60
50
40
30
20
10
0
10
5
0
-5
-10
-20
-15
4 hours 12 hrs
Cha
nge
in P
/F r
atio
fro
m b
asel
ine
Cha
nge
in O
I fr
om b
asel
ine
ControliNO
*
**
*
4 hours 12 hrs
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Nitric oxide in ARDS
Dellinger RP Crit Care Med 1998; 26:15
Michael JR Am J Respir Crit Care Med1999; 157:1372
n=177n=40 n=30
Troncy EAm J Respir Crit Care Med1997; 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
40 - 60% of patients are “responders”
No data suggests any improvement in outcome
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Steroids in ARDS
MODS Score Outcome
Meduri GU JAMA 1998; 280:159
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Effect of prone position on survival in ARDSGattinoni 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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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 <88 40 20
Mortality (%) Supine Prone
RCT of prone vs supine ventilation in ARDS/ALIGattinoni L N Engl J Med 2001; 345:568
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HFOV in Paediatric ARDS
CMV HFOV
No. of patients 29 29
Duration of CMV 80 ± 81 143 ± 240
FiO2 0.83 ± 0.18 0.84 ± 0.15
PEEP 21 ± 5 22 ± 3
OI 29 ± 14 26 ± 10
Arnold J. Crit Care Med 1994; 22:1530
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Algorithm for the use of HFOV
MAP >5 cmH2O above CMV setting (25-30 cmH2O)High FiO2 (>0.8)
Maintain MAP for 10-15 minsAttempt to decrease FiO2
yes
Decrease FiO2 in increments to <0.6
no
Increase the MAP in increments of 2 cmH2O
Response usually at 30-35 cmH20
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Oxygen extraction ratio = (CaO2 - CvO2)/CaO2
DO2 = Q x CaO2
Oxygen delivery/consumption
VO2 = Q x (CaO2 - CvO2).
As DO2 decreases VO2 maintained by increased extraction
.
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Lamas 1991-2000 151 34 5(23%)
Hagen 1990-99 - 86 32(37%)
Jacobe 1994-98 210 36 15 (41%)
Keenan 1983-96 1080 121 19(16%)
Rossi 1986-95 355 39 17(44%)
Warwick 1976-92 869 196 79(40%)
Diaz de Heredia 1991-95 176 26 12(46%)
Hayes 1987-97 367 33 5(15%)
Nichols 1978-88 23 2(9%)
Bojko 1986-93 43 5(12%)
Todd 1973-90 54 6(11%)
Number of Number Survival BMTs ventilated ventilated patients
Published outcomes in paediatric BMT patients admitted to ICU
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AHRF: an integrated approach
Pressure control ventilation (PIP <35 cmH2O)
Prone position ventilation
iNO 5 -20 ppm
?ECMO
HFOV
Negative fluid balance (furosimide)
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Prognosis of paediatric BMT patients requiring ventilationRossi 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 patientsHagen SA Pediatric Crit Care Med 2003; 4:206
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Ventilation in paediatric BMT patientsHagen 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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