Mechanical Ventilation for children with Lung Disease ALI, ARDS, and Hypoxemic Respiratory Failure How should I manage these patients in the OR? Roby Khemani MD MsCI USC Keck School of Medicine Childrens Hospital Los Angeles Case Presentation • year old male with Leukemia with respiratory failure from Adenovirus pneumonia • days into ICU course develops acute upper GI bleed • Several attempts at endoscopic control of bleeding unsuccessful • Has received units of PRBCs over past 24 hours and still having ongoing losses • Surgical team wishes to take child to OR for exploratory laparatomy to control bleeding Current Support • Conventional Mechanical Ventilation – SIMV Pressure Control + Pressure Support • Rate 20; Peak Inspiratory Pressure 32; PEEP 12; FiO2 0.6 • Last ABG; 7.28/62/60/+3 • Lung Disease Severity Indicators – PaO2/FiO2 Ratio : 100 – Oxygenation Index (MAP *FiO2/PaO2) *100 = 19 • Fentanyl, Midazolam, Octreotide Infusions • No inotropes or Vasopressors Questions? • How I identify who is at high risk for worsening lung injury or poor outcome? • What type of ventilator management strategy should I employ for this patient in the operating room? • Any other adjuvant therapies/management I should be considering when managing this patient interoperatively Acute Lung Injury; Definitions  American-European Consensus (1994)  Acute Onset  Bilateral infiltrates on Chest Radiograph  PaO2/FiO2 ratio