TABLE 7.
Synthesis of the Second Pediatric Acute Lung Injury Consensus Conference Clinical Recommendations and Good Practice Statements Related to Nonpulmonary Management
| Topic | Recommendation | Good Practice Statement |
|---|---|---|
| Diagnosis | ||
| Screening and monitoring | Use of electronic algorithms to help identify PARDS (10.1) | Policy statement: Healthcare organizations support for developing, implementing, and using electronic tools (10.3) |
| Risk stratification | Measure dead space to tidal volume ratio and/or end-tidal alveolar dead-space fraction (2.1), beside oxygenation-based stratification | Monitor Fio2, pulse oximeter oxygen saturation, Pao2, mean airway pressure, positive end-expiratory pressure (6.3.1) |
| Use of chest imaging (6.5.1) | ||
| Hemodynamic monitoring | Monitor to assess impact of MV on RV/LV (6.6.1) | |
| Arterial line for blood pressure and arterial blood gas in severe PARDS (6.6.4) | ||
| Perform cardiac ultrasound in severe PARDS or suspected RV/LV dysfunction (6.6.3) | ||
| ECMO | ||
| Failing response to treatment | Consider transfer to ECMO center (8.1.5) | |
| Evaluation | When lung protective strategies fail, and reversible cause. No strict criteria (8.1.1) | Structured evaluation by expert team (8.1.2) |
| Serial evaluations (8.1.3) | Education and competencies for ECMO clinicians (PS 8.2.1) | |
| Report data to Extracorporeal Life Support Organization (or equivalent) for benchmarking (PS 8.2.2) | ||
| Support type | Use of venovenous ECMO (8.1.4) | |
| Blood gas targets | Avoid hyperoxia (8.3.1a) | |
| Slow changes in Paco2 (8.3.1b) | ||
| MV | General lung protective strategy (8.3.2) | |
| Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility | ||
| Approach | Nonpharmacological multicomponent approaches (5.2.2; 5.7.1) | |
| Assessment | Use of scales (5.1.1) | |
| Daily assessment of activity and mobility goals (5.7.2) | ||
| Rehabilitation evaluation by 72 hr (5.7.3) | ||
| Daily assessment for delirium (5.2.1) | ||
| If treated ≥ 5 d assess for iatrogenic withdrawal syndrome (5.1.4) | ||
| Sedation | Titrate drugs for minimal, yet effective dose (5.1.2) | |
| Monitor and wean with goal-directed protocol (5.1.3) | ||
| NMBA | Use of NMBA, if protective ventilation is not achieved with sedation alone (5.3.1) | Monitor and titrate to goal-established (5.3.2) |
| Fluids | Optimize while preventing overload (5.5) | Monitor cumulative fluid balance (6.6.2) |
| Nutrition | Early start (< 72 hr) EN (5.4.1) | Nutrition plan (5.4.2) |
| Protein ≥ 1.5 g/kg/d (5.4.4) | EN monitoring with goal-directed protocol (5.4.3) | |
| Blood | No transfusion of pRBC for hemoglobin concentration ≥ 7 g/dL (5.6.2) | Use of pRBC for hemoglobin concentration < 5 g/dL (5.6.1) |
ECMO = extracorporeal membrane oxygenation, EN = enteral nutrition, LV = left ventricle, MV = mechanical ventilation, NMBA = neuromuscular blocking agent, PARDS = pediatric acute respiratory distress syndrome, pRBCs = packed RBCs, PS = policy statements, RV = right ventricle.
The corresponding definition statement numbers are indicated in parentheses.