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Fluid Management

Increased extravascular lung water has been associated with poor outcomes in adults with ARDS [31]. Furthermore, the NHLBI Fluid and Catheter Treatment Trial (FACTT) demonstrated decreased duration of mechanical ventilation, ICU length of stay and improved oxygenation with a conservative fluid strategy (i.e. CVP < 4 mmHg or pulmonary artery occlusion pressure < 8 mmHg) compared to a liberal fluid strategy (i.e. CVP 10-14 mmHg or PAOP 14-18 mmHg) in adults with acute lung injury in whom underlying shock had been reversed [139]. Such trials are lacking in PARDS. Observational prospective and retrospectively collected data have suggested though that increasing fluid balance in children with acute lung injury is associated with worse outcomes, including worsening of oxygenation, prolonged duration of mechanical ventilation and increased mortality, persisting after adjusting for severity of illness [51, 121, 143]. One study of 27 children with PARDS reported significantly lower extravascular lung water at baseline in survivors as compared to non-survivors [96]. This extravascular lung water was correlated with fluid overload, suggesting the need for restrictive fluid management.

As it cannot be ruled out that fluid balance is a proxy for greater severity of illness, the optimal fluid management in PARDS needs to be established. As such, there is no paediatric data related to the best choice of fluid for PARDS or the timing of using continuous renal replacement therapy (CRRT) to reduce fluid overload in PARDS. Greater fluid overload at the initiation of CRRT, after adjusting for illness severity, has been associated with increased mortality in critically ill children [61, 134]. Disappointingly, there is limited data reporting on the best method to determine adequate intravascular status in patients with PARDS in order to prevent fluid overload [89].

Transfusion

Red blood cell (RBC) transfusions are very common in critically ill children, despite the fact that a large randomised study confirmed an equivalent effect of a restrictive transfusion strategy (i.e. only transfusing when the haemoglobin is < 7.0 g/dL) compared to a liberal transfusion strategy in haemodynamically stable patients [87]. This observation also held true for patients with respiratory failure, including PARDS. However, there have been no RCTs evaluating RBC transfusion thresholds specifically focusing on PARDS.

 
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