Have you ever worked with Nitric Oxide?

lily0004us · Aug 24, 2003

We have used Nitric Oxide in our unit for a few years. It seems to have decreased the need for ECMO in many of our PPHN patients. We initiate it at 20 ppm in patients demonstrating PPHN. These patients are already on maximum ventilatory support (Sensorimedic High-Frequency). An ABG is obtained 30 minutes after initiation and then q 1 hr. OI's (oxygenation index=MAP x fiO2/paO2) are figured with each gas. Hopefully those numbers trend downward; however, if they reach the 30's and stay there, ECMO is usually initiated. In addition to N.O., we use minimal stim precautions, sedation (no paralytic), inotropic support if indicated, and some of our attendings lean toward keeping the patient alkalotic (depends on what conference they attended recently!). If the patient responds to treatment, we begin to wean fiO2 on the vent first (very slowly, by 2% for paO2 well over 100). When we get to 60%, we begin to wean the Nitric by 5 ppm. We have a protocol left over from when it was a study drug, but weaning really depends on the attending who is present that day. Some are more aggressive than others. We also use Nitric on some of our post-op heart patients.

Like I said, I believe it has made a difference. It's ashame that it is so expensive, even more than ECMO. But if it saves a baby from all the potential complications related to ECMO (plus the carotid), I guess it's well worth it!:)

Tiki_Torch · Aug 25, 2003

Hi Lilly,

Thank you so very much for the wealth of information!!! Such a fine explanation too!!

If you don't mind, I have some other questions:

What is the average length of time a patient is receiving the NO?
Have any or your attendings used Viagra along with the NO? (I've read on the internet that some studies show promise using the two together... just wondering if the drug is in human trials with NO yet.)
How is the NO delivered? Is it "piggybacked" into the vent?

I really do appreciate your earlier response to my post Lilly and want to thank you again for sharing your information! :kiss

I agree, anything to keep the babies off of ECMO is extremely beneficial. Of course I'm thankful for ECMO when it's necessary but if something less invasive can be healing for these little ones, I say "Yippee!", even if the monitary expense is so great... hopefully this will come down over time.

Thanks again!

KRVRN, BSN, RN · Aug 25, 2003

On average, we seem to have kids on NO for a few days but sometimes we have the occasional kid that needs it for a few weeks. I'm not an RT but I believe the gas is piggybacked into the vent circuit. We've even had kids that wean off the vent before the NO and end up receiving NO via NC or NCPAP.

We haven't used Viagra but I have heard of it before. I think it's still in study trials?

Tiki_Torch · Aug 26, 2003

KRVRN,

Thank you very much for your response. I had seen, on some internet sites, NO being delivered via face mask and the mention of it being delivered via oxyhood. It's very interesting to know it can be delivered so many different ways... not only on a ventillator. It's especially interesting to know a baby can be weaned from a vent and still be receiving NO via supplemental oxygen routes. A site describing its use in adults mentioned that in ARDS cases the NO seems to be beneficial only for about 24 hours...

:idea: If anyone is interested, I found a very good website with some excellent information about the use of Neonatal NO. It includes an overview, diagrams and photos of the machines, monitoring guidelines for the nurses to use and potential complications, etc. The entire web site is excellent as well. The hospital is in New Zealand, and the address is: http://www.adhb.co.nz/newborn/NursingProtocols/NitricOxide/NOOverview.html where they show it being used with a Sensormedics High Frequency Oscillator as well as a Babylog 8000plus ventillator set up in HFOV mode.

NICU_Nurse, BSN, RN · Aug 26, 2003

Thank you for posting that link! They have teaching resources that include a very nice overview of HFOV/Resp. issues that would be beneficial for new grads/new NICU nurses! Very helpful! :)

lily0004us · Aug 26, 2003

On average, Nitric is used for a few days in our unit. As KRVRN said though, some babies require longer treatment. I have seen this more commonly with patients who have PPHN r/t congenital problems like CDH S/P repair, pulmonary hypoplasia, TAPVR S/P repair. I have also seen Viagra (with and without N.O.) used in this type of patient. I don't believe I have ever used it (Viagra) with secondary PPHN. Our physicians start with a low dose of Viagra and titrate up depending on BP stability. I don't know that I have ever seen impressive results using Viagra. That's probably because of the patient population. However, I've seen remarkable results with N.O. (again, not necessarily with the babies who have congenital problems!) It's great to see a PaO2 jump from 35 to 200 thirty minutes after starting the gas. That's not to say it might not plummet to 35 again after aggressive weaning! Respiratory Therapy piggybacks Nitric into the patient's vent circuit. There is a ambubag and a flow meter attached to the Nitric delivery system, so, if needed, we can hand-bag with Nitric inline. This is the only way I've seen it delivered in our unit. I remember when we first started using it, there was such a fuss about possible gas leak. We kept protective suits that resembled really cheap space suits on hand, just in case! That has long since disappeared! We used to monitor methemaglobins on a regular schedule. I'm not sure exactly what our policy is now, but we no longer follow them so closely.

Have a great day!

nicudaynurse · Aug 27, 2003

Are unit is about to start using NO as well. We did have a very sick micropreemie that had severe pulmonary hypertension the doc wanted to use NO, but all the policies, guidelines, etc... weren't in place yet so he was unable to use it yet. What I found very interesting is he used Thorazine and it worked believe it or not. It apparentely is a pretty potent vasodilator. Have any of you used Thorazine???