PURPOSE: To assess safety and clinical viability of multiple transitions to inhaled iloprost from epoprostenol.
METHODS: A 25 year-old Caucasian male with a history of primary pulmonary hypertension previously on long-term epoprostenol therapy and plagued with complications of line sepsis, was successfully transitioned to inhaled iloprost. In the initial transition, patient was admitted to ICU and pulmonary artery catheter placed. Maintenance dose of epoprostenol was 17ng/kg/min with initial PA pressures of 84/60. Baseline cardiac output was 4.7 L/min. Epoprostenol was decreased to 15 ng/kg/min immediately prior to first dose of inhaled iloprost of 2.5 mcg. Second dose of inhaled iloprost of 5 mcg was given two hours after initial dose with further decrease of epoprostenol. Iloprost was continued every two hours while awake. In first ten hours of transition, PA pressures peaked at 110/59 but decreased to baseline within the next four hours and remained stable. Epoprostenol was decreased the following morning and iloprost was continued six times daily in three hour increments. Over next three days, epoprostenol was decreased by 2 ng/kg/min daily until discontinued. PA pressure was 85/33 at time of complete transition to inhaled iloprost with cardiac output stable at 5.1 L/min. Central catheters were removed and patient was discharged.
RESULTS: Six months later this patient underwent laparoscopic cholecystectomy. Postoperatively, patient experienced respiratory failure and cardiovascular collapse. The patient was still on mechanical ventilation and epoprostenol was restarted at 8 ng/kg/min. Thirty-six hours after initiation of epoprostenol, patient was extubated, hemodynamics improved and inhaled iloprost was restarted per the previously described regimen of six daily nebulized treatments. Epoprostenol was weaned over the next four days until discontinuation.
CONCLUSION: Multiple transitions from prostacyclin infusion to inhaled iloprost, initially to avoid problems with line sepsis and then following postoperative complications, can be successfully achieved in closely monitored settings.
CLINICAL IMPLICATIONS: Multiple transitions from IV to inhaled prostacyclins appear to be associated with continued hemodynamic stability and warrant further investigation.
DISCLOSURE: Kimberly Hobbs, None.