SESSION TYPE: Pharmacology in the ICU Posters
PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM
PURPOSE: Refractory hypoxemia in severe ARDS continues to present a challenge with few options for treatment. Inhaled Nitric Oxide (iNO) has been used in the patients with pulmonary hypertension and ARDS / ALI. In pulmonary hypertension, inhaled vasodilators offer selective pulmonary vasodilatation with fewer systemic side effects. In ARDS, iNO, and more recently inhaled aerosolized prostacyclin (iAP), have been shown to improve oxygenation, reduce pulmonary vascular pressures. Controlled trials have not shown efficacy of iNO in adults with ARDS. We describe our experience with iAP in patients with refractory hypoxia or severe pulmonary hypertension.
METHODS: Medical direction developed a policy and procedure for the use of iAP, specifically epoprostenol After studying delivery techniques, a BodyGuard 575 continuous infusion pump (CMEAmerica, Golden, CO) and the Aerogen Solo (Aerogen, Galway, Ireland) were chosen to deliver the iAP. The choice of inhaled pulmonary vasodilator was at the discretion of treating physician.
RESULTS: Over 7 months, 25 patients were started on iAP. 2 of the 25 were transitioned from iNO to inhaled Epoprostenol.The indications of iAP included refractory hypoxemia (n=19, 76%) and severe pulmonary hypertension (n=6, 24%). Delivery of iAP was through the ventilator circuit in most patients (n=18, 72%) but we were also able to deliver the drug through a face mask or high flow cannula system (n=7, 28%). The drug was considered efficacious in 84% of patients with severe hypoxemia based on improved arterial oxygen tension. Among patients with severe pulmonary hypertension, 2 patients had an adequate reduction in pulmonary artery pressure and / or increase in cardiac index based on PA catheter readings. There were no adverse effects and rescue iNO was not instituted in any patient. 2386 hours of iAP were delivered translating into a cost savings of $257,968(average savings of $10,318 per patient) for comparable use of iNO.
CONCLUSIONS: We found inhaled epoprostenol to be a cost effective alternative to iNO.
CLINICAL IMPLICATIONS: iAP offers a reasonable alternative to iNO at a much reduced cost.
DISCLOSURE: The following authors have nothing to disclose: Rory Mullin, Simon Lam, Diego Conci, Gustavo Heresi, Madhu Sasidhar
No Product/Research Disclosure InformationRespiratory Institute, Cleveland Clinic, Cleveland, OH