2004 OPEN FORUM Abstracts
TREATMENT OF A NEWBORN WITH NEBULIZED PROSTACYCLIN AND INHALED NITRIC OXIDE: A CASE STUDY.
Angela D. Hedgman AS, RRT-NPS, Susan Ferry AS,
RRT, CCRC, Anne Ades, MD. The Children’s Hospital of
Philadelphia, Philadelphia, PA.
A 2-day-old 39 wk.gestation, 3500g newborn female with Pulmonary Hypertension (PHTN), right heart failure, and grade II-III left IVH was transferred to our facility for treatment. Mother was a 25-year old G1P0 with multiple genetic illnesses complicating the pregnancy. Baby was born via stat C-section due to worsening fetal heart tones with Apgar score 0, 0, 4. CPR was initiated with two rounds of epinephrine upon delivery. Upon arrival, we initiated mechanical ventilation in pressure control (PCV) with inhaled nitric oxide (iNO) at 40 ppm and 1.0 oxygen. The initial arterial blood gas revealed refractory hypoxemia with hypercarbia (PaCO2 90 mmHG). HFOVwas attempted twice unsuccessfully due to hemodynamic instability, therefore the patient was returned to PCV with iNO. The patient was evaluated for ECMO and considered a poor candidate in light of IVH. Cardiology consult with the team led to the decision to trial nebulized prostacyclin.1, 2 Prostacyclin was dosed at 10.5ng/min for a dose of 3.5ng/kg/min.3 The continuous infusion ran at 4.2 mL/hr via medication infusion syringe pump, nebulized by the miniHeart nebulizer at 2L/m. After 2 hours with no significant response, prostacyclin therapy was discontinued. With all other modalities exhausted, the patient was placed on VA ECMO. After 4 days of ECMO, the head ultrasound showed expanding IVH. A family meeting resulted in parental decision to withdrawal support.
Discussion: Many factors contributed to the severity of this patient’s illness. A multidisciplinary team rapidly formed to optimize care for this challenging medical case. The patient had severe cardiac compromise: right heart failure resulting in PVR 1.3 times greater than SVR, and significant PDA requiring pharmacologic support. Neurologic insult included grade II-III left IVH, which progressed to the thalamus and third ventricle. Multiple medical interventions were initiated with no response. Little data exists to describe the use of inhaled prostacyclin therapy in infants. This experience has inspired the team to identify potential opportunities to trial this therapy. Further investigation of nebulized prostacyclin therapy may prove beneficial in the treatment of pulmonary hypertension of the newborn.
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