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.
- Kelly, L., Porta N., Goodman D., and Carroll, C. (2002). Inhaled prostacyclin for term infants with persistent pulmonary hypertension refractory to inhaled nitric oxide. The Journal of Pediatrics, 141, 830-32.
- Hill, L., & Pearl, R. (1999). Combined inhaled nitric oxide and inhaled prostacyclin during experimental chronic pulmonary hypertension. Journal of American Psychological Society, 1160-4.
- Lowson, S. (2002). Inhaled alternatives to nitric oxide. Anesthesiology, 96(6), 1504-1513.