2007 OPEN FORUM Abstracts
ESTABLISHING AND IMPLEMENTING INHALED NITRIC OXIDE (iNO) GUIDELINES IN ADULT INTENSIVE CARE UNITS: IMPACT ON DURATION OF iNO THERAPY.
B. Taylor1, S. E. Mann1, A. Bilenki1, T. Dorman1, J. Ulatowski1, P. Mendez-Tellez1
INTRODUCTION: Inhaled Nitric Oxide (iNO) is a selective pulmonary vasodilator used for the treatment of hypoxemic respiratory failure and pulmonary hypertension. iNO has been approved by the U.S. Food and Drug Administration solely for treatment of term and near-term neonates with hypoxemic respiratory failure. Off-label, iNO is extensively used for treatment of Acute Respiratory Distress Syndrome (ARDS), lung and cardiac transplantations, congenital and acquired heart disease, chronic pulmonary hypertension (PAH), and sickle cell disease. The high cost of iNO administration and lack of evidence demonstrating survival benefit led our institution to evaluate use and create guidelines to discontinue use as soon as clinically possible in Adult Intensive Care Units (AICUs).
Methods: In January 2006, “Adult Nitric Oxide Use and Weaning Guidelines” were implemented in six different AICUs. Guideline goals were: (1) establish criteria for initiation of iNO; (2) establish criteria to assess the response to iNO; and (3) assure appropriate use. Decisions on indication, initiation, and discontinuing of iNO therapy were guided by clinicians familiar with the guidelines. iNO use was recorded by the Respiratory Therapist caring for these patients.
Results: One-hundred twenty-four AICU patients received iNO in 2005 and 176 in 2006. After Guidelines implementation, duration of iNO therapy decreased from a median interquartile range (IQR) of 30.4 (16.5-64.5) hours per patient in 2005 to 27.1 (15 â 69.75) hours per patient in 2006. By contrast, in both Pediatric (PICU) and Neonatal (NICU) ICUs, where iNO use is not regulated, iNO consumption remains high. In PICU, the median (IQR) duration of iNO therapy was 56.8 (22 -96.25) vs. 59.8 (23.5-101) hours per patient, whereas in NICU, the median (IQR) iNO therapy duration was 136.5 (32.2-222) vs. 115 (34-189.4) hours per patient, in 2005 and 2006 respectively.
Conclusion: Despite increasing off-label indications, implementing iNO guidelines with clear criteria for initiation, monitoring, and discontinuing use, may decrease consumption, variability, and costs associated with iNO therapy compared to non-regulated use.