inocrit

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Nitric Protocol (June 2000)
Brigham & Women's Hospital, Boston, MA
Inhaled Nitric Oxide (INO)
Protocol for Newborns with Hypoxemic Respiratory Failure

INCLUSION CRITERIA
EXCLUSION CRITERIA
COMMUNICATIONS
CALCULATIONS
APPLICATION

Inclusion Criteria
    1. infant requiring assisted ventilation for hypoxic respiratory failure
    2. Indwelling arterial line
    3. GA >= 34 weeks
    4. diagnosis of one of the following:
        a. PPHN
        b. RDS
        c. Aspiration syndrome (meconium, blood or amnionic fluid)
        d. pneumonia
        e. sepsis
        f. suspected pulmonary hypoplasia
    5. An OI >25 on two ABGs at least 30 minutes apart.
    6. Lung recruitment and other PPHN therapy optimized prior to initiating iNO (e.g.. surfactant therapy, alkalosis, hemodynamic support)

Exclusion Criteria:
    1. Decision not to provide full treatment
    2. Known structural heart disease (excluding PDA and atrial level shunts)
    4. Jet ventilation (any other HiFi is acceptable \

Communication
Process for Obtaining Nitric & InoVent

24 hour NO order/support line

1-877-566-9466 / 1-877-KNOW-INO

Eric Eichenwald must approve each NO pt.

1 SET UP - There should always be one complete set up ready for use

a. ino vent/one d cylinder/injector mod.
b. ino cal kit/backup cal gas
c. emergency gas - 2 ds and 1 88 of NO
d. emergency injector module
e. one way valve for oscillator use

2 TRIAL - call above # as soon as infant goes on NO. This keeps INO Ther. aware of our status. (within 20 min of going on NO) Trial may last 30-60 minutes.

a. State, "infant on NO trial" , exact time
b. give name/ hospital/fax# 617-732-7421 - Barbara Schultz
c. give your call back #
d. where to deliver backup vent (CWN6)
e. 'd' cylinder bar code #
f. obtain "ino order #" for that infant

3 INITIATION - Call above # (again) once it is determined that infant is a 'responder' & will remain on NO therapy for 2 reasons:

a. Backup vent/gas and full '88' will be delivered via Mediq PRN (arranged by INO Therapeutics customer service) 2 hours weekdays, 3 hours weekends
b. Billing begins - $3000/day/infant , maximum $12,000/month/infant

4 Once backup equipment arrives, replace 'D' cylinder on patient's vent with '88' cylinder so that gas supply is sufficient for length of therapy. Keep 'D' cyl on this vent for emergency use only (turned off and disconnected).
5 CONTINUATION - When '88' reaches 500 psi, call above # for another '88'. Please give INO customer support person the INO order.
6 DISCONTINUATION - When therapy is discontinued, call above # ASAP to cease billing at time therapy was stopped. You will be asked:

a. final '88' bar code #
b. INO order #
c. exact discontinuation time

7 Patient billing: please be very diligent about this!

a. Keep a record of each 24 hr. infant is on NO on your report sheet.
b. Inform David & Michael so that they may enter code #218021 for each 24 hrs. the infant is on therapy.

8 RECORD KEEPING: It is critical to document:

a. exact equipment delivered/ince cylinder
b. exact trial start time
c. exact initiation start time
d. exact discontinuation time

e. each 24 hour period infant is on NO

Calculations

To figure O.I., enter data in the boxes above, & then click "calculate". Note: your browser must support Javascript, or this will not work.

O.I. = (MAP X FiO2 X 100)/PaO2

For instance, if your MAP is 11, FiO2 is 1.00 and PaO2 is 44, your O.I. is 25 and you must call the Medical Director.

Therapy Recommendations

Start INO at 20 ppm* A 20% improvement in PaO2 with SpO2 >90% should occur within 15-30 min., or SpO2 lability should decrease in that time.

RARELY , a dose of 40 ppm may be needed if no improvement in oxygenation is seen at 20 ppm.

Decrease INO to 10 ppm if PaO2 >60 mmHg on FiO2 < 60 and SpO2 >90%; If SpO2 decreases by >5% and SpO2 <90%, return to 20 ppm.
Decrease INO in 10-15 min intervals from 10 to 5 to 1 ppm if PaO2 > 60 mmHg on FiO2 <60 and SpO2 >90%; If SpO2 decreases by >5% and SpO2 <90%, stop weaning and maintain on previous INO dose.
If PaO2 > 60 mm Hg on FiO2 <40 and SpO2 > 90; increase FiO2 to 60 and discontinue INO
Wean FiO2 over 1 hour
Restarting INO at 1 ppm may be considered if FiO2 > 60, SpO2 is labile and ventilator settings increase after 1 hour off INO.
Attempt to discontinue INO 4-8 hours later
Obtain MetHb the morning after INO was started. If MetHb >1% obtain MetHb QD otherwise, MetHb does not need to be obtained unless clinical circumstances change. Treat with Vitamin C if MetHb >5%
The course of INO therapy for newborns with hypoxemic respiratory failure is generally 3 to 4 days.

MAP FiO2 PaO2 O.I. =

O.I. = (MAP X FiO2 X 100)/PaO2

MAP FiO2 PaO2
O.I. =