Characterization of inhaled nitric oxide utilization in a pediatric intensive care unit

Learning Objectives: Pulmonary hypertension (PH) is a major cause of morbidity and mortality in critically ill children. Inhaled nitric oxide (iNO) is an FDA approved medication but only for the indication of persistent pulmonary hypertension of the newborn. However, its use has become widespread in children with other forms of PH and its usage needs to be better characterized. Methods: We conducted a retrospective chart review of iNO use in a single children's hospital. Cases were identified by a respiratory therapy database. Electronic health records from 1/2015-12/2015 were examined for details of hospitalization. Exemption from informed consent was granted by the institutional IRB. Results: iNO was administered to 83 patients encompassing 3428 hospital- days. Mean± SD, age was 6.2 ± 7 y. 64% were male. 13 pt (16%) died. Length of stay (LOS) was 42 ± 49 d. Pediatric Index of Mortality 3 was 11 ± 3. Length of iNO therapy was 170 ± 173 h; duration of iNO wean to off was 84 ± 89 h. 54 pts had congenital heart disease (CHD). CHD pts (vs non-CHD) trended towards longer LOS (44 ± 48 d vs 39 ± 50 d, p=NS). Length of iNO therapy was greater (190 ± 181 h vs 135 ± 153 h, p=.05). And duration of iNO wean was longer (95 ± 98 h vs 60 ± 63 h, p <.05). Pulmonary Vascular Disease Specialists (PVDS) were involved in the care of 23 pts. Involvement of a PVDS (vs no PVDS care) resulted in shorter LOS (18 ± 14 d vs 50 ± 53 d, p<.05). Length of iNO therapy and duration of iNO wean were decreased by PVDS involvement (129 ± 136 h vs 188 ± 182 h, p<.05 and 56 ± 51 h vs 91 ± 96 h, p <.05, respectively). Patients under care of PVDS were more frequently transitioned to other pulmonary vasodilators (65% vs 15%, p<.05).Conclusions: This study identified several patterns pertaining to iNO usage. Involvement of a PVDS is associated with decreased duration of therapy, time to wean off iNO and hospital stay. A possible explanation of these findings is the PVDS is more likely to transition to other pulmonary vasodilator therapy. Increasingly iNO therapy is used for off-label indications with considerable use in children with CHD. More research is warranted to optimize use of iNO.