To Use Nitric Oxide or Flolan ® ?…That Is the Question???

1. To Use Nitric Oxide or Flolan®?…That Is the Question???

2. What is Flolan® you ask??? • Flolan®, or epoprotenol, is an synthetic prostacyclin use to treat pulmonary hypertension. It can be used to manage acute right heart dysfunction, hypoxemia, and pulmonary arterial hypertension. • The half-life is 2-3 minutes and its duration of action lasts 15-25 minutes.

3. Are there similarities between Nitric Oxide and Epoprostenol??? • Comparable beneficial effects of pulmonary vasodilation without affecting systemic systems: - Reduced pulmonary artery pressure - Reduced pulmonary vascular resistance - Reduced transpulmonary gradient (Chest 1998; 114; 780-786) • Improved oxgenation. • Lack of data showing increased survival for ARDS patients.

4. Are there differences between epoprostenol and nitric oxide??? • PRICE!!! ($135/hour vs ~$220/day) • Epoprostenol lacks the toxic effects/metabolites of nitric oxide and therefore does not need a complicated delivery system. • Epoprostenol has been shown to cause a slight increase in cardiac output. • Epoprostenol can inhibit platelet aggregation. • Epoprostenol does not bind with hemoglobin (no increase in methemoglobin)

5. Can anyone get this wonder drug? • Limited to Ross Heart Hospital/Open Heart Service and lung transplant patients in SICU. • Can only be ordered by qualified physicians taking care of these patients.

6. Setup • Will be initiated by anesthesia in the OR. • Will be bagged over by anesthesia to the ICU on epoprostenol via a Miniheart neb. • RT will have the vent set up with a heated wire circuit and the IV pump/blender ready in the ICU.

7. 2 Filters to Exhalation Port Heated Wire Circuit Ventilator Miniheart Nebulizer Neptune heater IV Pump running at 8 mL/hr O2 source 2-3 lpm Epoprostenol Dilution

8. The IV pump will be labeled for RT use only and will only be handled by respiratory therapy. Note: 2 filters connected to the exhalation port on vent. Make sure to use only a heated wire circuit. What does the set up look like in the ICU?

9. There is an IV Pump Connected to the Ventilator???? ****Click on the picture to start the movie.****

10. On/Off switch Attach the Miniheart to the Neptune heater using 2 blue cuff connectors, a valved tee-piece, and a multi adapter. Use the blender to match the patient’s set FiO2 and run the flowmeter at 2-3 lpm.

11. Set the Neptune to invasive ventilation and the temperature as would normally be set. Due to the Miniheart neb’s placement, try turning the concha water around to allow for easier access. ***Click on picture to start movie.****

12. Go to pharmacy website on Onesource to find the calculator. We’re Adding Extra Flow…What Do We Do About the Volume Change? Use the calculations to determine the volume to set on the ventilator based on the flow rate, ideal body weight, etc.

13. How do I set up and run the system? • Set the system up using the preceding diagram. • Begin with and maintain 15 mL of fluid in the Miniheart nebulizer at all times. • Run the blender flowmeter at 2-3 lpm only. • Consult pharmacy’s website under Drug Dosing/Calculators for “Inhaled Epoprostenol Calculator” to determine correction to ventilator volumes. • Monitor autopeep and resistance. • CHANGE THE FILTERS Q4 HOURS AND PRN. • Check on the Miniheart Q1hour to ensure proper filling and nebulization. • Green sheet pharmacy at least 1 hour before needing replacement medication.

14. How does the patient come off epoprostenol? Wean wean wean! • Wean as soon as hemodynamics are stable (hopefully within first 2 hours of arriving on unit). • At the start of each trial and concentration change attempt to discontinue medication. • Wean concentration every 4-6 hours as tolerated. • The medication will be titrated in half each time epoprosterol is weaned. • Weaning failure criteria: - Increase in PAP or PVR by 15% - Decline in cardiac index by 10% - Decline in PaO2/FiO2 ratio by 10% - Clinical decline in patient’s status • If discontinuing medication record the following: - Baseline hemodynamics and ABG - Q15 minutes hemodynamic parameters times 2 - Decision to discontinue or restart epoprosterol after 20-30 minutes • If weaning medication record the following: - Baseline hemodynamic parameters and ABG - Draw an ABG 1 hour after change - Q15 minute hemodynamic parameter time 3 - Change in concentration level on MAR and Cinivision - Patient’s vitals before and 10 minutes after concentration change

15. Remember: filters need to be changed at least once every four hours. How Do I Chart This in Clinivision???

16. The drop down box offers the choices of dosing available. Choose which one the patient is currently on.

17. Choose the condition for which the patient is using Flolan

18. If you wean the concentration keep the old IV bag in case the patient fails.

19. If there is an IV medication bag change enter the name of a second therapist as a witness into Clinision. This is required for a high risk medicine. The Concentration/IV Bag Has Been Changed…Now What?

20. Can We Bag the Patient on Flolan?

21. What Happens if the Patient is Extubated? ***Don’t forget to maintain nebulizer at 15 mL at all times with IV pump.***