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BACKGROUND: The objective of this study was to determine whether the implementation of an inhaled nitric oxide protocol (INO) in a pediatric ICU (PICU) would reduce cost associated with its use without negatively affecting patient outcomes. METHODS: This is a retrospective cohort study of 76 subjects who required INO therapy in the PICU during the study period. A nitric oxide setup and weaning protocol was implemented in the PICU. The medical records of subjects who had received INO 18 months after protocol implementation, as well as the medical records of subjects who had received INO in the 18 months before protocol implementation, were reviewed. Length of time on INO, cost of INO per subject, mortality, stay, and ventilator hours were recorded. RESULTS: There were 38 subjects in the pre-protocol group and 38 subjects in the post-protocol group. There was a statistically significant decrease in the median per subject cost of INO between the pre-and post-protocol groups (P < .01). There was no statistically significant difference in the median duration of INO use (P ‫؍‬ .06), median PICU (P ‫؍‬ .42) or hospital (P ‫؍‬ .58) stay, median duration of mechanical ventilation (P ‫؍‬ .79) or percent mortality (P ‫؍‬ .28) between the 2 groups. CONCLUSIONS: Implementation of an INO setup and weaning protocol in a PICU reduces the cost associated with its use without a statistically significant difference in mortality. In an era of increased awareness regarding healthcare spending, implementation of evidence-based protocols can provide a way to ensure the judicious utilization of medical resources.

The neonate has an increased susceptibility to infection, in part owing to an inability to produce antibody to thymus-independent antigens such as bacterial polysaccharides (PS). This poor response to PS antigens is likely owing to multiple factors. Neonatal B cells are of an immature phenotype, as evidenced by cell-surface marker characteristics and increased susceptibility to tolerance induction. The spleen of the neonate has a different cellular composition, which is most prominent in the marginal zone. Neonatal accessory cells such as macrophages and dendritic cells (DCs) appear to produce less stimulatory cytokines and an overabundance of inhibitory cytokines. This review examines the current data supporting the role of B cells and accessory cells in the neonatal unresponsiveness to PS antigens.

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