Intraoperative Administration of Nitric Oxide

Dietrich, Cassie C.; Tobias, Joseph D.

doi:10.1177/0885066603251615

Cited by 7 publications

(6 citation statements)

References 15 publications

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“…Additional attempts of OLV should be combined with strategies to improve ventilation-perfusion mismatching including elimination of dependent lung atelectasis with PEEP and recruitment maneuvers, 3,4 application of CPAP or low flow oxygen insufflations to the nondependent (surgical) lung, 5 elimination of volatile anesthetic agents, 6,7 and in specific circumstances the addition of inhaled nitric oxide (iNO) to the intraoperative gas regimen. 8,9 As demonstrated by our case, these methods are not universally effective nor are they without drawbacks. Increasing PEEP to the dependent lung has the potential to paradoxically worsen hypoxemia by increasing shunt fraction through the nondependent lung via its effects on pulmonary vascular resistance.…”

Section: Discussionmentioning

confidence: 81%

Phenylephrine to Treat Hypoxemia during One-Lung Ventilation in a Pediatric Patient

Schloss

Martín

Beebe

et al. 2013

THORAC CARDIOV SURG Reports

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To improve surgical visualization and facilitate the procedure, one-lung ventilation (OLV) is frequently used during thoracic surgery. Although generally well tolerated, the ventilation–perfusion inequality induced by OLV may lead to a decrease in oxygenation and, at times, hypoxemia. Effective treatment algorithms and strategies are necessary for the treatment of hypoxemia during OLV to ensure that the technique can be continued without interruption and allow for completion of the surgical procedure. Treatment strategies may include applying positive end expiratory pressure to the nonoperative lung, continuous positive airway pressure or low flow oxygen insufflation to the operative lung, decreasing anesthetic agents that interfere with hypoxic pulmonary vasoconstriction (HPV), or switching to total intravenous anesthesia. Although less commonly employed, α-adrenergic agonists may also improve oxygenation during OLV by augmenting HPV. We present a 12-year-old girl who developed hypoxemia during OLV, which was not corrected by the usual maneuvers. Hypoxemia was successfully treated with a phenylephrine infusion. The potential applications of α-adrenergic agonists such as phenylephrine in the treatment of hypoxemia during OLV are discussed and its physiologic basis reviewed.

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Section: Discussionmentioning

confidence: 81%

Phenylephrine to Treat Hypoxemia during One-Lung Ventilation in a Pediatric Patient

Schloss

Martín

Beebe

et al. 2013

THORAC CARDIOV SURG Reports

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“…NO was used to treat deleterious physiologic changes including increases MPAP that occurred after clamping of the right pulmonary artery to allow for placement of the BT shunt without the need for CPB. 7 NO was also effective in treating hypoxemia following OLV. Our current cohort was rounded out by 3 patients who received NO prior to weaning from ECMO.…”

Section: Discussionmentioning

confidence: 92%

“…In 4 patients, NO therapy was used solely intraoperatively to treat pulmonary hypertension and/or hypoxemia related to specific surgical or anesthetic procedures. 7 In these 4 patients, NO was started and stopped intraoperatively to treat deleterious physiologic changes (increase in MPAP or hypoxemia). In 2 of the patients, the cardiorespiratory deterioration resulted from the clamping the right pulmonary artery (PA) to allow for placement of a Blalock-Taussig (BT) shunt for palliation of cyanotic congenital heart disease (CHD).…”

Section: Resultsmentioning

confidence: 99%

“…In the other 2 patients, hypoxemia during 1-lung ventilation (OLV). 7 In these 4 cases, NO administration allowed for clamping of the right PA for performance of a BT shunt without the need for cardiopulmonary bypass or performance of OLV, which without the use of NO had formerly resulted in deleterious physiologic effects (hypoxemia, hypotension, or pulmonary hypertension). In 3 other patients, NO was started in the ICU to facilitate weaning from ECMO in patients with either CHD or hypoxemic respiratory failure.…”

Section: Resultsmentioning

confidence: 99%

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A 5-Year Survey of Nitric Oxide Use in a Pediatric Intensive Care Unit

Ryan

Tobias²

2007

American Journal of Therapeutics

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The authors retrospectively reviewed their experience with nitric oxide (NO) in a pediatric ICU. Given its cost ($3000/d), ongoing evaluations are required to ensure its effective use and avoid inappropriate applications. NO use included 4 categories: (1) hypoxemic respiratory failure, (2) pulmonary hypertension following surgery for congenital heart disease (CHD), (3) intraoperatively for surgical procedures such BT shunt placement or 1-lung ventilation, and (4) during ECMO. In the 19 patients with respiratory failure, NO resulted in an increase in oxygenation in 15 of 19 patients (Pao2/Fio2 ratio increased from 83 +/- 60 mm Hg to 188 +/- 105 mm Hg, P = 0.0007). In 4 patients, NO did not improve oxygenation. The 15 patients that responded to NO survived, whereas the 4 patients who did not respond died (P = 0.0003). NO was used to treat pulmonary hypertension in 19 patients following cardiopulmonary bypass (CPB) and surgery for CHD. In 13 of 19 patients, a high pulmonary artery (PA) pressure was documented by direct measurement with a needle inserted into the PA while the chest was open (n = 9) or a postoperative transthoracic PA catheter (n = 4). NO resulted in a decrease in the PA pressure in 9 of 13 patients (37 +/- 5 mm Hg to 21 +/- 3 mm Hg, P < 0.0001). In the one patient in whom NO did not lower intraoperative PA pressure, it was not possible to wean from CPB. For the 10 patients in whom NO was started in the PICU, 4 had PA catheters in place and documented elevated PA pressure. NO resulted in a significant decrease in the PA pressure in only 1 of these 4 patients. The survival of responders was 9 of 9 versus 1 of 4 for nonresponders (P = 0.014). No significant adverse effects requiring therapy other than decreasing the inhaled NO concentration were noted. Potential interventions and practices to limit the unwarranted use of this costly agent are discussed.

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“…If these measures fail in adequate control of PVR, the addition of inhaled NO may be considered. 17 NO has been shown to have additive effects when used in combination with milrinone in Fontan physiology. 18 There has been a progressive move toward early tracheal extubation during the postoperative period in Fontan patients as the resumption of pain free, spontaneous, negative pressure ventilation improves PBF and CO, thereby enhancing the hemodynamic performance following the Fontan procedure.…”

Section: Discussionmentioning

confidence: 99%

Perioperative Management of the Fontan Operation in an Adolescent With a Single Lung

et al. 2012

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The Fontan operation is performed to correct complex cardiac malformations characterized by single ventricle physiology. Following the procedure, the systemic venous blood fl ows directly into the lungs without passing through the single ventricle. Consequently, the Fontan circulation requires passive venous fl ow to the lungs, making it imperative for the pulmonary vascular resistance to be kept low in order to maintain adequate pulmonary blood fl ow and cardiac output. Given that the pulmonary circulation is important for a successful Fontan physiology, it would be intuitive that a single lung Fontan operation would do poorly because of the major loss in pulmonary vascular bed and the subsequent increase in pulmonary vascular resistance. The authors present a 14-year-old adolescent who was born with tricuspid atresia, pulmonary atresia, and right ventricular hypoplasia who underwent a successful Fontan operation into a single right lung, the left pulmonary artery being hypoplastic and disconnected from the right pulmonary artery. The authors describe the perioperative anesthetic management of the single lung Fontan operation and further discuss the perioperative treatment of elevated pulmonary vascular resistance.

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Intraoperative Administration of Nitric Oxide

Cited by 7 publications

References 15 publications

Phenylephrine to Treat Hypoxemia during One-Lung Ventilation in a Pediatric Patient

Phenylephrine to Treat Hypoxemia during One-Lung Ventilation in a Pediatric Patient

A 5-Year Survey of Nitric Oxide Use in a Pediatric Intensive Care Unit

Perioperative Management of the Fontan Operation in an Adolescent With a Single Lung

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