Post-Extubation Inhaled Nitric Oxide Therapy via High-Flow Nasal Cannula After Fontan Procedure

Abstract

In 2014, our hospital introduced inhaled nitric oxide (iNO) therapy combined with high-flow nasal cannula (HFNC) oxygen therapy after extubation following the Fontan procedure in patients with unstable hemodynamics. We report the benefits of HFNC-iNO therapy in these patients. This was a single-center, retrospective review of 38 patients who underwent the Fontan procedure between January 2010 and June 2016, and required iNO therapy before extubation. The patients were divided into two groups: patients in Epoch 1 (n = 24) were treated between January 2010 and December 2013, receiving only iNO therapy; patients in Epoch 2 (n = 14) were treated between January 2014 and June 2016, receiving iNO therapy and additional HFNC-iNO therapy after extubation. There were no significant differences between Epoch 1 and 2 regarding preoperative cardiac function, age at surgery, body weight, initial diagnosis (hypoplastic left heart syndrome, 4 vs. 2; total anomalous pulmonary venous return, 5 vs. 4; heterotaxy, 7 vs. 8), intraoperative fluid balance, or central venous pressure upon admission to the intensive care unit. Epoch 2 had a significantly shorter duration of postoperative intubation [7.2 (3.7-49) vs. 3.5 (3.0-4.6) hours, p = 0.033], pleural drainage [23 (13-34) vs. 9.5 (8.3-18) days, p = 0.007], and postoperative hospitalization [36 (29-49) vs. 27 (22-36) days, p = 0.017]. Two patients in Epoch 1 (8.3%), but none in Epoch 2, required re-intubation. Our results suggest that HFNC-iNO therapy reduces the duration of postoperative intubation, pleural drainage, and hospitalization.

Nitric Oxide Inhalationtherapy for Pulmonary Hypertension After Mitral Valve Surgery Does Not Shorten the Intubation Period and Length of Stay in the Intensive Care Unit: A Retrospective Study

“…Optimal NO therapeutic strategies should be reconsidered to establish an appropriate treatment for PH after mitral valve surgery that will shorten intubation time and length of ICU stay. In the eld of pediatric cardiac surgery, Tominaga et al reported that the duration of postoperative intubation and the length of hospital stay were shorter in patients who received NO inhalation therapy with a high-ow nasal cannula after extubation than in those who did not [14]. The report describes NO inhalation therapy based on the Fontan procedure, in which the use of NO via a high-ow nasal cannula after extubation shortened the tracheal intubation time in half.…”

Perioperative and long-term management of Fontan patients

“…34 Further investigation is warranted into the use of iNO with high-flow nasal oxygen therapy, as evidence shows this may reduce the duration of postoperative intubation, pleural draining, and LOS. 35 Sildenafil, a PDE-5 inhibitor and Ambrisentan, a hepatically metabolised endothelin receptor antagonist, can also be used postoperatively to dilate the pulmonary vasculature. Small trials have shown improved haemodynamics, lower use of inotropes, and reduced intubation times with Sildenafil use post-Fontan procedure.…”

A systematic review of the evidence supporting post-operative medication use in congenital heart disease

“…[108][109][110][113][114][115][116] Several smaller studies showed shorter hospital stays with inhaled nitric oxide, although a large retrospective cohort found that inhaled nitric oxide was associated with an increased length of hospital stay. 111,112 Inhaled nitric oxide in combination with other medications may have an additive effect. 117,118 Iloprost is appealing because it can be administered via inhalation; however, studies have shown unfavourable haemodynamics and pulmonary congestion.…”