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

To Use Nitric
Oxide or
Flolan®?…That Is
the Question???
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.
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.
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)
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.
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.
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
What does the set up look like in
the ICU?
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.
There is an IV Pump Connected
to the Ventilator????
****Click on the picture to start the movie.****
On/Off
switch
Attach the Miniheart to the
Neptune heater using 2 blue
cuff connectors, a valved teepiece, and a multi adapter.
Use the blender to match the
patient’s set FiO2 and run the
flowmeter at 2-3 lpm.
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.****
We’re Adding Extra Flow…What Do
We Do About the Volume Change?
Use the calculations Go to
to determine the pharmacy
volume to set on the website on
ventilator based onOnesource to
the flow rate, ideal find the
body weight, etc. calculator.
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.
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
How Do I Chart This in Clinivision???
Remember:
filters need
to be
changed at
least once
every four
hours.
The drop down box offers the choices of dosing available. Choose
which one the patient is currently on.
Choose
the
condition
for which
the
patient is
using
Flolan
If you wean
the
concentration
keep the old
IV bag in case
the patient
fails.
The Concentration/IV Bag Has Been
Changed…Now What?
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.
Can We Bag the Patient on Flolan?
What Happens if the Patient is Extubated?
***Don’t forget to maintain nebulizer at 15 mL at all times with IV pump.***