PLACE LABEL HERE
NITRIC OXIDE, INHALED (iNO)
INFANT < 34 EGA PROTOCOL
The following orders will be implemented by Respiratory Therapists per physician order of this protocol 7506-11-09-12.
Orders with a “q” are indicator choices and are NOT implemented unless checked. Initial bottom of each page.
1. Eligibility criteria (Patient meets ALL criteria listed below):
q EGA < 34 weeks
q Diagnosis of Persistent Pulmonary Hypertension of the Newborn (PPHN)
and/or
q Diagnosis of severe Hypoxic Respiratory Failure (HRF) in an infant on mechanical ventilation as evidenced by an oxygenation index (OI) ≥ 25 in 2 arterial blood gas samples obtained within 30 minutes of each other or a single OI ≥ 25 and the infant’s oxygen saturation by pulse oximetry (SpO2) is less than 75% and is rapidly decreasing.
q The infant’s blood pressure has been adequately supported
q The infant is not anemic
q Radiographic evidence of a significant pneumothorax or other air leak phenomena has been attended to
q Echocardiogram to exclude congenital heart disease, if not previously done (this is not mandatory before therapy is initiated but is necessary for the continuation of therapy beyond 8 hrs)
2. Physician or Neonatal Nurse Practitioner (NNP) has obtain an informed consent from the parent prior to the use of iNO in all infants < 34 weeks.
3. Administration by Neonatal Respiratory Therapists:
Inhaled Nitric Oxide (iNO): start dosage off at 20 parts per million for the first 2 hrs.
· Keep PaO2 40-60 or SpO2 85-95%.
· Draw blood gas (preferably arterial) at 15 to 30 minutes after initiating and obtain baseline MetHb level.
· Accept pH 7.25-7.35
· Accept PCO2 40 to 50
· After baseline blood gas is obtained repeat in 1 hr and then run blood gases q 4 hrs and prn (discuss frequency with Physician/NNP).
· Repeat MetHb at 24 hrs and then at 72 hrs
· Wean FiO2 by 5-10% each time for Pa02 >60 or SpO2 persistently (15 mins or longer) > 95% post-ductally
4. Wean iNO at ≥ 2 hrs when a positive clinical response has been determined to have occurred. A positive clinical response is considered as anyone of the following in < 2 hrs:
· Increase in PaO2 of ≥ 20 mmHg
· Decrease of O.I. by 20%
· Sustained increase in post-ductal SpO2 > 95%
Weaning criteria:
· If Fi02 is < 0.6 and PaO2 is > 60 or post-ductal SpO2 > 95%, wean the ventilator per Respiratory Care Plan
· Decrease iNO to 10ppm and increase Fi02 by 5-10% weaning when SpO2 is stable.
· If the infant fails weaning, take iNO flow back to 20 ppm and wean to 15 ppm when the PaO2 and/or SpO2 is/are back to baseline.
· Continue to wean by 2-5 ppm until iNO is down to 5 ppm then if patient is stable, wean by 1 ppm until it is discontinued.
· If infant does not tolerate weaning or discontinuation, then restart at 5 ppm higher than the previous flow at which he/she failed.
· Continue weaning iNO for the next 24 hrs as long as the patient continues to maintain a positive clinical response and is stable.
Copy to pharmacy Order writer’s initials ______
*3-32768* FORM 3-32768 INITIATED 04/2014 Page 1 of 2
PLACE LABEL HERE
NITRIC OXIDE, INHALED (iNO)
INFANT < 34 EGA PROTOCOL
The following orders will be implemented by Respiratory Therapists per physician order of this protocol (policy # ).
Orders with a “q” are indicator choices and are NOT implemented unless checked. Initial bottom of each page.
5. Draw blood gases q 4 hrs and prn (discuss frequency with Physician/NNP) during the period the patient is on iNO. The patient’s FiO2 and/or iNO can be weaned between blood gases by post-ductal SpO2 persistently (15 minutes or longer) greater than 95%.
6. After 7 days of iNO therapy, discuss with Physician/NNP about alternate therapy and discontinue iNO therapy for MetHb 4% or NO2 > 5 ppm (notify the physician or NNP when this occurs).
7. DC iNO therapy if none of the following occurs:
· after 2 hours on initiation the PaO2 has increased by 20 mmHg.
· after 2 hours of initiation the O.I. has decreased by 20%.
· after 2 hours of initiation the post-ductal SpO2 is persistently ≥ 95%.
· at any time outside the 2 hr period of initiation if the infant’s post ductal saturation is not ≥ 80% for more than 2 hrs on 20 ppm and all other factors that determine oxygen delivery have been optimized.
8. Document Procedure on Respiratory Care flow sheet with vent checks.
a. iNO flow rate
b. NO2 inline levels
c. NO2 levels in ambient air every eight hours
______
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-32768 INITIATED 04/2014 Page 2 of 2