To Use Nitric Oxide or Flolan

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

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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.

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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)

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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.

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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.

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What does the set up look like in the ICU?
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There is an IV Pump Connected to the
Ventilator????
Click on the picture to start the movie.
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• Attach the Miniheart to the Neptune heater using
  2 blue cuff connectors, a valved tee-piece, and a
  multi adapter.

Use the blender to match the patients set FiO2
and run the flowmeter at 2-3 lpm.
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Set the Neptune to invasive ventilation and the
temperature as would normally be set. Due to the
Miniheart nebs placement, try turning the concha
water around to allow for easier access.
Click on picture to start movie.
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Were Adding Extra FlowWhat Do We Do About the
Volume Change?
Use the calculations to determine the volume to
set on the ventilator based on the flow rate,
ideal body weight, etc.
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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 pharmacys 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.

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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 patients 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
• - Patients vitals before and 10 minutes after
  concentration change

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How Do I Chart This in Clinivision???
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The drop down box offers the choices of dosing
available. Choose which one the patient is
currently on.
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The Concentration/IV Bag Has Been ChangedNow
What?
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Can We Bag the Patient on Flolan?
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What Happens if the Patient is Extubated?
Dont forget to maintain nebulizer at 15 mL at
all times with IV pump.