how i use inhaled nitric oxide -ino
TRANSCRIPT
How I use inhaled nitric oxide ?
Per P. BredmoseAir Ambulance Dept, Oslo University HospitalNorwegian Air Ambulance Foundation
Director of TrainingConsultant in Prehospital and Retrieval MedicineConsultant Anaesthetist/Intensivist
SMACC Dublin 2016
@VikingOne_
No disclosures !!
Bring the doctor to the patient
Bring the emergency dept into the street
Bring the hospital to the patient
Bring iNO to the patient
The «transporters perspective»
Transferable !!!!!
Wrong place at the wrong time
With the wrong disease
iNO as a bridge
What is this....???
Endothelial derived potent short acting vasodilator in the pulmonary tree
Delivered via the respiratory tract as iNO there is no systemic effect
Traditional use«accepted use»
PPHNPersistent Pulmonary Hypertension of the Newborn
iNO = drug of choice when severe
Well established use
Being in the wrong place
Why don’t you go straight to ECMO ?
Mobile ECMO
HEMS physicianHEMS nurse/HCM
Perfusionist
Not a quick fix
ECMO is a Complex transformation
iNO
Bridge to:
RecoveryECMO
via
Transport
For me this is a tool to get the patient to a specialised centre
Rapid deployment
iNO in any vehicle
The Rationale...
Inhaled nitric oxide for acute respiratory distress syndrome and acute lung injury in adults and children: a systematic review with meta-analysis and trial sequential analysis.
Anesth Analg. 2011 Jun;112(6):1411-21
We found a statistically significant but transient improvement in oxygenation in the first 24 hours, expressed as the ratio of Po₂ to fraction of inspired oxygen (mean difference [MD] 15.91, 95% CI 8.25 to 23.56;
Our goalOur Experience
A team treating ahigh volume of patients with a particular illness isexpected to achieve good results compared with unitsthat might treat such severe respiratory failure only onceor twice per year.
CESAR trial, Lancet 2009
Why the bad reputation....
iNO appears to increase the risk of renal impairment among adults (RR 1.59, 95% CI 1.17 to 2.16)
The specials
Pulmonary Hypertensionoutside PPHN situations
Pulmonary emboli
Combination of a clot
and
Downstream vasoconstriction
Non thrombotic pulmonary vasoconstriction
Resuscitation
Cardiac arrest
In a patient with severe pulmonary hypertesion
Case time
Theatre
Postpartum atonic uterusGoes to TheatreCardiac arrest x 2 on table when maneuvering
uterus
Amniotic fluid emboli syndrome !!
ROSC
30+ yrs old woman
ICU
High dose vasopressorsAdr + NA (++++++++++)
PULM HT
High ventilator settings
Pulm HT
«Saturation is
dropping»
ROSC w iNO
Retrieved in helicopter toUniversity Hospital
iNO treatmentReduce vasopressors
Survivor
ConclusionPotent selective pulmonary vasodilator
iNO is a BRIDGE to....something
Mobile
Can bring your patient to right centre and might
prevent an ECMO run
Conclusion (short version)
iNO is underused in retrieval medicine of severe respiratory failure
iNO is a SUPERB tool for special case resuscitation
Don’t ask what sildenafil can do for you (or your partner)
Ask what iNO can do for your patient !!!
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