1 / 21

Inhaled Epoprostenol

Inhaled Epoprostenol. Considerations for Use in Ventilated Patients Shari McKeown, Practice Leader Respiratory Services VA. Aliases. Naturally occurring prostaglandin Epoprostenol sodium Flolan Prostacyclin PGI 2 PGX. …the point….

christmas
Download Presentation

Inhaled Epoprostenol

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Inhaled Epoprostenol Considerations for Use in Ventilated Patients Shari McKeown, Practice Leader Respiratory Services VA

  2. Aliases • Naturally occurring prostaglandin • Epoprostenol sodium • Flolan • Prostacyclin • PGI2 • PGX

  3. …the point… • Inhaled vasodilators can reduce PAP and redistribute pulm blood flow to ventilated lung regions with little systemic effect1,2,3,4,5 • Della Rocca G., Coccia C, Pompei L. et al. Inhaled aerosolized prostacyclin and pulmonary hypertension during anesthesia for lung transplantation. 2001 Transplant Proc, 33, 1634-1636. • Lowson SM. Inhaled Alternatives to Nitric Oxide. Anesthesiology 2002;96(6):1504-1513 • Mikhail G, Gibbs S, Richardson G, Wright G, Khaghani A, Banner N, Yacoub M. An evaluation of nebulized prostacyclin in patients with primary and secondary pulmonary hypertension. Eur Heart J 1997, 18;1499-1504. • Olschewski H. et al. Inhaled prostacycin and iloprost in severe pulmonary hypertension secondary to lung fibrosis. Respiratory and Critical Care Medicine 160(2) 1999:600-607. • Walmrath D, Schneider T, Schermuly R, et al. Direct comparison of inhaled nitric oxide and aerosolized prostacyclin in acute respiratory distress syndrome. Am J Respir Crit Care Med 1996; 153:991-996.

  4. Pharmacologic Actions • Selective vasodilation of pulmonary vascular beds1 • Decreased PVR, PAP • Inhibition of platelet aggregation • (but no evidence of platelet dysfunction or bleeding noted clinically) • Increased arterial oxygenation • Improved V/Q matching in lung (Cochrane review planned for 2009) • Olschewski H. et al. Inhaled prostacycin and iloprost in severe pulmonary hypertension secondary to lung fibrosis. Respiratory and Critical Care Medicine 160(2) 1999:600-607.

  5. Indications • Primary and Secondary Pulmonary Hypertension • Cardiac surgery-associated pulmonary hypertension and RV failure • Lung transplantation-related reperfusion injury • Liver transplantation portopulmonary hypertension • Hypoxemia due to single-lung ventilation or ARDS

  6. Contraindications • Hypersensitivity to drug or diluent

  7. Cost Analysis (compared with nitric oxide) • Average runtime 45.6 hours1 (for PPH) • Flolan (based on average weight 80kg at 31 mcg/kg/min) • Medication - $12.50 hour • PALL filter unit cost - $4.99 (changes Q2H) = $113.77 • Disposable aeroneb system - $50.00 • = $733.77 • Nitric Oxide • $95.00 hour • = $4332.00 1. De Wet CJ. Inhaled prostacyclin is safe, effective and affordable in patients with pulmonary hypertension, right heart dysfunction, and refractory hypoxemia after cardiothoracic surgery. J Thoracic and Cardiovascular Surgery 2006;127:1058-67

  8. Setup • Must be reconstituted with glycine • Not compatible with any other solution • Glycine is sticky and viscous • Needs to be shielded from light • Recommended to keep reconstituted solution cold with icepacks during administration (2-8 degrees C) (stable for 8 hrs room temp, 24 hours refrigerated) • Nebulizer, infusion tubing, connections, changed every 24 hrs (refrigerated) or every 8 hrs (unrefrigerated) as drug expires • Option A: continuous flow-driven nebulizer (Miniheart) + infusion pump • Option B: continuous electronically-driven nebulizer (Aeroneb) + infusion pump

  9. Option A: Miniheart neb • Continuous flow-driven nebulizer • Dose delivery is dependent on flowrate • 8 ml/hr nebulizer output with 2 Lpm flowrate set on neb • Fluctuating dosing may occur during delivery • Easy to wean by adjusting neb input from pumps • Added flow to ventilator circuit affects ventilation • patient triggering affected • Triggering will be made less sensitive or could cause autocycling • Delivered tidal volumes and pressures increased • Delivered FiO2 changes unless nebulizer connected to blender • Accuracy of monitored values is affected – exhaled tidal and minute volumes will be inaccurate • Alarm functions may be inaccurate – particularly low tidal volume/low minute volume/leak alarms • Certain ventilator modes will malfunction (PRVC, CMV with Autoflow, VC+, PAV) • Safest mode to be on is PSV or PCV

  10. Option A: Miniheart neb • Accidental disconnection of nebulizer tubing is possible due to backpressure from nebulizer causing sudden stoppage of dosing (no alarm) • Accidental disconnection or maladjustment from wall flowmeter is possible (causing increased or stoppage of dosing) (no alarm) • Nebulizer tipping is possible, causing accidental instillation of entire dose into endotracheal tube or sudden stoppage of dosing (no alarm)

  11. Option B: Aeroneb • Continuous (mesh screen sifter) electronically-driven neb • Dose delivery is dependent on constant output • On-off switch only – nebulizer output is set at 30 ml/hr • Dosage depends on concentration of medication in nebulizer • Difficult to wean – med must be remixed • Does not affect ventilator performance – no flow added to circuit • Nebulizer dysfunction is likely (no alarm) • Unit stops functioning if battery dies • Have had to replace batteries in all of our controllers • Cables can be kinked • Powercords malfunction frequently • Limited number of controllers available – would need backup unit on standby • Cost of controller unit is $1425. ( we have 3, often all are in use for nebulized antibx) • Nebulizer tipping is possible. Would not spill dose into endotracheal tube, but may result in sudden stoppage of dose (no alarm)

  12. Benchmarking • Barnes Jewish Hospital, St. Louis, MO • 126 patients • Miniheart continuous nebulizer • Filter changes Q2 hrs • Adverse event – vent exhalation valve became sticky, significant autopeep/hypotension • Sudbury Regional Hospital, Sudbury, ON • Filter changes Q6 hrs and PRN • Kingston General Hospital, Kingston, ON • Miniheart continuous nebulizer • Filter changes Q4H and PRN • Harborview Medical Centre, Seattle, WA • Aeroneb • No filtering? • Bench test only • St Pauls Hospital, Vancouver, BC • Miniheart nebulizer • Filter changes Q 2-4 hrs and PRN

  13. Patient Safety • Neb must run continuously • Product has biological half-life of 2-3 minutes • Rebound pulmonary hypertension may be life-threatening • Dyspnea, dizziness, asthenia • Rare reports of death (IV use)1, 2 • Augoustides J, Culp K, Smith S. Rebound pulmonary hypertension and cardiogenic shock after withdrawl of inhaled prostacyclin. (Case Report) Anesthesiology 2004(100):1023-1025 • Barst RJ. Rubin LJ. McGoon MD, et al. Survival in primary pulmonary hypertension with long-term continuous intravenous prostacyclin. Ann Intern Med 1994; 121:409-415. • GlaxoSmithKline Inc. Product Monograph, Flolan for Injection, 2008.

  14. Patient Safety cont’d • Filter clogging • Glycine is sticky and viscous; quickly clogs filters • Bench testing for filter resistance1 1. David Sima, RT Clinical Educator, bench testing data June 2009

  15. Standard dose (31 mcg/kg/min, 80 kg)- 10 Lpm minute volume- calibrated equipment, reproducible results- filter resistance after 1 hour = 18.8 cmH20/Lps

  16. Standard dose (31 mcg/kg/min, 80 kg)- 20 Lpm minute volume- calibrated equipment, reproducible results- filter resistance at 1 hour = 23.09 cmH20/Lps

  17. Filter Clogging • ↑expiratory resistance • ↑ autopeep • ↑ intrathoracic pressure • ↑ PVR • Affect V/Q matching in lung • Affect ventilator performance and safety • Hourly circuit changes may clog vent exp filter • ‘Vent-inop’ at 5 cmH20 transducer difference • Would necessitate immediate manual ventilation and vent change

  18. Occupational Health and Safety • Would require frequent (Q30min) circuit disconnections • PPE protection for staff during exposure times • Minimal data on exposure during pregnancy

  19. Alternatives? • Prostaglandins • IV Epoprostenol • Iloprost • Treprostinol • Beraprost • PGE1 • NO donors • Inhaled Nitric Oxide • Inhaled sodium nitroprusside • Inhaled nitroglycerine • Phosphodiesterase Inhibitors • Sildenafil • Milrinone • Endothelin Antagonists • Bosentan • Nesiritide • Adrenomedullin

  20. Recommendations • Evaluate risk-benefits • Explore alternatives • If we must? • Aeroneb recommended as best delivery system • Q 30 minute filter changes • Purchase additional controller sets • Backup equipment on standby • Patient care guideline development, education and vigilance for patient safety • Investigate alarm possibility with manufacturer

  21. Summary • Patient benefit for use (PPH, ARDS?) • Inexpensive in comparison with N.O. • 2 delivery systems, both have significant safety concerns • Is it worth it? Or investigate alternatives?

More Related