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Published on: May 4, 2021
Characterization of Inhaled Nitric Oxide Use for Cardiac Indications in Pediatric Patients
Andrew R Yates1, John T Berger2, Ron W Reeder3
1Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH.
Insights
Inhaled nitric oxide (iNO) for pediatric cardiac patients showed high mortality and morbidity. Right ventricular dysfunction, not pulmonary hypertension, predicted worse outcomes in these critically ill children.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Cardiology
- Pulmonary Hypertension Management
Background:
- Inhaled nitric oxide (iNO) is used for pediatric cardiac patients, but its outcomes and predictors are not fully characterized.
- Understanding patient characteristics associated with iNO use is crucial for optimizing treatment in this vulnerable population.
Purpose of the Study:
- To characterize the utilization of inhaled nitric oxide (iNO) in pediatric cardiac patients.
- To assess the relationship between pre-initiation patient characteristics and outcomes after cardiac surgery in patients receiving iNO.
Main Methods:
- An observational cohort study was conducted across seven Collaborative Pediatric Critical Care Research Network hospitals.
- Included were 407 pediatric patients (age < 18) mechanically ventilated before or within 24 hours of iNO initiation for a cardiac indication.
- Echocardiographic variables prior to iNO initiation were analyzed in 160 postoperative cardiac surgical patients.
Main Results:
- The study included 407 pediatric patients receiving iNO for cardiac dysfunction, with a median treatment duration of 4 days.
- Significant morbidity was observed: 13% required extracorporeal membrane oxygenation, 7% needed renal replacement therapy, and 28-day mortality was 11%.
- In postoperative cardiac surgical patients, right ventricle dysfunction was associated with increased mortality and fewer ventilator-free days (p < 0.001), while tricuspid valve regurgitation was linked to fewer ventilator-free days (p < 0.001). Pulmonary hypertension was not associated with mortality or ventilator-free days.
Conclusions:
- Pediatric patients receiving iNO for cardiac indications experience high mortality and significant morbidity.
- Right ventricular dysfunction, identified pre-iNO via echocardiography, is a significant predictor of mortality and reduced ventilator-free days.
- Pulmonary hypertension, on its own, was not found to be a significant predictor of mortality or ventilator-free days in this cohort.
Objectives:
Characterize the use of inhaled nitric oxide (iNO) for pediatric cardiac patients and assess the relationship between patient characteristics before iNO initiation and outcomes following cardiac surgery.
Design:
Observational cohort study.
Setting:
PICU and cardiac ICUs in seven Collaborative Pediatric Critical Care Research Network hospitals.
Patients:
Consecutive patients, less than 18 years old, mechanically ventilated before or within 24 hours of iNO initiation. iNO was started for a cardiac indication and excluded newborns with congenital diaphragmatic hernia, meconium aspiration syndrome, and persistent pulmonary hypertension, or when iNO started at an outside institution.
Interventions:
None.
Measurements And Main Results:
Four-hundred seven patients with iNO initiation based on cardiac dysfunction. Cardiac dysfunction patients were administered iNO for a median of 4 days (2-7 d). There was significant morbidity with 51 of 407 (13%) requiring extracorporeal membrane oxygenation and 27 of 407 (7%) requiring renal replacement therapy after iNO initiation, and a 28-day mortality of 46 of 407 (11%). Of the 366 (90%) survivors, 64 of 366 patients (17%) had new morbidity as assessed by Functional Status Scale. Among the postoperative cardiac surgical group (n = 301), 37 of 301 (12%) had a superior cavopulmonary connection and nine of 301 (3%) had a Fontan procedure. Based on echocardiographic variables prior to iNO (n = 160) in the postoperative surgical group, right ventricle dysfunction was associated with 28-day and hospital mortalities (both, p < 0.001) and ventilator-free days (p = 0.003); tricuspid valve regurgitation was only associated with ventilator-free days (p < 0.001), whereas pulmonary hypertension was not associated with mortality or ventilator-free days.
Conclusions:
Pediatric patients in whom iNO was initiated for a cardiac indication had a high mortality rate and significant morbidity. Right ventricular dysfunction, but not the presence of pulmonary hypertension on echocardiogram, was associated with ventilator-free days and mortality.
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