A Protocolized Intravenous Epoprostenol Pathway for Frostbite: A Canadian Burn Centre Quality Improvement and...

Severe frostbite is a dynamic microvascular injury that can progress to delayed tissue loss despite appropriate initial care. Contemporary management emphasizes rapid rewarming, antithromboxane therapy, clinical grading, selective thrombolysis, and prostacyclin-based treatment. Iloprost is the prostacyclin analogue most often described, but access may be delayed in some Canadian settings. We developed and implemented a monitored intravenous epoprostenol pathway for Cauchy grade 2 to 4 frostbite and retrospectively evaluated 23 patients treated between December 2017 and November 2025. The pathway incorporated rapid rewarming, grading, topical and systemic antithromboxane therapy, eligibility criteria, dose titration, physiologic monitoring, dose modification, multidisciplinary care, and follow-up. Overall, 153 of 216 affected digits were preserved. Preservation varied by severity: 62 of 65 grade 2 digits, 74 of 100 grade 3 digits, and 7 of 41 grade 4 digits were preserved. Twelve patients avoided amputation altogether. Mean treatment duration was 3.8 days, and most patients reached 8 ng/kg/min at least once. Documented adverse effects or dose-limiting symptoms occurred in nine patients and were managed with dose reduction or temporary interruption. Available records did not identify thrombolytic therapy, permanent discontinuation for adverse reaction or grade 2 reassessment, or serious drug-attributed adverse events. Protocol-guided intravenous epoprostenol was feasible and generally well tolerated. Findings should be interpreted as descriptive and hypothesis-generating rather than evidence of treatment efficacy.