Nitric Oxide and Pulmonary Vasodilators

Nitric Oxide and Pulmonary Vasodilators

I have included a few references.It has worked well in my hands and  premptive use presurgery(Milrinone) helps a lot. It also works well postop and this hasvirtually abolished the use of iNO. I usually neb the milrinone  in the anesthesia circuit during cannulation for CPB.Post op I routinely neb nitroprusside after removing IV nitroprussideand starting  Sildenafil via  a Ryles tube. In fact it seems to workbetter when Sildenafil is on during PA surgesPrasannaVolume 31, Issue 6, Pages 1081-1087 (June 2007)View previous. 20 of 47 View next.ABSTRACTFULL TEXTFULL-TEXT PDF (120 KB)CITATION ALERTCITED BYRELATED ARTICLESEXPORT CITATIONEMAIL TO A COLLEAGUENEED REPRINTS?BOOKMARK ARTICLEFULL TEXT ELSEWHEREPreliminary experience with inhaled milrinone in cardiac surgery☆Yoan Lamarcheab, Louis P. Perraultab, Simon Maltaisab, KarineTétreaultd, Jean Lambertd, André Y. DenaultcCorresponding AuthorInformationemail addressReceived 27 September 2006; received in revised form 21 February 2007;accepted 23 February 2007.AbstractBackground: Inhaled administration of milrinone reduces pulmonaryartery pressure. Pulmonary hypertension (PH) and right heart failureare associated with difficult separation from cardiopulmonary bypass(CPB). Therefore, inhaled milrinone could facilitate separation fromCPB. Objective: To determine the impact and timing of administrationof inhaled milrinone. Methods: A retrospective analysis of our experience on high-risk patients receiving inhaled milrinone wasconducted to evaluate the postoperative course after administration ofthe drug. Results: Seventy-three patients received inhaled milrinonefrom June 2002 to February 2005. Mean age was 64±13 years, with a meanpreoperative Parsonnet score of 27±14. Inhaled milrinone (5mg) wasadministered before (n=30) or after (n=40) CPB, three patients hadoff-pump procedures and were excluded. CPB time was 145±78min withcross-clamping times of 91±56min without any significant differencebetween groups. Fifty-four patients (74%) had difficult separation from CPB, 14 patients (19%) required an intra-aortic balloon pump and10 patients (14%) needed emergency reinitiation of CPB for hemodynamic instability. Ten patients died in the perioperative period (13.7%).Patients receiving inhaled milrinone prior to CPB initiation had alowering pulmonary artery pressure after CPB (p<.01) and had lessemergency reinitiation of CPB after weaning (3% vs 23%, p=.02) ascompared to those with administration after CPB. No detectable sideeffects were directly linked to the administration of the drug.Conclusion: In this high-risk cohort, use of inhaled milrinone waswell tolerated. Administration before initiation of CPB could helpweaning from CPBInhaled Milrinone: A New Alternative in Cardiac Surgery?André Y. Denault, MD, FRCPCDepartment of Cardiac Anesthesiology, Montreal Heart Institute,Université de Montréal, Montreal, Quebec, Canada, denault@videotron.caYoan Lamarche, MD, MScCardiac Surgery, Montreal Heart Institute, Université de Montréal,Montreal, Quebec, CanadaPierre Couture, MD, FRCPCFrancois Haddad, MD, FRCPCMedicine (Division of Cardiology), Montreal Heart Institute,Université de Montréal, Montreal, Quebec, CanadaJean Lambert, PhDBiostatistics, Montreal Heart Institute, Université de Montréal,Montreal, Quebec, Canada Jean-Claude Tardif, MD, FRCPCMedicine (Division of Cardiology), Montreal Heart Institute,Université de Montréal, Montreal, Quebec, Canada Louis P. Perrault, MD, PhD, FRCSCCardiac Surgery, Montreal Heart Institute, Université de Montréal,Montreal, Quebec, CanadaThe administration of milrinone through inhalation has been studied inonly a few animal and human studies. Compared to the intravenousadministration, inhaled milrinone has been shown to reduce pulmonaryartery pressure without systemic hypotension. Therefore, this approachcould represent an alternative to nitric oxide. This current state ofknowledge of intravenous and inhaled milrinone is presented andsummarized.Key Words: milrinone • pulmonary artery pressure • nitric oxide • heart failureSeminars in Cardiothoracic and Vascular Anesthesia, Vol. 10, No. 4,346-360 (2006) DOI: 10.1177/1089253206294400   * Performing your original search, inhaled Nitroprusside, inPubMed will retrieve 250 records.Crit Care Med. 2002 Nov;30(11):2560-5.Direct comparison of the effects of nebulized nitroprusside versusinhaled nitric oxide on pulmonary and systemic hemodynamics duringhypoxia-induced pulmonary hypertension in piglets.Schreiber MD, Dixit R, Rudinsky B, Hipps R, Morgan SE, Keith RRT A, Meadow W.Department of Pediatrics, University of Chicago, IL 60637, USA.OBJECTIVE: To test the hypothesis that nebulized nitroprusside and inhaled nitric oxide would not differ in producing selective pulmonary vasodilation during hypoxia-induced pulmonary hypertension in piglets. SETTING: University laboratory. SUBJECTS: Five piglets. INTERVENTIONS: Piglets (n = 5) were anesthetized and instrumented to monitor systemic arterial pressure, pulmonary artery pressure, and cardiac output continuously. Hypoxia was induced (DeltaFio2 from 0.5 to 0.08), andeither nebulized nitroprusside (5 mg/mL at 4 L/min flow; total dose 25mg) or inhaled nitric oxide (20 ppm) was introduced into theventilator circuit for 15 mins. Normoxia was then restored, and arepeat cycle of hypoxia followed by the alternate vasodilatortreatment was initiated. MEASUREMENTS AND MAIN RESULTS: Hypoxiasignificantly reduced Pao2 (from 206 to 30 torr) and elevatedpulmonary artery pressure (from 18 to 33 torr) while not significantlyaffecting systemic arterial pressure or cardiac output. During hypoxia, inhaled nitric oxide reduced pulmonary artery pressure from33 to 21 torr (p <.01), whereas systemic arterial pressure and cardiacoutput were unchanged. During hypoxia, nebulized nitroprusside alsoreduced pulmonary artery pressure from 33 to 23 mm Hg (p <.01; p =nonsignificant vs. inhaled nitric oxide), whereas systemic arterialpressure and cardiac output again remained constant. The time courseof the reduction in pulmonary artery pressure during inhaled nitricoxide was roughly ten-fold more rapid (<5 secs) than during nebulizednitroprusside ( approximately 1 min). Neither inhaled nitric oxide nornebulized nitroprusside altered pH, Pao2, or Paco2. CONCLUSION: Bothinhaled nitric oxide and nebulized nitroprusside produced prompt,significant, selective reduction of pulmonary artery pressure and pulmonary vascular resistance in piglets with hypoxia-inducedpulmonary hypertension, without apparent effects on systemichemodynamics or pulmonary gas exchange. The equivalence of the twoeffects in this animal model suggests that cautious extrapolation ofthe use of nebulized nitroprusside as a convenient bridge to inhalednitric oxide in selected clinical contexts for human infants may bewarranted.PMID: 12441770 [PubMed – indexed for MEDLINE]

There are two methods to administer it, intermittent and continuous. You can take the aliquotes for the hour and manually put it into the in circuit nebulizer and nebulize it or use a disposable nebulizer , pierce it with an 18G needle and hook  a syringe pump to deliver the drug through the nebulizer. The dose starts from (Nitroprusside) 0.1 mics/Kg/min and never more than 5 mics/Kg/min .(Practically you never need more than 1 mic/Kg/min and higher doses are only required in PH crisis. What you need to titrate is pulmonary vasodilatation till systemic effects start happening when you down titrate to achieve a stable delivery. Milrinone is dosed as 0.35 to 1 mic/Kg/min

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