Inhaled nitric oxide to improve oxygenation for safe critical care transport of adults with severe hypoxemia.
BACKGROUND
Inhaled nitric oxide (iNO) is a rescue treatment for severe hypoxemia in the intensive care unit setting.


OBJECTIVE
To evaluate the effectiveness and safety of iNO in adult patients with severe hypoxemia before and during transport to a tertiary care center.


METHODS
Prospective data were examined in a retrospective cohort study. Patients with severe hypoxemia and cardiopulmonary failure (n=139) at referring hospitals in whom conventional therapy was unsuccessful were treated with iNO in the intensive care units in anticipation of transfer to a tertiary center. Treatment wih iNO was initiated by the critical care transport team in 114 patients and continued in 25 patients. Arterial blood gas analysis was done before and after iNO treatment.


RESULTS
Patients treated with iNO had significant improvement in oxygenation: mean (SD) for PaO2 increased from 60.7 (20.2) to 72.3 (40.6) mm Hg (P=.008), and mean (SD) for ratio of PaO2 to fraction of inspired oxygen (P:F) increased from 62.4 (26.1) to 73.1 (42.6) (P= .03). Use of iNO was continued through transport in 102 patients, all of whom were transported without complication. The P:F continued to improve, with a mean (SD) of 109.7 (73.8) from 6 to 8 hours after arrival at the tertiary center (P< .001 relative to values both before and after treatment). Among patients treated with iNO, 60.2% survived to discharge. In 35 nonresponders, iNO was discontinued, and 15 patients could not be transferred owing to life-threatening hypoxemia; 2 were later transferred on extracorporeal membrane oxygenation. Of 18 patients transported without iNO, 9 (50%) survived.


CONCLUSIONS
Use of iNO significantly improves oxygenation of patients with severe hypoxemia and allows safe transfer to a tertiary care center.
Nicholas R. Teman and Benjamin S. Bryner are general surgery residents and Pauline K. Park is a professor of surgery, University of Michigan Health System, Ann Arbor, Michigan. Lena M. Napolitano is division chief, Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), director, Trauma and Surgical Critical Care, and associate chair, Department of Surgery, University of Michigan Health System. Jeffrey Thomas is a flight nurse specialist mastery for University of Michigan Survival Flight and Mark J. Lowell is an associate professor, Department of Emergency Medicine, Carl F. Haas is a respiratory therapy supervisor, Department of Adult Respiratory Care, and Jonathan W. Haft is an associate professor of cardiac surgery and anesthesiology, University of Michigan Health System.
Nicholas R
NR
Teman
Nicholas R. Teman and Benjamin S. Bryner are general surgery residents and Pauline K. Park is a professor of surgery, University of Michigan Health System, Ann Arbor, Michigan. Lena M. Napolitano is division chief, Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), director, Trauma and Surgical Critical Care, and associate chair, Department of Surgery, University of Michigan Health System. Jeffrey Thomas is a flight nurse specialist mastery for University of Michigan Survival Flight and Mark J. Lowell is an associate professor, Department of Emergency Medicine, Carl F. Haas is a respiratory therapy supervisor, Department of Adult Respiratory Care, and Jonathan W. Haft is an associate professor of cardiac surgery and anesthesiology, University of Michigan Health System.
Jeffrey
J
Thomas
Nicholas R. Teman and Benjamin S. Bryner are general surgery residents and Pauline K. Park is a professor of surgery, University of Michigan Health System, Ann Arbor, Michigan. Lena M. Napolitano is division chief, Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), director, Trauma and Surgical Critical Care, and associate chair, Department of Surgery, University of Michigan Health System. Jeffrey Thomas is a flight nurse specialist mastery for University of Michigan Survival Flight and Mark J. Lowell is an associate professor, Department of Emergency Medicine, Carl F. Haas is a respiratory therapy supervisor, Department of Adult Respiratory Care, and Jonathan W. Haft is an associate professor of cardiac surgery and anesthesiology, University of Michigan Health System.
Benjamin S
BS
Bryner
Nicholas R. Teman and Benjamin S. Bryner are general surgery residents and Pauline K. Park is a professor of surgery, University of Michigan Health System, Ann Arbor, Michigan. Lena M. Napolitano is division chief, Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), director, Trauma and Surgical Critical Care, and associate chair, Department of Surgery, University of Michigan Health System. Jeffrey Thomas is a flight nurse specialist mastery for University of Michigan Survival Flight and Mark J. Lowell is an associate professor, Department of Emergency Medicine, Carl F. Haas is a respiratory therapy supervisor, Department of Adult Respiratory Care, and Jonathan W. Haft is an associate professor of cardiac surgery and anesthesiology, University of Michigan Health System.
Carl F
CF
Haas
Nicholas R. Teman and Benjamin S. Bryner are general surgery residents and Pauline K. Park is a professor of surgery, University of Michigan Health System, Ann Arbor, Michigan. Lena M. Napolitano is division chief, Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), director, Trauma and Surgical Critical Care, and associate chair, Department of Surgery, University of Michigan Health System. Jeffrey Thomas is a flight nurse specialist mastery for University of Michigan Survival Flight and Mark J. Lowell is an associate professor, Department of Emergency Medicine, Carl F. Haas is a respiratory therapy supervisor, Department of Adult Respiratory Care, and Jonathan W. Haft is an associate professor of cardiac surgery and anesthesiology, University of Michigan Health System.
Jonathan W
JW
Haft
Nicholas R. Teman and Benjamin S. Bryner are general surgery residents and Pauline K. Park is a professor of surgery, University of Michigan Health System, Ann Arbor, Michigan. Lena M. Napolitano is division chief, Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), director, Trauma and Surgical Critical Care, and associate chair, Department of Surgery, University of Michigan Health System. Jeffrey Thomas is a flight nurse specialist mastery for University of Michigan Survival Flight and Mark J. Lowell is an associate professor, Department of Emergency Medicine, Carl F. Haas is a respiratory therapy supervisor, Department of Adult Respiratory Care, and Jonathan W. Haft is an associate professor of cardiac surgery and anesthesiology, University of Michigan Health System.
Pauline K
PK
Park
Nicholas R. Teman and Benjamin S. Bryner are general surgery residents and Pauline K. Park is a professor of surgery, University of Michigan Health System, Ann Arbor, Michigan. Lena M. Napolitano is division chief, Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), director, Trauma and Surgical Critical Care, and associate chair, Department of Surgery, University of Michigan Health System. Jeffrey Thomas is a flight nurse specialist mastery for University of Michigan Survival Flight and Mark J. Lowell is an associate professor, Department of Emergency Medicine, Carl F. Haas is a respiratory therapy supervisor, Department of Adult Respiratory Care, and Jonathan W. Haft is an associate professor of cardiac surgery and anesthesiology, University of Michigan Health System.
Mark J
MJ
Lowell
Nicholas R. Teman and Benjamin S. Bryner are general surgery residents and Pauline K. Park is a professor of surgery, University of Michigan Health System, Ann Arbor, Michigan. Lena M. Napolitano is division chief, Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), director, Trauma and Surgical Critical Care, and associate chair, Department of Surgery, University of Michigan Health System. Jeffrey Thomas is a flight nurse specialist mastery for University of Michigan Survival Flight and Mark J. Lowell is an associate professor, Department of Emergency Medicine, Carl F. Haas is a respiratory therapy supervisor, Department of Adult Respiratory Care, and Jonathan W. Haft is an associate professor of cardiac surgery and anesthesiology, University of Michigan Health System. lenan@umich.edu.
Lena M
LM
Napolitano
D000280:Administration, Inhalation; D000328:Adult; D000465:Algorithms; D001784:Blood Gas Analysis; D003422:Critical Care; D005260:Female; D006801:Humans; D000860:Hypoxia / Q000097:blood / Q000209:etiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009569:Nitric Oxide / Q000008:administration & dosage* / Q000009:adverse effects; D010100:Oxygen / Q000097:blood*; D010313:Partial Pressure; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000150:complications; D012189:Retrospective Studies; D015996:Survival Rate; D014187:Transportation of Patients; D014665:Vasodilator Agents / Q000008:administration & dosage* / Q000009:adverse effects
D014665:Vasodilator Agents; D009569:Nitric Oxide; D010100:Oxygen