ORIGINAL ARTICLE

Utilization of inhaled nitric oxide after surgical repair of truncus arteriosus: A multicenter analysis

Corresponding Author

Christine M. Riley MSN, APRN

[email protected]

orcid.org/0000-0003-2224-0649

Department of Pediatrics, Division of Cardiac Critical Care, Children's National Health System, Washington, District of Columbia

Correspondence

Christine M. Riley, Department of Pediatrics, Division of Cardiac Critical Care, Children’s National Health System, 111 Michigan Ave, Washington, DC 20010.

Email: [email protected]

Search for more papers by this author

Christopher W. Mastropietro MD,

Christopher W. Mastropietro MD

orcid.org/0000-0002-7409-7664

Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana

Search for more papers by this author

Peter Sassalos MD,

Peter Sassalos MD

Department of Cardiac Surgery, Section of Pediatric Cardiovascular Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan

Search for more papers by this author

Jason R. Buckley MD,

Jason R. Buckley MD

Department of Pediatrics, Division of Cardiology, Medical University of South Carolina Children's Hospital, Charleston, South Carolina

Search for more papers by this author

John M. Costello MD, MPH,

John M. Costello MD, MPH

Department of Pediatrics, Division of Cardiology, Medical University of South Carolina Children's Hospital, Charleston, South Carolina

Search for more papers by this author

Ilias Iliopoulos MD,

Ilias Iliopoulos MD

Department of Pediatrics, Division of Cardiac Critical Care, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

Search for more papers by this author

Aimee Jennings MSN, APRN,

Aimee Jennings MSN, APRN

Department of Pediatrics, Division of Critical Care, Seattle Children’s Hospital, Seattle, Washington

Search for more papers by this author

Katherine Cashen DO,

Katherine Cashen DO

Department of Pediatrics, Division of Critical Care, Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, Michigan

Search for more papers by this author

Sukumar Suguna Narasimhulu MD,

Sukumar Suguna Narasimhulu MD

Department of Pediatrics, Division of Cardiac Intensive Care, University of Central Florida College of Medicine, The Heart Center at Arnold Palmer Hospital for Children, Orlando, Florida

Search for more papers by this author

Keshava M. N. Gowda MBBS,

Keshava M. N. Gowda MBBS

Department of Pediatrics, Division of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio

Search for more papers by this author

Arthur J. Smerling MD,

Arthur J. Smerling MD

Department of Pediatrics, Division of Critical Care, Columbia University College of Physicians & Surgeons, Morgan Stanley Children's Hospital of New York, New York, New York

Search for more papers by this author

Michael Wilhelm MD,

Michael Wilhelm MD

Department of Pediatrics, Division of Cardiac Intensive Care, University of Wisconsin, Madison, Wisconsin

Search for more papers by this author

Aditya Badheka MBBS,

Aditya Badheka MBBS

Department of Pediatrics, Division of Critical Care Medicine, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa

Search for more papers by this author

Adnan Bakar MD,

Adnan Bakar MD

Department of Pediatrics, Division of Cardiac Critical Care, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York

Cohen Children's Medical Center, New Hyde Park, New York

Search for more papers by this author

Elizabeth A. S. Moser MS,

Elizabeth A. S. Moser MS

Department of Biostatistics, Indiana University School of Medicine & Richard M. Fairbanks School of Public Health, Indianapolis, Indiana

Search for more papers by this author

Venu Amula MD,

Venu Amula MD

Department of Pediatrics, Division of Critical Care Medicine, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah

Search for more papers by this author

Collaborative Research in Pediatric Cardiac Intensive Care (CoRe-PCIC) Investigators

Christine M. Riley MSN, APRN,

Corresponding Author

Christine M. Riley MSN, APRN

[email protected]

orcid.org/0000-0003-2224-0649

Department of Pediatrics, Division of Cardiac Critical Care, Children's National Health System, Washington, District of Columbia

Correspondence

Christine M. Riley, Department of Pediatrics, Division of Cardiac Critical Care, Children’s National Health System, 111 Michigan Ave, Washington, DC 20010.

Email: [email protected]

Search for more papers by this author

Christopher W. Mastropietro MD,

Christopher W. Mastropietro MD

orcid.org/0000-0002-7409-7664

Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana

Search for more papers by this author

Peter Sassalos MD,

Peter Sassalos MD

Department of Cardiac Surgery, Section of Pediatric Cardiovascular Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan

Search for more papers by this author

Jason R. Buckley MD,

Jason R. Buckley MD

Department of Pediatrics, Division of Cardiology, Medical University of South Carolina Children's Hospital, Charleston, South Carolina

Search for more papers by this author

John M. Costello MD, MPH,

John M. Costello MD, MPH

Department of Pediatrics, Division of Cardiology, Medical University of South Carolina Children's Hospital, Charleston, South Carolina

Search for more papers by this author

Ilias Iliopoulos MD,

Ilias Iliopoulos MD

Department of Pediatrics, Division of Cardiac Critical Care, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

Search for more papers by this author

Aimee Jennings MSN, APRN,

Aimee Jennings MSN, APRN

Department of Pediatrics, Division of Critical Care, Seattle Children’s Hospital, Seattle, Washington

Search for more papers by this author

Katherine Cashen DO,

Katherine Cashen DO

Department of Pediatrics, Division of Critical Care, Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, Michigan

Search for more papers by this author

Sukumar Suguna Narasimhulu MD,

Sukumar Suguna Narasimhulu MD

Department of Pediatrics, Division of Cardiac Intensive Care, University of Central Florida College of Medicine, The Heart Center at Arnold Palmer Hospital for Children, Orlando, Florida

Search for more papers by this author

Keshava M. N. Gowda MBBS,

Keshava M. N. Gowda MBBS

Department of Pediatrics, Division of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio

Search for more papers by this author

Arthur J. Smerling MD,

Arthur J. Smerling MD

Department of Pediatrics, Division of Critical Care, Columbia University College of Physicians & Surgeons, Morgan Stanley Children's Hospital of New York, New York, New York

Search for more papers by this author

Michael Wilhelm MD,

Michael Wilhelm MD

Department of Pediatrics, Division of Cardiac Intensive Care, University of Wisconsin, Madison, Wisconsin

Search for more papers by this author

Aditya Badheka MBBS,

Aditya Badheka MBBS

Department of Pediatrics, Division of Critical Care Medicine, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa

Search for more papers by this author

Adnan Bakar MD,

Adnan Bakar MD

Department of Pediatrics, Division of Cardiac Critical Care, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York

Cohen Children's Medical Center, New Hyde Park, New York

Search for more papers by this author

Elizabeth A. S. Moser MS,

Elizabeth A. S. Moser MS

Department of Biostatistics, Indiana University School of Medicine & Richard M. Fairbanks School of Public Health, Indianapolis, Indiana

Search for more papers by this author

Venu Amula MD,

Venu Amula MD

Department of Pediatrics, Division of Critical Care Medicine, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah

Search for more papers by this author

Collaborative Research in Pediatric Cardiac Intensive Care (CoRe-PCIC) Investigators

First published: 11 November 2019

https://doi.org/10.1111/chd.12849

Citations: 3

Participating Institutions (where work was performed): Riley Hospital for Children, Indianapolis, IN; Cleveland Clinic, Cleveland, OH; Children’s Hospital of Michigan, Detroit, MI; Morgan Stanley Children’s Hospital of New York, New York, NY; Cohen Children's Medical Center, New Hyde Park, NY; Medical University of South Carolina Children's Hospital, Charleston, SC; Children's National Health System, Washington, DC; Arnold Palmer Hospital for Children, Orlando, FL; Seattle Children’s Hospital, Seattle, WA; Ann & Robert H. Lurie Children’s Hospital of Chicago, IL; University of Iowa Stead Family Children’s Hospital, Iowa City, IA; Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Primary Children's Hospital, Salt Lake City, UT; University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI; American Family Hospital, Madison, WI.

Funding information

Funding from the Department of Pediatrics at Indiana University School of Medicine was provided for this study through a Riley Children’s Foundation Grant (Intramural) for administrative support. No honorarium or other form of payment was provided to anyone to produce the manuscript.

Share a link

Email
Wechat
Bluesky

Abstract

Background

Elevated pulmonary vascular resistance (PVR) is common following repair of truncus arteriosus. Inhaled nitric oxide (iNO) is an effective yet costly therapy that is frequently implemented postoperatively to manage elevated PVR.

Objectives

We aimed to describe practice patterns of iNO use in a multicenter cohort of patients who underwent repair of truncus arteriosus, a lesion in which recovery is often complicated by elevated PVR. We also sought to identify patient and center factors that were more commonly associated with the use of iNO in the postoperative period.

Design

Retrospective cohort study.

Setting

15 tertiary care pediatric referral centers.

Patients

All infants who underwent definitive repair of truncus arteriosus without aortic arch obstruction between 2009 and 2016.

Interventions

Descriptive statistics were used to demonstrate practice patterns of iNO use. Bivariate comparisons of characteristics of patients who did and did not receive iNO were performed, followed by multivariable mixed logistic regression analysis using backward elimination to identify independent predictors of iNO use.

Main Results

We reviewed 216 patients who met inclusion criteria, of which 102 (46%) received iNO in the postoperative period: 69 (68%) had iNO started in the operating room and 33 (32%) had iNO initiated in the ICU. Median duration of iNO use was 4 days (range: 1-21 days). In multivariable mixed logistic regression analysis, use of deep hypothermic circulatory arrest (odds ratio: 3.2; 95% confidence interval: 1.2, 8.4) and center (analyzed as a random effect, p = .02) were independently associated with iNO use.

Conclusions

In this contemporary multicenter study, nearly half of patients who underwent repair of truncus arteriosus received iNO postoperatively. Use of iNO was more dependent on individual center practice rather than patient characteristics. The study suggests a need for collaborative quality initiatives to determine optimal criteria for utilization of this important but expensive therapy.

CONFLICT OF INTEREST

None of the authors have conflicts of interest to disclose.

Supporting Information

REFERENCES

1Checchia PA, Bronicki RA, Goldstein B. Review of inhaled nitric oxide in the pediatric cardia surgery setting. Pediatr Cardiol. 2012; 33(4): 493-505. https://doi.org/10.1007/s00246-012-0172-4.
10.1007/s00246-012-0172-4
PubMed Web of Science® Google Scholar
2Barr FE, Macrae D. Inhaled nitric oxide and related therapies. Pediatr Crit Care Med. 2010; 11(2 Suppl): S30-S36. https://doi.org/10.1097/PCC.0b013e3181c76b42.
10.1097/PCC.0b013e3181c76b42
PubMed Web of Science® Google Scholar
3Taylor MB, Laussen P. Fundementals of management of acute postoperative pulmonary hypertension. Pediatr Crit Care Med. 2010; 11(2 Suppl): S27-S29. https://doi.org/10.1097/PCC.0b013e3181c769a4.
10.1097/PCC.0b013e3181c769a4
PubMed Web of Science® Google Scholar
4James C, Millar J, Horton S, et al. Nitric oxide administration during paediatric cardiopulmonary bypass: a randomized controlled trial. Intensive Care Med. 2016; 42(11): 1744-1752. Epub 30 September 2016.
10.1007/s00134-016-4420-6
CAS PubMed Web of Science® Google Scholar
5Gorenflo M, Gu H, Xu Z. Peri-operative pulmonary hypertension in paediatric patients: current strategies in children with congenital heart disease. Cardiology. 2010; 116: 10-17. https://doi.org/10.1159/000313864.
10.1159/000313864
PubMed Web of Science® Google Scholar
6Muhiudeen Russell IA, Zwass MS, Fineman JR, et al. The effect of inhaled nitric oxide on postoperative pulmonary hypertension in infant and children undergoing surgical repair of congenital heart diease. Anesth Analg. 1998; 87: 46-51.
PubMed Web of Science® Google Scholar
7Bando K, Turrentine MW, Sharp TG, et al. Pulmonary hypertension after operations for congenital heart diease: analysis of risk factor and management. J Thorac Cardiovasc Surg. 1996; 112(6): 1600-1609.
10.1016/S0022-5223(96)70019-3
CAS PubMed Web of Science® Google Scholar
8Bizzarro M, Gross I, Barbosa FT. Inhaled nitric oxide for the postoperative management of pulmonary hypertension in infants and children with congenital heart disease. Cochrane Database Syst Rev. 2014; 7: CD005055.
Google Scholar
9Wilson J. A description of a very unusual malformation of the human heart. Phil Trans R Soc London (Biol). 1798; 18: 346.
Google Scholar
10Thompson LD, McElhinney DB, Reddy VM, Petrossian ED, Silverman NH, Hanley FL. Neonatal repair of truncus arteriosus: continuing improvement in outcomes. Ann Thorac Surg. 2001; 72: 391-395.
10.1016/S0003-4975(01)02796-5
CAS PubMed Web of Science® Google Scholar
11Kalavrouziotis G, Purohit M, Ciotti G, Corno AF, Pozzi M. Truncus arteriosus communis: early and midterm results of early primary repair. Ann Thorac Surg. 2006; 82: 2200-2206.
10.1016/j.athoracsur.2006.07.017
PubMed Web of Science® Google Scholar
12Sandrio S, Ruffer A, Purbojo A, et al. Common arteria trunk: current implementation of the primary and staged repair strategies. Interact Cardiovasc Thorac Surg. 2015; 21: 754-760.
PubMed Web of Science® Google Scholar
13Shamszad P, Moore RA, Ghanayem N, Cooper DS. Intensive care management of neonates with d-transposition of the great arteries and common arterial trunk. Cardiol Young. 2012; 22(6): 755-760.
10.1017/S1047951112001965
PubMed Web of Science® Google Scholar
14 DG Nichols, RM Ungerleider, PJ Spevak, et al., eds. Critical Heart Disease in Infants and Children. 2nd ed. Philadelphia, PA: Mosby; 2006.
Google Scholar
15Mavroudis C, Jacobs JP, Siegel A, et al. Procedure-based complications to guide informed consent: analysis of society of thoracic surgeons-congenital heart surgery database. Ann Thorac Surg. 2014; 97: 1838-1849.
10.1016/j.athoracsur.2013.12.037
PubMed Web of Science® Google Scholar
16Gupta P, Rettiganti M, Wilcox A, Eble BK, Schmitz ML, Zakaria D. Spectrum of off-label nitric oxide utilization after pediatric cardiac surgery among centers of varying surgical volume. J Intensive Care Med. 2017 Jan. https://doi.org/10.1177/0885066617728494.
PubMed Web of Science® Google Scholar
17Putnam LR, Tsao K, Morini F, et al. Evaluation of variability in inhaled nitric oxide use and pulmonary hypertension in patients with congenital diaphragmatic hernia. JAMA Pediatr. 2016; 170(12): 1188-1194.
10.1001/jamapediatrics.2016.2023
PubMed Web of Science® Google Scholar
18Stenger MR, Slaughter JL, Kelleher K, et al. Hospital variation in nitric oxide use for premature infants. Pediatrics. 2012; 129(4): e945-e951.
10.1542/peds.2011-1809
PubMed Web of Science® Google Scholar
19Hughes Driscoll CA, Davis NL, Miles M, El-Metwally D. A quality improvement project to improve evidence-based inhaled nitric oxide use. Respir Care. 2018; 63(1): 20-27.
10.4187/respcare.05619
PubMed Web of Science® Google Scholar
20Simsic JM, Harrison S, Evans L, et al. Reducing variation in the use of nitric oxide. Pediatrics. 2014; 133(6): e1753-e1758.
10.1542/peds.2013-4011
PubMed Web of Science® Google Scholar
21Todd Tzanetos DR, Housley JJ, Barr FE, May WL, Landers CD. Implementation of an inhaled nitric oxide protocol decreases direct cost associated with its use. Respir Care. 2015; 60(5): 644-650.
10.4187/respcare.03308
PubMed Web of Science® Google Scholar
22Smith AH, Gay JC, Patel NR. Trending in resource utilization associated with the inpatient treatment of neonatal congenital heart disease. Congenit Heart Dis. 2013; 9: 96-105.
10.1111/chd.12103
PubMed Web of Science® Google Scholar
23Wernovsky G, Wypij D, Jonas RA, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation. 1995; 92(8): 2226-2235.
10.1161/01.CIR.92.8.2226
CAS PubMed Web of Science® Google Scholar
24Cooper WA, Duarte IG, Thourani VH, et al. Hypothermic circulatory arrest causes multisystem vascular endothelial dysfunction and apoptosis. Ann Thorac Surg. 2000; 69: 696-702.
10.1016/S0003-4975(99)01524-6
CAS PubMed Web of Science® Google Scholar

Citing Literature

Volume14, Issue6

November/December 2019

Pages 1078-1086

Utilization of inhaled nitric oxide after surgical repair of truncus arteriosus: A multicenter analysis

Abstract

Background

Objectives

Design

Setting

Patients

Interventions

Main Results

Conclusions

CONFLICT OF INTEREST

Supporting Information

REFERENCES

Citing Literature

References

Information

About Wiley Online Library

Help & Support

Opportunities

Connect with Wiley

Utilization of inhaled nitric oxide after surgical repair of truncus arteriosus: A multicenter analysis

Abstract

Background

Objectives

Design

Setting

Patients

Interventions

Main Results

Conclusions

CONFLICT OF INTEREST

Supporting Information

REFERENCES

Citing Literature

References

Related

Information