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Effects of inhaled nitric oxide for postoperative hypoxemia in acute type A aortic dissection: a retrospective observational study.

ABSTRACT: BACKGROUND:Postoperative hypoxemia in acute type A aortic dissection (AADA) is a common complication and is associated with negative outcomes. This study aimed to analyze the efficacy of low-dose (5-10?ppm) inhaled nitric oxide (iNO) in the management of hypoxemia after AADA surgery. METHODS:In this retrospective observational study, Medical records of patients who underwent AADA surgery at two institutions between January 2015 and January 2018 were collected. Patients with postoperative hypoxemia were classified as iNO and control groups. Clinical characteristics and outcomes were compared using a propensity score-matched (PSM) analysis. RESULTS:Among 436 patients who underwent surgical repair, 187 (42.9%) had hypoxemia and 43 were treated with low-dose iNO. After PSM, patients were included in the iNO treatment (n?=?40) and PSM control (n?=?94) groups in a 1:3 ratio. iNO ameliorated hypoxemia at 6, 24, 48, and 72?h after initiation, and shortened the durations of ventilator support (39.0?h (31.3-47.8) vs. 69.0?h (47.8-110.3), p?

SUBMITTER: Zhang H

PROVIDER: S-EPMC6977331 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Effects of inhaled nitric oxide for postoperative hypoxemia in acute type A aortic dissection: a retrospective observational study.

Zhang Hang H Liu Yaoyang Y Meng Xiangdong X Yang Dicheng D Shi Sheng S Liu Jian J Yuan Zhongxiang Z Gu Tongtong T Han Lin L Lu Fanglin F Xu Zhiyun Z Liu Yang Y Yu Min M

Journal of cardiothoracic surgery 20200122 1

<h4>Background</h4>Postoperative hypoxemia in acute type A aortic dissection (AADA) is a common complication and is associated with negative outcomes. This study aimed to analyze the efficacy of low-dose (5-10 ppm) inhaled nitric oxide (iNO) in the management of hypoxemia after AADA surgery.<h4>Methods</h4>In this retrospective observational study, Medical records of patients who underwent AADA surgery at two institutions between January 2015 and January 2018 were collected. Patients with postop ...[more]

PMID: 31969173

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Project description:BackgroundThe inhaled vasodilators nitric oxide and epoprostenol may be initiated to improve oxygenation in mechanically ventilated patients with severe acute respiratory failure (ARF); however, practice patterns and head-to-head comparisons of effectiveness are unclear.Research questionWhat are the practice patterns and comparative effectiveness for inhaled nitric oxide and epoprostenol in severe ARF?Study design and methodsUsing a large US database (Premier Healthcare Database), we identified adult patients with ARF or ARDS who were mechanically ventilated and started on inhaled nitric oxide, epoprostenol, or both. Leveraging large hospital variation in the choice of initial inhaled vasodilator, we compared the effectiveness of inhaled nitric oxide with that of epoprostenol by limiting analysis to patients admitted to hospitals that exclusively used either inhaled nitric oxide or epoprostenol. The primary outcome of successful extubation was modeled using multivariate Fine-Grey competing risk (death or hospice discharge) time-to-event models.ResultsAmong 11,200 patients (303 hospitals), 6,366 patients (56.8%) received inhaled nitric oxide first, 4,720 patients (42.1%) received inhaled epoprostenol first, and 114 patients (1.0%) received both therapies on the same day. One hundred four hospitals (34.3%; 1,666 patients) exclusively used nitric oxide and 118 hospitals (38.9%; 1,812 patients) exclusively used epoprostenol. No differences were found in the likelihood of successful extubation between patients admitted to nitric oxide-only hospitals vs those admitted to epoprostenol-only hospitals (subdistribution hazard ratio, 0.97; 95% CI, 0.80-1.18). Also no differences were found in total hospital costs or death. Results were robust to multiple sensitivity analyses.InterpretationLarge variation exists in the use of initial inhaled vasodilator for respiratory failure across US hospitals. Comparative effectiveness analyses identified no differences in outcomes based on inhaled vasodilator type.

Project description:BackgroundHypoxemia is a common complication after Stanford type A acute aortic dissection surgery (AADS), however, few studies about hypoxemia after AADS exist. The aims of this study were to identify independent risk factors for hypoxemia after AADS and to clarify its association with clinical outcomes.MethodsPatients undergoing AADS from 2016 to 2019 in our hospital were identified and used as a training set. Preoperative variables were first screened by univariate analysis and then entered into a multivariate logistic regression analysis to identify independent risk factors. A nomogram and an online risk calculator were constructed based on the logistic model to facilitate clinical practice and was externally validated in an independent dataset.ResultsSevere hypoxemia developed in 119 of the 492 included patients (24.2%) and poorer clinical outcomes were observed in these patients. Five independent risk factors for severe hypoxemia after AADS were identified by multivariate analysis, including older age, smoking history, renal insufficiency, higher body mass index, and white blood cell count. The model showed good calibration, discrimination, and clinical utility in the training set, and was well validated in the validation set. Risk stratification was performed and three risk groups were defined as low, medium, and high risk groups. Hypertension was identified as an independent risk factor for moderate hypoxemia besides the five predictors mentioned above, and renal insufficiency was not significant for mild hypoxemia by multivariate analysis. In addition, although frozen elephant trunk was associated with increased risk of postoperative hypoxemia in the univariate analysis, frozen elephant trunk was also not identified as an independent risk factor for postoperative hypoxemia in the multivariate analysis.ConclusionHypoxemia was frequent following AADS, related to poorer clinical outcomes. Predictors were identified and a nomogram as well as an online risk calculator predicting severe hypoxemia after AADS was developed and validated, which may be helpful for risk estimation and perioperative management.

Project description:Objectives:The objectives of this study were to evaluate the efficacy and safety of inhaled epoprostenol and inhaled nitric oxide in patients with refractory hypoxemia secondary to coronavirus disease 2019. Design:Retrospective single-center study. Setting:ICUs at a large academic medical center in the United States. Patients:Thirty-eight adult critically ill patients with coronavirus disease 2019 and refractory hypoxemia treated with either inhaled epoprostenol or inhaled nitric oxide for at least 1 hour between March 1, 2020, and June 30, 2020. Interventions:Electronic chart review. Measurements and Main Results:Of 93 patients screened, 38 were included in the analysis, with mild (4, 10.5%), moderate (24, 63.2%), or severe (10, 26.3%), with acute respiratory distress syndrome. All patients were initiated on inhaled epoprostenol as the initial pulmonary vasodilator and the median time from intubation to initiation was 137 hours (68-228?h). The median change in Pao2/Fio2 was 0 (-12.8 to 31.6) immediately following administration of inhaled epoprostenol. Sixteen patients were classified as responders (increase Pao2/Fio2 > 10%) to inhaled epoprostenol, with a median increase in Pao2/Fio2 of 34.1 (24.3-53.9). The mean change in Pao2 and Spo2 was -0.55 ± 41.8 and -0.6 ± 4.7, respectively. Eleven patients transitioned to inhaled nitric oxide with a median change of 11 (3.6-24.8) in Pao2/Fio2. A logistic regression analysis did not identify any differences in outcomes or characteristics between the responders and the nonresponders. Minimal adverse events were seen in patients who received either inhaled epoprostenol or inhaled nitric oxide. Conclusions:We found that the initiation of inhaled epoprostenol and inhaled nitric oxide in patients with refractory hypoxemia secondary to coronavirus disease 2019, on average, did not produce significant increases in oxygenation metrics. However, a group of patients had significant improvement with inhaled epoprostenol and inhaled nitric oxide. Administration of inhaled epoprostenol or inhaled nitric oxide may be considered in patients with severe respiratory failure secondary to coronavirus disease 2019.

Project description:ObjectiveTo compare the efficacy and outcomes with inhaled nitric oxide (iNO) and inhaled epoprostenol (iEPO) in patients with refractory hypoxemia due to COVID-19.DesignRetrospective Cohort Study.SettingSingle health system multicenter academic teaching hospitals.Patients or subjectsAge group of 18-80 years admitted to the medical ICU.InterventionsMechanically ventilated patients with COVID-19 infection, who received either iNO or iEPO between March 1st, 2020, and June 30th, 2020.Measurements and main resultsThe primary outcome was the change in the PaO2/FiO2 (P/F) ratio 1 hour after initiation of pulmonary vasodilator therapy. Secondary outcomes include P/F ratios on days 1-3 after initiation, positive response in P/F ratio (increase of at least 20% in PaO2), total days of treatment, rebound hypoxemia (if there was a drop in oxygen saturation after treatment was stopped), ventilator free days (if any patient was extubated), days in ICU, days to extubation, days to tracheostomy, mortality days after intubation, 30-day survival and mortality. 183 patients were excluded, as they received both iNO and iEPO. Of the remaining 103 patients, 62 received iEPO and 41 received iNO. The severity of ARDS was similar in both groups. Change in P/F ratio at one hour was 116 (70.3) with iNO and 107 (57.6) with iEPO (Mean/SD). Twenty-two (53.7%) patients in the iNO group and 25 (40.3%) in the iEPO group were responders to pulmonary vasodilators n(%)(p = 0.152) (more than 20% increase in partial pressure of oxygen, Pao2), and 18 (43.9%) and 31 (50%) patients in the iNO and iEPO group (p = 0.685), respectively, had rebound hypoxemia. Only 7 patients in the cohort achieved ventilator free days (3 in the iEPO group and 4 in iNO group).ConclusionsWe found no significant difference between iNO and iEPO in terms of change in P/F ratio, duration of mechanical ventilation, ICU, in-hospital mortality in this cohort of mechanically ventilated patients with COVID-19. Larger, prospective studies are necessary to validate these results.

Dataset Information

Effects of inhaled nitric oxide for postoperative hypoxemia in acute type A aortic dissection: a retrospective observational study.

Publications

Effects of inhaled nitric oxide for postoperative hypoxemia in acute type A aortic dissection: a retrospective observational study.

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