This episode continues on from last time's talk by Sara Crager on Right Ventricular Failure. This is a Q&A session with a focus on inhaled pulmonary vasodilators.
Nitric Oxide
Sara likes it through ETT or Hi-Flo NC (can also be done through BIPAP)
Start at 20 ppm
See results within 5-10 minutes
Monitor with CVP
Problems
- Nitric Dioxide (NO2) may be formed which can lead to pulmonary edema or even alveolar hemorrhage.
- MetHb can be formed and some people do routine monitoring for this dyshemoglobinemia.
Additional Resources
- PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP?
- Review Article on Inhaled NO
Epoprostenol (Flolan)
May be more complicated to set-up
go back to marker 5
Epoprostenol @ 0.05 mcg/kg/min
Must have filters on the circuit
Milrinone
Get the vial, you want 1 mg/ml with 15 mls in vial
5 ml (5 mg) q 6 hours (According to Dr. Crager–may be more frequent if symptoms rebound (down to q 3 hrs))
Ideally use ultrasonic nebulizer
onset ~15 minutes
Must have filters on circuit
LVOTO & RVOTO contraindication for the milrinone
respigard!!!
aeroneb pro
must have filters on vent
Additional Resources
Intratracheal Milrinone Bolus for a Crashing Patient
50-80 mcg/kg or 5 mg (1/2 a bolus is also used by some)
onset 4-5 minutes
from the amazing Hospitalist & the Resuscitationist Lecture 2019 by Andre Denault
Nitro
Need conc. of 1 mg/ml (standard bottle is 200 mcg/ml)
Doses in studies range from 2.5-25 mcg/kg/min for 10 minutes or 50 ug/kg total given over 8 minutes (perhaps easiest to put 4-5 mg in neb and let it run)
Additional New Information
More on EMCrit
Inhaled Pulmonary Vasodilators(Opens in a new browser tab)
Right Ventricular failure(Opens in a new browser tab)
Additional Resources
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- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
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Hi Scott, I love listening to you from Brisbane Australia. I’m a nurse who owns an education company , and known for my dogmalysing posts and teaching.
I wanted to run a very short concept past you for opinion.
It’s about Shock classifications. I think the books are missing one.
https://knowingyourjargon.blogspot.com/2020/05/a-5th-category-of-shock-pneumogenic.html?m=1
Thank you both for an amazing series!
Any thoughts on nebulized and inhaled phentolamine?
With regards to the volume concerns with 200mcg/mL nitro, thoughts on using the sublingual spray nitro with some sterile water to dilute into the nebulizer? It is much more concentrated, but also an imprecise dose (and kind of hit or miss if EDs stock it). I wonder if 5mg in 5-6 mL would be too potent?
I don’t know about the availibility in the US, but Takeda sells concentrated GTN, 5mg/ml. It is widely used both in-hospital and pre-hospital settings in Norway. A bit more straightforward to dilute this to 1mg/ml than starting from 200 micrograms/ml
In Brazil we have nitroglicerin 5mg/ml amp
Hi Sara,
I had a question relating to the use of isosorbide dinitrate instead of nitro.
My hospital does not have nitro as it adsorbs onto PVC cannulas, rendering the medication ineffective.
Could ISDN be used as an alternative & if so, in what dose/concentration?