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B7180 - 84.1 Santa Clara Valley Medical Center N: 10/08, R-NC: 6/12 Respiratory Care Attachment A Nitric Oxide (NO) Administration Protocol MD writes order for Nitric Oxide Therapy Ordering Indications _________ Class I RCP Documents baseline parameters for: PaO2 ______ PAP ______ Sp02 ______ PVR ______ ______ Class II MAP ______ CI _______ ______ Class III ______ Class IV Start Nitric Oxide at 20 ppm Wait 15 minutes After 15 minutes, is there a > 10% DESIRED Change in: Pa02 _____ SpO2 _____ MAP ____ PAP _____ CI ______ NO Increase Nitric Oxide to 40 ppm YES Wean Nitric Oxide to 10 ppm After 15 minutes, is there a DESIRED Change in: Pa02 _____ SpO2 _____ MAP ____ PAP _____ Wait 15 minutes After 15 minutes, is there a > 10% NO CI ______ > 10% DESIRED Change in: Pa02 _____ SpO2 _____ MAP ____ PAP _____ CI ______ NO Discontinue Nitric Oxide YES YES Return patient at 20 ppm and evaluate for weaning every 4 hours Wean Nitric Oxide to 5 ppm Decrease Nitric Oxide to 30 ppm After 15 minutes, is there a DESIRED Change in: Pa02 _____ SpO2 _____ MAP ____ PAP _____ CI ______ > 10% Wait 15 minutes NO After 15 minutes, is there a DESIRED Change in: Return patient at 10 ppm and evaluate for YES weaning every 4 hours Pa02 _____ MAP ____ SpO2 _____ PAP _____ > 10% NO CI ______ Leave patient at 5 ppm and evaluate for DC every 4 hours YES PaO2 = Arterial Oxygenation Level Sp02 = Pulse Oximetry Oxygen Saturation Level MAP = Mean Arterial Pressure PAP = Mean Pulmonary Artery Pressure CI = Cardiac Index Return patient at 40 ppm and evaluate for weaning every 4 hours 1. Class I. Documented Efficacy in Clinical Trials Use of Nitric Oxide (NO) is Unrestricted with these indicators a. Neonatal Hypoxic Respiratory Failure b. Neonates with documented Persistent Pulmonary Hypertension of the Neonate (PPHN) 1. Echocardiographic evidence 2. Clinical evidence PVR = Pulmonary Vascular Resistance 2. Class II. Probable to Possible Efficacy--Use NO restricted to those patients Showing documented improvement of elevated PAP or improved pulmonary bloo Flow or CVP on ECHO or Pulmonary Artery line a. Infant and Pediatric patients with Pulmonary HTN b. Infant and Pediatric patients with Single Ventricle palliation and elevated PVR 3. Class III. Probable to Possible Efficacy—Use NO restricted to trial therapy. Must be a documented positive effect within ½ hour of initiation. Improved PAP, and/or increased C.O., and/or improved oxygenation and/or oxygen Saturation shall be considered positive effect for these indications. a. Cardiac surgery complicated by Pulmonary Arterial Hypertension (PAH) and RV dysfunction. b. RV failure due to acute MI or Pulmonary Embolism. c. Heart Transplant patients with elevated PAP and/or RV dysfunction. d. RV failure post insertion of a left ventricular assist device (LVAD). e. Treatment of pulmonary ischemia-reperfusion injury following lung transplantation. 4. Class IV. Unknown Efficacy -- Use NO restricted to short trial of therapy for immediate life-threatening condition. Continued use only with documented Improved PAP, Improved MAP, and/or increased C.O. /C.I., and/or improved oxygenation and/or oxygen saturation. a. Acute Respiratory Distress Syndrome (ARDS).