Download Sp02 = Pulse Oximetry Oxygen Saturation Level PAP = Mean

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).