GA2-65
Intra-operative use of continuous inhaled epoprostenol: A case series
Diaz-Rodriguez N, Wadia R, Goswami D, Coulson J, Romer L
Johns Hopkins Medical Institutions, Baltimore, MD, United states
Introduction: Pulmonary hypertension (PH) has multiple etiologies and can contribute to substantial perioperative morbidity and mortality. With increases in PH incidence, recognition, improvements in targeted care, and emerging therapies, the inflation-adjusted hospital charges in the United States for pediatric PH hospitalization have increased from $926 million in 1997 to $3.12 billion in 2012 (1). Inhaled nitric oxide (iNO) has long been the preferred treatment of acute PH management in pediatric patients; however, continuous inhaled epoprostenol (iEpo) has been shown to be a possible alternative (2). Continuous inhaled epoprostenol (Flolan®, GlaxoSmithKline) may provide a cost savings of up to fifty-fold when compared to iNO, and therefore, may challenge iNO as a preferred therapeutic agent in PH management. We examined our children's center's use of iEpo during surgical procedures over a 14-month period. To our knowledge this is the first report of intraoperative use of iEpo in children. We summarize our experience, challenges and recommendations.
 
Methods: We conducted a retrospective chart review of all children <18 years of age that were treated with iEpo at the Johns Hopkins Bloomberg Children's Center between 7/1/16 and 8/30/17. Anesthetic record(s) of the patients who underwent surgical procedures while receiving iEpo were reviewed.  
 
Results:  We identified 74 patients treated with iEpo. Twenty-four patients (32.4%) underwent 38 surgical procedures while receiving this therapy.  Ten patients were female, 14 were male, and the mean age was 2.87 years. A pediatric cardiac anesthesiologist staffed 25 (65.6%) procedures while a non-cardiac pediatric anesthesiologist staffed 13 (34.4%). The intra-operative dose of iEpo was 50 ng/kg/min in all cases, and no titrations were made. Patients were on additional pulmonary vasodilators (i.e. oral sildenafil, IV treprostinil) for 29 of the 38 anesthetics (76.3%). Challenges associated with iEpo delivery were encountered in 8 (21%) procedures, and included: loss of end-tidal CO2 (etCO2) monitoring, inability to monitor exhaled volatile anesthetic concentration, and malfunction of the water trap within the gas sampling module.  
 
Discussion: Continuous inhaled prostacyclin analog therapy is being used with increased frequency in the management of acute PH. As this approach becomes more accepted, its use in the operating room will likely also increase. Optimal care of these patients requires reliable medication delivery via aerosol nebulizing system and delivery pump, and a continuous anesthesia machine gas monitoring system. Alternatively, the aerosolized delivery system may be used with an ICU ventilator and infrared etCO2 monitoring. The later approach precludes the use of inhalational gas administration, and mandates a total intravenous anesthetic. We demonstrate that by circumventing these challenges, patients on iEpo can safely continue this medication throughout the perioperative period.
 
References: 
1- Maxwell BG, et al. Pediatrics. 2015;136(2):241-50
2- Preston IR, et al. Pulm Circ. 2013; 3(1):68-73
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