Implementation of an Inhaled Nitric Oxide Weaning Protocol and Stewardship in a Level 4 NICU to Decrease Inappropriate Use

Walid A Hussain; Deborah S Bondi; Pooja Shah; Sherwin E Morgan; Sudhir Sriram; Michael D Schreiber

doi:10.5863/1551-6776-27.3.284

Implementation of an Inhaled Nitric Oxide Weaning Protocol and Stewardship in a Level 4 NICU to Decrease Inappropriate Use

J Pediatr Pharmacol Ther. 2022;27(3):284-291. doi: 10.5863/1551-6776-27.3.284. Epub 2022 Mar 21.

Authors

Walid A Hussain¹, Deborah S Bondi², Pooja Shah², Sherwin E Morgan³, Sudhir Sriram⁴, Michael D Schreiber⁴

Affiliations

¹ Section of Neonatology, Department of Pediatrics (WAH), Loyola University Medical Center, Maywood, IL.
² Department of Pharmacy (DSB, PS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL.
³ Department of Respiratory Care Services (SEM), University of Chicago Medicine, Chicago, IL.
⁴ Section of Neonatology, Department of Pediatrics (SS, MDS), University of Chicago Medicine Comer Children's Hospital, Chicago, IL.

Abstract

Objective: Inhaled nitric oxide (iNO) is an effective but expensive treatment of pulmonary hypertension in newborns, with limited data regarding weaning. Our institution implemented a multidisciplinary iNO weaning protocol and stewardship to reduce inappropriate use of iNO. The objective of this study was to evaluate our institutional iNO usage before and after implementation.

Methods: Single-center study comparing a retrospective control group to a prospective cohort after implementation of an iNO weaning protocol. All infants in the neonatal intensive care unit (NICU) who received iNO during the study timeframe were included. The primary outcome was duration of iNO per course.

Results: A total of 47 courses of iNO occurred during the pre-protocol timeframe compared with 37 courses in the post-protocol timeframe. Median iNO usage per course was 149 hours (IQR, 63-243) in the pre-protocol group versus 59 hours (IQR, 37-122) in the post-protocol group (p = 0.008). Length of stay was significantly longer in the pre-protocol group (p = 0.02), likely related to significantly longer ventilator days in the pre-protocol group (p = 0.02). Compliance with initiation of weaning when recommended per the protocol was 72%, and the incidence of successful weaning was 74%.

Conclusions: The implementation of an iNO weaning protocol in the NICU significantly decreased iNO usage by approximately 60% with no notable negative effects.

Keywords: inhaled nitric oxide; neonatal; stewardship; weaning protocol.