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Is Administration of Nitric Oxide During Extracorporeal Membrane Oxygenation Associated With Improved Patient Survival?

Tadphale, Sachin D. MBBS, MPH; Rettiganti, Mallikarjuna PhD; Gossett, Jeffrey M. MS; Beam, Brandon W. JD; Padiyath, Asif MBBS; Schmitz, Michael L. MD; Gupta, Punkaj MBBS

doi: 10.1097/PCC.0000000000000939
Extracorporeal Support
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Objective: To evaluate the outcomes associated with the use of inhaled nitric oxide during extracorporeal membrane oxygenation.

Design: Post hoc analysis of data from an existing administrative national database, Pediatric Health Information system (2004–2014). Multivariable logistic regression models were fitted to study the effect of inhaled nitric oxide during extracorporeal membrane oxygenation on study outcomes.

Setting: Forty-two children’s hospitals across the United States.

Patients: Patients in the age group from 1 day through 18 years admitted to an ICU who received extracorporeal membrane oxygenation during their hospital stay were included.

Interventions: None.

Measurements and Main Results: In total, 6,419 patients qualified for inclusion. Of these, inhaled nitric oxide was used among 3,629 patients during extracorporeal membrane oxygenation run. Approximately one half of the study patients received inhaled nitric oxide at extracorporeal membrane oxygenation initiation. The proportion of patients receiving inhaled nitric oxide during extracorporeal membrane oxygenation decreased with increasing duration of extracorporeal membrane oxygenation. After adjusting for patient characteristics and center variables, use of inhaled nitric oxide was not associated with any survival benefit. However, higher proportion of patients receiving inhaled nitric oxide were associated with prolonged hospital length of stay and prolonged duration of extracorporeal membrane oxygenation. In adjusted models, the hospital charges were higher in the inhaled nitric oxide group. The median hospital costs among patients receiving inhaled nitric oxide were higher by $39,732 (95% CI, $31,074–48,390) as compared to the patients who did not receive inhaled nitric oxide, after adjusting for patient (including hospital length of stay) and center level variables. As the duration of inhaled nitric oxide therapy increased, proportion of patients with prolonged duration of extracorporeal membrane oxygenation and prolonged hospital length of stay increased.

Conclusions: This large observational analysis of use of nitric oxide during extracorporeal membrane oxygenation calls into question the benefits of inhaled nitric oxide among patients receiving extracorporeal membrane oxygenation for pulmonary or cardiac failure. Given our inability to determine type of extracorporeal membrane oxygenation and control for severity of illness, these findings should be interpreted as exploratory.

Supplemental Digital Content is available in the text.

1Division of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR.

2Biostatistics Program, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR.

3Department of Bioinformatics, Arkansas Children’s Hospital, Little Rock, AR.

4Division of Pediatric Anesthesia, Department of Anesthesia, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: pgupta2@uams.edu

©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies