A review of the use of inhaled nitric oxide in the PICU at Red Cross War Memorial Children's Hospital, 2011-2015: A retrospective cohort study.

Background: Inhaled nitric oxide (iNO) functions as a selective pulmonary vasodilator. It is an expensive treatment that is often employed as rescue therapy for refractory hypoxaemia in acute respiratory distress syndrome (ARDS) and pulmonary hypertension (PHT) following cardiac surgery. Objectives: To describe the use of iNO and the cost of treatment in our paediatric intensive care unit (PICU). Methods: A retrospective descriptive study of all patients treated with iNO in the PICU at Red Cross War Memorial Children's Hospital (RCWMCH) from 2011 - 2015. Results: We treated 140 patients with iNO, 82 for PHT following cardiac surgery, 53 for ARDS and 5 for persistent pulmonary hypertension of the newborn (PPHN). A response to treatment was observed in 64% of the cohort as a whole, 80% of those with PPHN, 67% of those with PHT post-cardiac surgery, and 64% of those with ARDS. A longer duration of PICU and hospital admission, and higher in-hospital mortality (53%), was seen in the group with ARDS, in particular those with adenoviral infection (63%), when compared with patients treated for PHT post-cardiac surgery (18%) and for PPHN (20%). The total cost of treatment with iNO was ZAR1 441 376 for the 5-year period studied. There are no protocols guiding the use of iNO in our unit, and it was found that response to treatment was not being objectively measured and documented, and that practice varied between clinicians. Conclusion: Considering the cost of treatment and lack of evidence showing improved outcomes with iNO therapy, its continued use in our resource-limited setting should be guided by protocol. Contributions of the study: There is a paucity of data regarding the indications for use, and outcomes of patients treated with iNO in resource-limited settings. We did not find evidence of improved outcomes in patients treated with iNO despite the high costs of the therapy. Protocols should be developed to guide the use of iNO in resource-limited settings.