Anesth Analg 2006;102:964
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000198589.85524.60
COCHRANE CORNER
Inhaled Nitric Oxide for the Postoperative Management of Pulmonary Hypertension in Infants and Children with Congenital Heart Disease
M. Buzzarro, and
I. Gross
Background:
Nitric oxide (NO) is a prevalent molecule in the human body responsible for many physiologic activities, including pulmonary vasodilation. An exogenous, inhaled form (iNO) exists that mimics this action without directly affecting systemic blood pressure. This therapy has been implemented in the treatment of pulmonary hypertension of the newborn. This review examines the efficacy of iNO in the postoperative management of infants and children with congenital heart disease.
Objectives:
We compared the effects of postoperative iNO versus placebo and/or conventional management on infants and children with congenital heart disease. The primary outcome was mortality, while secondary outcomes included length of hospital stay, assessment of neurodevelopmental disability, number of pulmonary hypertensive crises (PHTC), changes in hemodynamics, including mean pulmonary arterial blood pressure (MPAP), mean arterial pressure (MAP), and heart rate (HR), changes in oxygenation measured as the ratio Pao2:Fio2, and measurement of maximum methaemoglobin level as a marker of toxicity.
Search strategy:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2004), MEDLINE (1966 to 2004), and EMBASE (1980 to 2004). We included abstracts and all languages.
Selection criteria:
We included randomized and quasi-randomized controlled trials comparing iNO with placebo and conventional management, or both. Trials included only children with congenital heart disease requiring surgery and complicated by pulmonary hypertension.
Data collection and analysis:
Data were collected on mortality, number of PHTC, changes in MPAP, MAP, HR, and Pao2:Fio2, and maximum methaemoglobin level, while data on long-term mortality, neurodevelopmental disability, and length of hospital stay were unavailable. We performed subgroup analysis by age and method of control. We performed sensitivity analysis using studies of highest methodologic quality.
Main results:
We included four randomized trials. We observed no differences between groups with respect to mortality (P = 0.50), PHTC (P = 0.79), change in MPAP (P = 0.16), MAP (P = 0.40), HR (P = 1.00), or Pao 2:Fio 2 (P = 0.46). There was a significant reduction in MPAP in the subgroup of patients from birth to 3 months (P = 0.005), although this finding was based on a small number of patients (n = 23).
Reviewers’ conclusions:
We observed no differences with the use of iNO as compared with control in the majority of outcomes reviewed. No data were available for analysis with respect to several clinical outcomes including long-term mortality and neurodevelopmental outcome. We found it difficult to draw valid conclusions because of concerns regarding methodologic quality, bias, sample size, and heterogeneity.
Citation:
Bizzarro M, Gross I. Inhaled nitric oxide for the postoperative management of pulmonary hypertension in infants and children with congenital heart disease. (Cochrane Review). In: The Cochrane Library, Issue 4, 2005. Chichester, UK: John Wiley & Sons, Ltd. Copyright Cochrane Library, reproduced with permission
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