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RESPIRATORY THERAPY MANUAL
Hôpital régional de Sudbury Regional Hospital
ISSUED BY:
AUTHORIZED BY:
ICU Patient Care Team
Pharmacy & Therapeutics Committee
Critical Care Program Council
03 July 2003
REVISION DATE:
25 Jan 2008
27 Nov 2007
13 July 2005
12 May 2004
11 Dec 2003
CATEGORY:
Policy and Procedure cross-ref with Medication Administration
PAGE:
1
SUBJECT:
Epoprostenol sodium (Flolan) Administration via Nebulizer
ISSUE DATE:
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VALUE STATEMENT
It is the mission of the HRSRH to deliver safe and quality administration of flolan to patients.
POLICY
Inhalation of nebulized epoprostenol sodium is used in the treatment of pulmonary hypertension to provide
selective pulmonary vasodilation and improve arterial oxygenation. Flolan may also improve cardiac output,
especially in RV failure caused or exacerbated by pulmonary vasoconstriction.
Nebulized Epoprostenol sodium will be administered by the Registered Respiratory Therapist or Registered
Nurse in the Intensive Care Unit on the order of the physician for the following clinical conditions:
• Acute Respiratory Distress Syndrome (ARDS)
• Hypoxia evidenced by FiO2 requirements > 0.60
• RV Failure caused or exacerbated by pulmonary vasoconstriction
The methods of delivery of nebulized epoprostenol sodium include:
• Ventilator
• Non-invasive ventilation
• Mask and nebulizer
NOTE: There is minimal data available on the side effects of exposure to epoprostenol sodium in
pregnancy, therefore pregnant staff should avoid exposure when the delivery method is non-invasive
ventilation or mask and nebulizer.
PROCEDURE
Respiratory Therapist Responsibilities:
A. Ventilator
Prior to Epoprostenol sodium administration
• Ventilate as per Mechanical Ventilation Guidelines in ALI/ARDS (NIH) policy and procedure
• Arterial Blood Gases
• Calculate and record PaO2/FIO2 ratio
• Record peak airway pressure
• Record plateau pressure
Ventilator set up requirements
• Use AVEA ventilator or equivalent
• Set up air/oxygen blender
• Remove heat moisture exchanger (HME)
• Install heated humidifier and disposable dual heated wire circuit
CATEGORY:
SUBJECT:
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Policy and Procedure cross-ref with Medication Administration
Epoprostenol sodium (Flolan) Administration via Nebulizer
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Put Pall filter on expiratory line of ventilator circuit and change Q6H and PRN. NOTE: Due to the
“sticky” nature of the glycine diluent, the filter may have to be changed more frequently.
Install nebulizer system with IV port (for continuous infusion of medication) on inspiratory line of
ventilator circuit at patient wye.
Set blender to same FIO2 as set on ventilator
Set flow from blender to nebulizer at 6 Lpm
B. Non-Invasive Ventilation
Prior to Epoprostenol sodium administration
• Arterial blood gases
• Calculate and record PaO2/FIO2 ratio
Non-Invasive Ventilator set up requirements
• Set up air/oxygen blender
• Install heated humidifier
• Change non-invasive circuit to disposable heated wire circuit
• Install nebulizer system with IV port (for continuous infusion of medication) on non-invasive circuit distal
to temperature probe.
• Set blender to same FIO2 as set on non-invasive ventilation unit
• Set flow from blender to nebulizer at 6 Lpm
C. Face Mask and Nebulizer
Prior to Epoprostenol sodium administration
• Arterial blood gases
• Calculate and record PaO2/FIO2 ratio
Face Mask and Nebulizer set up requirements
• Set up air/oxygen blender
• Install nebulizer system with IV port onto face mask
• Set blender to same FIO2 as patient currently on
• Set flow from blender to nebulizer at 6 Lpm
Assessments following initiation of Epoprostenol sodium
A. Ventilated Patients
• Record peak airway pressure and plateau pressure at 15, 30 and 60 minute interval and then q2h and PRN:
-
If peak airway pressure increases, but remains < 45 cm H2O → no change
-
If peak airway pressure increases to > 45 cmH2O → decrease airway flow by 5 Lpm and repeat
measurements in 15 minutes
-
If plateau pressure increases but remains < 35 cmH2O → no change
-
If plateau pressure increases, but remains > 35 cmH2O → decrease VT by 50 mL and repeat
measurements in 15 minutes
•
Repeat ABG and calculate PaO2/FiO2 ratio at 60 minute interval then every 8 hours for 24 hours and
then as ordered by physician
CATEGORY:
SUBJECT:
Policy and Procedure cross-ref with Medication Administration
Epoprostenol sodium (Flolan) Administration via Nebulizer
PAGE:
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If no increase in PaO2/FIO2 ratio after 1 vial Epoprostenol sodium infused, DISCONTINUE
nebulized infusion. Notify physician on next rounds.
B. Non-Invasive Ventilation/ Mask and Nebulizer
•
Repeat ABG and calculate PaO2/FiO2 ratio at 60 minute interval then every 8 hours for 24 hours and
then as ordered by physician
If no increase in PaO2/FIO2 ratio after 1 vial Epoprostenol sodium infused, DISCONTINUE
nebulized infusion. Notify physician on next rounds.
Nursing Responsibilities:
EQUIPMENT
• Epoprostenol sodium (15 or 30 micrograms/mL) prepared by pharmacy
• Primary IV Plumset IV tubing
• IV pump
• Aluminum foil
• Amber ultaviolet bag
• Ice packs
•
During pharmacy off-hours:
• Flolan (Epoprostenol sodium) vial 1.5 mg
• Diluent vial(s) (50 mL or 100mL based on patient weight)
• Viaflex bag
PROCEDURE
• Cover prepared Epoprostenol sodium bag with amber ultraviolet bag. Place between 2 ice / gel packs (cold
and dark)
• Spike convertible piercing pin of IV tubing into viaflex bag.
• Prime tubing and insert into IV pump.
• Attach pump tubing to nebulizer port. Cover nebulizer and tubing with aluminum wrap.
• Infuse 3 mL prepared Epoprostenolsodium into nebulizer system as initial volume for nebulization.
• Commence nebulized infusion by setting delivery rate and volume.
• Start drip in nebulizer chamber at 50mg/kg/min (refer to Weight Based Infusion Rate tables)
• Once infusion via pump commences, solution can be administered for up to 24 hours through use of
frozen gel packs in a cold pouch. Gel packs should be changed every 12 hours or every 8 hours (if ambient
temperature approaches 30° celcius).
• When stored or in use, reconstituted Epoprostenol sodium must not be exposed to direct sunlight.
CATEGORY:
SUBJECT:
Policy and Procedure cross-ref with Medication Administration
Epoprostenol sodium (Flolan) Administration via Nebulizer
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Drug preparation instructions (for pharmacy off-hours):
• Prepare syringe and needle.
• Draw up 5 mL sterile diluent. Reconstitute only with specific STERILE DILUENT for
Epoprostenol sodium supplied by manufacturer in 50 mL glass vial(s). No other diluent to be
used in preparation of drug.
• Inject 5 mL sterile diluent gently onto the side of the Epoprostenol sodium vial. Always direct the flow of
the sterile diluent towards the side of the vial and inject it gently to prevent foaming of the solution. Mix
by gently swirling the vial. Never shake the vial.
• Withdraw entire vial contents once drug dissolved.
• Inject mixed Epoprostenol sodium into medication port of viaflex bag. Add remaining STERILE
DILUENT as required to make total of 50 or 100 mL (refer to Weight Based Infusion Rate tables).
• Label medication
Weight Based Infusion Rate
(round up to nearest weight)
Patient < 80 kg : Epoprostenol sodium 1.5 mg/ 100 mL diluent (15 micrograms/ml)
Weight (kg) Rate (mL/hr)
50
10
55
11
60
12
65
13
70
14
75
15
Patient > 80 kg : Epopostenol sodium 1.5mg/50 mL diluent (30 micrograms/ml)
Weight (kg) Rate (mL/hr)
80
8
85
8.5
90
9
95
9.5
100
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CATEGORY:
SUBJECT:
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•
Policy and Procedure cross-ref with Medication Administration
Epoprostenol sodium (Flolan) Administration via Nebulizer
PAGE:
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Blood Pressure monitoring parameters:
(Epoprostenol sodium may be associated with some systemic effect and hypotension)
• prior to commencement of Epoprostenol sodium infusion
• at 15 and 30 minute interval following commencement of infusion, as ordered and PRN.
If hypotension occurs, requiring increase in current vasopressors or initiation of vasopressors, notify
Intensivist
APPROVAL
APPROVED
REVIEWED
17 Sept 2003
09 sept 2003
11 Dec 2003
Dec 2003
16 June 2004
14 Sept 2004
25 June 2004
Critical Care Clinicians/Educators
Critical Care Patient Care Teams
Respiratory Therapy Committee
Critical Care Council
Pharmacy & Therapeutics
Critical Care Planning
Clinical Managers
Committees
Date of
Draft
Approval
Final
Approval
Date
Reviewed
16 June 2004
10 Jan 2008
06 Dec 2007
14 Sept 2005
07 Nov 2007
13 July 2005
25 Jan 2008
23 Sept 2005
Manager/Nurse Clinician/Educator
ICU Patient Care Team
Respiratory Therapy Committee
Critical Care Program Council
Medical Advisory Committee
Clinical Management Committee
All Rights Reserved
H/p&p/online/ICU/EPOPROSTENOL SODIUM (FLOLAN) ADMINISTRATION VIA NEBULIZER/R Nov 2007/R Jan 2008
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