A Stewardship Program to Optimize the Use of Inhaled Nitric Oxide in Pediatric Critical Care

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Inhaled nitric oxide (iNO) is a pulmonary vasodilator that is approved for use in term and near-term neonates with hypoxic respiratory failure associated with evidence of pulmonary hypertension. However, it is commonly used in infants and children to treat a variety of other cardiopulmonary diseases associated with pulmonary hypertension and hypoxic respiratory failure. In critically ill children, iNO therapy may be continued for a prolonged period, and this increases the risk for adverse consequences including toxicity and unnecessary costs. We implemented an iNO Stewardship Program with the aim of improving adherence to guidelines and reducing unnecessary iNO utilization.


Between April 1, 2011, and March 31, 2015, a before and after cohort study was conducted at The Hospital for Sick Children. Prospective iNO usage and outcome variables in the poststewardship period were examined.


Patient characteristics and outcomes were similar before and after stewardship implementation. The number of iNO therapy courses were also similar in the before and after period. Inhaled nitric oxide utilization in the pediatric intensive care unit and the cardiac critical care unit decreased from 15 765 hours in the prestewardship period (April 2011 to March 2013) to 10 342 hours in the poststewardship period (April 2013 to March 2015), with significant improvement in adherence to the iNO guideline and a small decrease in expenditure (3%).


Implementation of the iNO Stewardship was successful at reducing overall iNO utilization. This quality improvement initiative helped us optimize practice and subsequently expand the methodology to inform the clinical indication for iNO.

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