Practical approach to the use and monitoring of dofetilide therapy

FDA's requirements for the use of dofetilide are described, and one hospital's strategy for meeting the requirements is discussed. Dofetilide is a specific class III antiarrhythmic agent approved for use in the conversion of atrial fibrillation and atrial flutter and the maintenance of normal sinus rhythm. It is available as an option for highly symptomatic patients who fail to respond to or do not tolerate other antiarrhythmic agents and patients with structural heart disease. Because of the risk of torsade de pointes associated with dofetilide, FDA has mandated in-hospital initiation of dofetilide therapy and has restricted its availability to hospitals and prescribers who have received appropriate education on dofetilide treatment initiation and dosing. Control of the drug's distribution is limited to a single wholesaler and a single mail-order pharmacy. These restrictions, along with the FDA labeling and the inherent risks associated with dofetilide use, have made this drug a complicated agent to use within an institution. When dofetilide was added to the formulary at Harper University Hospital, policies and procedures were developed to ensure appropriate use and monitoring. The use of dofetilide within health systems requires detailed procedures for prescribing, dispensing, and monitoring and thorough education of caregivers about those procedures. Pharmacists have a pivotal role in ensuring the appropriate use of dofetilide.

Utilization of Neurally Adjusted Ventilatory Assist (NAVA) Mode in Infants and Children Undergoing Congenital Heart Surgery: A Retrospective Review

We assessed the feasibility and the impact of NAVA compared to conventional modes of mechanical ventilation in ventilatory and gas exchange parameters in post-operative children with congenital heart disease. Infants and children (age < 18 years) that underwent congenital heart surgery were enrolled. Patients were ventilated with conventional synchronized intermittent mechanical ventilation (SIMV) and subsequently transitioned to NAVA during their cardiovascular intensive care unit (CVICU) stay. The ventilatory and gas exchange parameters for the 24 h pre- and post-transition to NAVA were compared. Additional parameters assessed included pain scores and sedation requirements. Eighty-one patients met inclusion criteria with a median age of 21 days (interquartile range 13 days-2 months). The majority of patients enrolled (75.3%) had complex congenital heart disease with high surgical severity scores. The transition to NAVA was tolerated by all patients without complications. The mean peak inspiratory pressure (PIP) was 1.8 cm H2O lower (p < 0.001) and mean airway pressure (Paw) was 0.5 cm H2O lower (p = 0.009) on NAVA compared to conventional modes of mechanical ventilation. There was no significant difference in patients' respiratory rate, tidal volume, arterial pH, pCO2, and lactate levels between the two modes of ventilation. There was a decreased sedation requirement during the time of NAVA ventilation. Comfort scores did not differ significantly with ventilator mode change. We concluded that NAVA is safe and well-tolerated mode of mechanical ventilation for our cohort of patients after congenital heart surgery. Compared to conventional ventilation there was a statistically significant decrease in PIP and Paw on NAVA.

Noninvasive Neurally Adjusted Ventilatory Assist Versus High Flow Cannula Support After Congenital Heart Surgery

BACKGROUND

Extubation failure rates for critical patients in pediatric intensive care units (ICUs) range from 5% to 29%. Noninvasive (NIV) ventilation has been shown to decrease extubation failure. We compared reintubation rates and outcomes of patients supported with NIV neurally adjusted ventilation assist (NAVA) versus historical controls supported with high-flow nasal cannula (HFNC).

METHODS

Case-control study of infants less than three months of age who underwent cardiac surgery and received NIV support after extubation from January 2011 to May 2017. All patients supported with NIV NAVA after it became available in September 2013 were compared to matched patients extubated to HFNC from prior to September 2013.

RESULTS

Forty-two patients identified for the NIV NAVA group were matched with 42 historical controls supported with HFNC. Groups had similar baseline characteristics based on rate of acute kidney injury, number of single ventricle patients, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category, age, weight, bypass time, and duration of intubation. There was no significant difference in reintubation rates within 72 hours (14.3% in the HFNC group and 16.7% in the NIV NAVA group, P = 1.0). Median duration from extubation to coming off NIV support was longer in the NIV NAVA group (3.6 days vs 0.6 days, P < .001). Median time from extubation to ICU discharge was longer in the NIV NAVA group (10.5 vs 6.8 days, P = .02), as was total postoperative ICU length of stay (LOS; 17.6 vs 12.2, P = .01).

CONCLUSIONS

Introduction of NIV NAVA for postextubation support did not reduce reintubation rates compared to HFNC. Further study is needed as adoption of NIV NAVA may prolong LOS.