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Table 6 Agents used to reduce PVR in the ICU setting

From: Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

Drug Dose Half-life (duration of action) Potential adverse effects
   Prostacyclin (Epoprostenol, Flolan) Start at 1 ng/kg/min; titrate upward in 2-ng/kg/min increments according to effect 3-5 minutes (10 minutes) Systemic hypotension, worsening oxygenation (increased V/Q mismatch), antiplatelet effect, headache, flushing, jaw pain, nausea, diarrhea
   Iloprost 1-5 ng/kg/min 30 minutes Similar to Flolan; also syncope (5%)
   Sildenafil [325] (NB off-license use in hemodynamically unstable patients) Low dose, 0.05 mg/kg; high dose, 0.43 mg/kg) (comes as 0.8 mg/ml) 3-5 hours Hypotension: caution if fluid depleted, severe LV-outflow obstruction, autonomic dysfunction. Hypoxemia due to V/Q mismatch. Common: headache, flushing, diarrhea, epistaxis, tremor. Rare but important: anterior ischemic optic neuropathy
   Milrinone 50 μg/kg over 10 minutes followed by 0.375-0.75 μg/kg/min infusion 1-2 hours Tachyarrhythmias, hypotension
   Adenosine 50-350 μg/kg/min, titrate up in 50 μg/kg/min increments 5-10 seconds (2 minutes) Bradycardia, bronchospasm, chest pain
Inhaled (preferred; Note variable absorption likely)    
   Prostacyclin (Epoprostenol, Flolan) [286, 303] 0.2-0.3 ml/min of 10-20 μg/ml nebulized into inspiratory limb of ventilator circuit (30-40 ng/kg/min) 3-5 minutes As above but less hypotension and improved oxygenation compared with intravenous use
   Iloprost [275] 2.5-5 μg 6-9 times/day, 1 mg/ml milrinone into the ventilator circuit at 0.2-0.3 ml/min for 10-20 minutes 30 minutes As above and bronchospasm
   Milrinone [176, 178, 179] 5-80 ppm continuously 1-2 hours Less systemic hypotension than with IV milrinone
   NO   15-30 seconds (5 minutes) Methemoglobinemia; withdrawal PH
ORAL (rarely in ICU)    
   Bosentan 62.5-125 mg b.d. 5 hours Liver-function test abnormalities; drug interactions; edema
   Sildenafil 0.25-0.75 mg/kg 4 hrly 3-4 hours As above; less hypotension and hypoxemia in stable patients