Levosimendan versus milrinone in heart failure: a study of hemodynamic changes

Levosimendan is a drug with a considerable cardiotonic properties; it improve myocardial contractility without causing an increase in myocardial oxygen consumption. The aim of this randomized double blinded study was to compare the effect of levosimendan and milrinon on heamodynamic performance in patients with severe cardiac dysfunction due to acute heart failure. A total of 375 patients admitted to general I.C.U with acute heart failure with the need for hemodynamic monitoring and further hemodynamic support were allocated to this study. After exclusion of 215 patients, 160 patients were randomized to receive levosimendan [Group L, no.=81], or milrinon [Group M no.=79]. Group L patients [no.=81] received an initial loading dose of 12 micro g/kg i.v over 10 minutes, followed by a continuous infusion of 0.1 micro g/kg/min in a maximum of 0.4 micro g/min [according to hemodynamic tolerance]. Group M patients [no.=79] received a loading dose of 25 micro g/kg up to 75 micro g/kg followed by 0.375 micro g/kg/min that was escalated to 0.75 micro g/kg/min to reach satisfactory hemodynamic response. The favored target was to increase cardiac output to more than 30% of the baseline and decrease after load especially that of the right side [pulmonary artery pressure PAP] to more than -25% of the initial reading. Those hemodynamic results were expected to occur within 24 hours from starting the infusion. Hemodynamic parameters monitored were: Repeated baseline measurement of cardiac output [CO], pulmonary capillary wedge pressure [PCWP], mean right atrial pressure [CVP], mean pulmonary artery pressure [PAP] by means of pulmonary artery catheter. Cardiac index [CI], systemic vascular resistance [SVR], pulmonary vascular resistance [PVR] was calculated through hemodynamic measurements. Readings were taken 10 minutes after beginning of loading dose infusion, 1 hour, 4 hours, 8 hours, 12 hours, 18 hours and 24 hours, whilst systolic and diastolic blood pressure was continuously monitored by arterial cannula and heart rate and rhythm through ECG monitoring. The study target was achieved in 49 patients in the levosimendan group and 33 patients of the milrinone group. After tracing the study patients for 180 days, 7 patients of the levosimendan group had died, compared with 9 patients of the milrinone group. Levosimendane showed an improvement in hemodynamic performance than milrinone in case of acute heart failure and showed a lower mortality incidence than the latter drug as well

ALI/ARDS: controlled mechanical ventilation + PEEP versus pressure controlled inverse ratio ventilation

In this prospective randomized clinical trial study, 40 patients requiring mechanical ventilation for ALI ARDS were divided into 2 groups [n=20 each]. Group I patients underwent mechanical ventilation with CMV+ PEEP and those in group 2 were ventilated with PC-IRV technique. The initial mode of ventilation for all patients was the conventional control mechanical ventilation [CMV+ PEEP] which was applied for 1 hour after which the mode of ventilation was changed over to PC-IRV in group 2 while the same mode of ventilation [CMV + PEEP] was continued in group 1. The ventilator parameters [tidal volume [VT]], respiratory rate [RR] minute ventilation [VE], fraction of inspired oxygen [FIO[2]], [PEEP] and inspiratory flow wave form were selected and adjusted according to patients needs in the one hour before start of the study protocol. Once the chosen ventilator mode was started the ventilalatory parameters were studied for 24 hours without interruption. The mean blood pressure [MAP], HR, CVP, Spo[2], mean airway pressure [Pmean], plateau pressure [Pplat], peak inspiratory pressure [PIP], ABG, and PaO[2]/FIO[2] were measured before start of the chosen ventilator mode [zero hour], 1 hour, 6 hour, 12 hours and 24 hours after initiation of ventilator mode and the results were compared to those obtained at zero hour and between groups. Despite a general trend toward a drop in MAP in group 1 [CMV + PEEP], the difference between groups was statistically insignificant regarding hemodynamic parameters. PaO[2] and SpO[2] were both increased at 1 and 6 hours of ventilatory support in both groups, and the PaO[2] results obtained at 6, 12 and 24 hours were significantly higher in patients in group 2 [PC-IRV] compared to patients on CMV + PEEP. The PIP and Pplat were lower through out the study period in PC -IRV group compared to CMV + PEEP group. The PaO[2]/ FIO[2] ratio was significantly higher at 12 and 24 hours in PC- IRV group compared to CMV + PEEP group. These data shows that PC-IRV improves oxygenation and allows the generation of a lower PIP and Pplat in patients with ALI/ARDS compared to CMV + PEEP