Continuous Intravenous Inotropes in Ward Units: Expanding Therapy Outside Intensive Care using a Safety-Oriented Protocol / Inotrópicos Intravenosos Contínuos em Unidades de Enfermaria: Expandindo o Tratamento Além da Unidade de Terapia Intensiva Utilizando um Protocolo Orientado em Segurança

Abstract Selected clinically stable patients with heart failure (HF) who require prolonged intravenous inotropic therapy may benefit from its continuity out of the intensive care unit (ICU). We aimed to report on the initial experience and safety of a structured protocol for inotropic therapy in non-intensive care units in 28 consecutive patients hospitalized with HF that were discharged from ICU. The utilization of low to moderate inotropic doses oriented by a safety-focused process of care may reconfigure their role as a transition therapy while awaiting definitive advanced therapies and enable early ICU discharge.

Resumo Pacientes selecionados com insuficiência cardíaca (IC), clinicamente estáveis que necessitam de terapia inotrópica intravenosa prolongada podem se beneficiar de sua continuidade fora da unidade de terapia intensiva (UTI). Nosso objetivo foi relatar a experiência inicial e a segurança de um protocolo estruturado para terapia inotrópica em unidades de terapia não-intensiva em 28 pacientes consecutivos hospitalizados com IC que receberam alta da UTI. A utilização de doses inotrópicas baixas a moderadas, orientadas por um processo de cuidado focado na segurança, pode reconfigurar seu papel como terapia de transição enquanto aguarda terapias avançadas definitivas e permite a alta precoce da UTI.

Milrinona inhalada en hipertensión pulmonar: A propósito de un caso / Case Report: Inhaled milrinone in pulmonary hypertension

INTRODUCCIÓN: Pulmonary hypertension (PH) is a disease that is characterized for an elevated pressure in the pulmonary artery and an increased pulmonary vascular resistance (PVR). Inhaled milrinone has demonstrated acting as a selective pulmonary vasodilator, being a useful tool for the treatment of patients with PH in the perioperative. MATERIALS AND METHODS: We report a successful case of inhaled milrinone in PH in cardiovascular surgery. The patient signed the informed consent for this report. DISCUSSION: Patients with PH has increased risk of perioperative complications (mortality as far as 37-90%) The management with intravenous vasodilators is frequently limited because of secondary effects of vasodilation and hypotension affecting the myocardial perfusion pressure. Milrinone is an inodilator that acts as an inhibitor of the phosphodiesterase III. Wang et al., and posterior studies have demonstrated that administered by inhalation it acts as a selective pulmonary vasodilator and inotrope, with a minor systemic effect. CONCLUSION: Inhaled milrinone have demonstrated to be a useful drug to lower PH, PVR and to enhance inotropism without deleterious systemic effects. Wide availability, lower costs and ease of administration make you think as it could be an ideal tool for perioperative management in patients with PH. There are still more studies to define it´s potentials.

INTRODUCCIÓN: La hipertensión pulmonar (HTP) es una enfermedad caracterizada por la elevación de las presiones de arteria pulmonar (PAP) y un aumento de la resistencia vascular pulmonar (RVP). La milrinona inhalada ha demostrado actuar como un vasodilatador pulmonar selectivo siendo una herramienta útil en el manejo de los pacientes con HTP en el perioperatorio. MATERIALES Y MÉTODOS: Reportamos un caso exitoso de milrinona inhalada en HTP en cirugía cardiovascular. La paciente firmó el consentimiento informado para este reporte. DISCUSIÓN: Pacientes con HTP tienen mayor riesgo de complicaciones perioperatorias (mortalidad hasta 37-90%). Su manejo con vasodilatadores intravenosos es frecuentemente limitado por sus efectos secundarios de vasodilatación e hipotensión, perjudicando la presión de perfusión miocárdica. La milrinona es un inodilatador que actúa como inhibidor de la fosfodiesterasa III. Wang et al., y estudios posteriores, han demostrado que administrada por vía inhalatoria actúa como un vasodilatador pulmonar selectivo e inótropo, con menor efecto sistémico. CONCLUSIÓN: La milrinona inhalada ha demostrado ser una herramienta útil para la disminución de la PAP, RVP y mejoría del inotropismo, sin efectos sistémicos deletéreos. Su amplia disponibilidad, menor costo y facilidad de administración, hacen pensar que podría ser una herramienta útil para el manejo perioperatorio de los pacientes con HTP. Hacen falta más trabajos para definir sus potencialidades.

Effects of different dose regimens of milrinone on hemodynamics and left ventricular systolic function after cardiopulmonary bypass

Milrinone can improve myocardial systolic function and hemodynamics by increasing contractility and decreasing afterload, although its appropriate dose regimen has not yet been established for cardiac surgical patients. Despite milrinone effectively increases cardiac function after cardiopulmonary bypass, few studies have specifically evaluated its efficacy during cardiac surgery. We investigated the effects of milrinone on hemodynamics and left systolic ventricular function in cardiac surgical patients immediately after emergence from cardiopulmonary bypass [CPB]. Forty five patients undergoing cardiac surgery were studied. They received milrinone [25, 50, or 75 ug/kg] bolus dose over ten minutes followed by 0.25, 0.5, 0.75 ug/kg/min in three patients groups. Heart rate, mean arterial blood pressure, pulmonary capillary wedge pressure, and cardiac index were determined before and after the administration of milrinone and transesophageal echocardiogram were recorded while constant filling pressures were maintained by volume reinfusion from the CPB reservoir. All three doses of milrinone significantly increased CI [2.5, 3.1,3.2 L/min/m2], HR [98, 96,100 bpm], SV [61,66,67 ml/beat] and EF [61, 66, 66%] after 5 min from the milrinone use [p<0.001] and significantly decreased the MAP [80, 81, 82 mmHg], SVR [1127, 965, 928 dyn.s.cm-5] and PVR [183, 165, 157 dyn.s.cm-5] at the same time interval [p<0.001] while the PCWP and CVP did not show valuable change. The 50- and 75-ug/kg doses produced significantly larger increases in cardiac index than the 25-ug/kg dose; however, the 75 ug/kg dose did not produce a significantly larger increase in cardiac index than did the 50-ug/kg dose. Two patients receiving milrinone 25 ug/kg developed premature ventricular contractions. The 75-ug/kg dose was associated with a case of ventricular tachycardia treated with xylocaine infusion and three cases of severe hypotension [BP <60 mmHg] requiring phenylephrine infusion and IV fluid replacement. Thus, milrinone improves hemodynamics and left ventricular systolic function when constant loading conditions are maintained

Milrinona a la salida de CEC: estudio preliminar / Milrinone at out of CEC: preliminar study

Describimos nuestra experiencia clínica con un inhibidor de la fosfodiesterasa plásmatica de tipo III (IPDE), la milrinona, como inotrópico a la salida de circulación extracorporea (CEC) en pacientes con mala función ventricular previa. Seleccionamos 10 pacientes, 8 varones y 2 mujeres, programados para cirugía extracorporea. Todos ellos tenían una fracción de eyección (FE) menor de 0.45, edades comprendidas entre los 50 y 80 años y se preveía unos tiempos de isquemia y de perfusión prolongados. Al desclampar la aorta se administró milrinona a una dosis de 50 mcg/Kg durante 15 minutos, seguido de una infusión a 0.375 mcg/Kg/min. Se recogieron diferentes parámetros hemodinámicos mediante presión arterial invasiva y catéter de arteria pulmonar en momentos fijos de la cirugía y el postoperatorio. La milrinona resulta útil al mejorar el gasto cardiaco y facilitar la salida de bomba de CEC en pacientes con mala función ventricular previa, si bien su uso conlleva requerimientos elevados de líquidos intravenosos y la asociación de una segunda droga vasoactiva.