Milrinone is better choice for controlled low central venous pressure during hepatectomy: A randomized, controlled trial comparing with nitroglycerin
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Milrinone
Cardiac index
We have reviewed the current data evaluating the effects of intravenous milrinone in patients following cardiac surgery. Milrinone has been shown to be effective in the treatment of acute low output syndrome, and a loading bolus infusion of 50 micrograms kg-1 over 10 min causes an increase in cardiac index and a fall in pulmonary capillary wedge pressure. These effects are easily maintained by a continuous infusion regimen. Other haemodynamic effects are seen, including systemic and pulmonary vasodilatation and an increase in heart rate. These effects are not confined to one patient group, but the increase in cardiac index does appear to be more pronounced in those patients with poor haemodynamics prior to treatment. There is a low incidence of adverse events including arrhythmias and hypotension. Thus milrinone appears to be well tolerated in a broad group of adult patients recovering from cardiac surgery.
Milrinone
Cardiac index
Pulmonary wedge pressure
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The phosphodiesterase inhibitor, milrinone is used to treat low cardiac output syndrome, especially after cardiac surgery. But there were few reports about the precise hemodynamic effects at separation from cardiopulmonary bypass (CPB). We examined the hemodynamic effects of milrinone in 24 patients undergoing elective coronary artery bypass graft (CABG). Patients were assigned to the milrinone group (n = 12) and the control group (n = 12). Before separation from CPB, milrinone was administered as a loading dose of 50 micrograms.kg-1 into the reservoir of CPB at rectal temperature 33.5 degrees C and simultaneously a continuous infusion of 0.5 microgram.kg-1.min-1 was started. In addition, dopamine and nitroglycerine were administered in both groups. Hemodynamic measurements were performed before CPB, just after the weaning from CPB, 15, 30, 60 minutes after the weaning from CPB. Cardiac index increased significantly (P < 0.01) in the milrinone group as compared with the control group. Systemic vascular resistance index and mean arterial pressure decreased significantly (P < 0.0001, P < 0.05, respectively) in the milrinone group as compared with the control group. There were no significant differences in heart rate, mean pulmonary arterial pressure, pulmonary artery occlusion pressure, mean right atrial pressure, stroke volume index, and pulmonary vascular resistance index between the two groups. These hemodynamic effects showed that milrinone supported cardiac performance after CPB for CABG.
Milrinone
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Mean arterial pressure
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Milrinone
Cardiac index
Pulmonary wedge pressure
Concomitant
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The aim of this study was to evaluate the hemodynamic effects of a slow induction of milrinone after open heart surgery. Twenty patients who underwent elective coronary artery bypass grafting were randomized into two groups, with 10 patients receiving a continuous infusion of milrinone (5 microg/kg/min) (group M), and 10 patients undergoing treatment without milrinone (group C). This is a preliminary study for evaluating the efficacy of a slow induction of milrinone, so patients in low cardiac output state were excluded. A continuous infusion without an initial loading dose was initiated in the intensive care unit. Hemodynamic parameters and the concentration of milrinone were measured 90 minutes and 3 hours after initiation of the milrinone infusion. A significant decrease in arterial pressure occurred at 3 hours in group M, and both the systemic vascular resistant indices decreased significantly (p<0.05) at 90 minutes. No significant changes occurred in group C. Cardiac index and heart rate increased significantly (p<0.05) in group M, but were unchanged in group C. No significant change in double product was observed in either group. Hypotension (systolic blood pressure less than 100 mmHg) or arrhythmia did not occur in group M. The concentration of milrinone at 90 minutes and 3 hours was 97+/-22 and 124+/-27 ng/ml, respectively. A slow induction of milrinone is safe and effective in patients following cardiac surgery.
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Mean arterial pressure
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The haemodynamic and biological effects of intravenous milrinone were studied in 24 adult patients with a low cardiac output syndrome following cardiac surgery. The patients received a milrinone bolus of 50 micrograms kg-1 over 10 min followed by a 0.375-0.750 micrograms kg-1 min-1 infusion over 48 h. After the first hour of treatment, an increase in cardiac index, systolic index and left ventricular stroke work index, and a decrease in right and left loading pressures, pulmonary artery pressure, systemic vascular resistance and pulmonary vascular resistance were observed while heart rate and systemic arterial pressure were not modified. These haemodynamic effects were maintained over the 48 h of treatment and persisted 3 h after discontinuation of treatment. Milrinone, which possesses inotropic and vasodilatory effects, increased cardiac performance and corrected the low cardiac output in all patients.
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Cardiac index
Enoximone
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Milrinone can reverse acute postischemic myocardial dysfunction after cardiopulmonary bypass, although neither the appropriate bolus dose nor its pharmacokinetics has been established for cardiac surgical patients.Consenting patients undergoing cardiac surgery received milrinone (25, 50, or 75 micro gram/kg) in an openlabel, dose-escalating study if their cardiac index was <3 L centered dot min-1 centered dot m-2 after separation from bypass. Heart rate, mean arterial blood pressure, pulmonary capillary wedge pressure, and cardiac index were determined before and after the administration of milrinone. Timed blood samples were obtained for measurement of milrinone plasma concentrations and pharmacokinetic analysis. Twenty-nine of 60 consenting patients had cardiac indices <3 L centered dot min-1 centered dot m-2 after separation from bypass, received milrinone, and completed the protocol. All three bolus doses of milrinone significantly increased cardiac index. The 50- and 75-micro gram/kg doses produced significantly larger increases in cardiac index than the 25-micro gram/kg dose; however, the 75-micro gram/kg dose did not produce a significantly larger increase in cardiac index than did the 50-micro gram/kg dose. Two of 10 patients receiving milrinone 25 micro gram/kg, but no patient receiving either 50 or 75 micro gram/kg, required early epinephrine rescue when the cardiac index failed to increase by >15%. The 75-micro gram/kg dose was associated with a case of ventricular tachycardia. The three-compartment model better described milrinone drug disposition than the two-compartment model by both visual inspection and Schwartz-Bayesian criterion. There was only limited evidence of dose-dependence, so data from all three doses are reported together (and normalized to the 50-micro gram/kg dose). Data from one patient was discarded (samples mislabeled). Using mixed-effects nonlinear regression (for n = 28), the following volumes were determined for the three compartments: V (1) = 11.1 L, V2 = 16.9 L, and V3 = 363 L. Similarly, the following clearances were estimated for the three compartments: Cl1 = 0.067 L/min, Cl2 = 1.05 L/min, and Cl3 = 0.31 L/min. The 50-micro gram/kg loading dose appeared more potent than the 25-micro gram/kg dose, and, as potent, but with possibly fewer side-effects than the 75-micro gram/kg dose. The short context-sensitive half-times of 6.7 or 10.2 min after 1- or 10-min bolus infusions underscore the need for prompt institution of a maintenance infusion when milrinone concentrations must be maintained. Simulations based on our best drug disposition using this study's variables predict a context-sensitive half-time of 4.9 h for plasma milrinone concentrations after a 50-micro gram/kg bolus 1-min infusion with an immediate 24-h maintenance infusion of 0.5 micro gram centered dot min-1 centered dot kg-1. (Anesth Analg 1995;81:783-92)
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Objective
To study the hemodynamic effects of Milrinone in patients with sepsis and low cardiac output.
Methods
The study was conducted on 13 patients with sepsis and low cardiac output recruited at the surgical intensive care unit(SICU)of Beijing Hospital from March 2011 to June 2012.Continuous IV infusion of Milrinone was made at 0.25-0.50μg·kg-1·min-1.Hemodynamic variables were monitored by PiCCO, and data at baseline, 10 min, 2 h, and 24 h after infusion were analyzed.
Results
No statistical differences were found between measurements at baseline and 10min after milrinone infusion in variables such as systolic pressure, diastolic pressure, mean arterial pressure(MAP), heart rate, central venous pressure(CVP), global end diastolic volume index(GEDI), cardiac index(CI), cardiac function index CFI), stroke volume index(SVI)and systemic vessel resistance index(SVRI). Increased CI(2.73±0.62, 2.93±0.49 vs.2.33±0.57), CFI(3.59±0.84, 3.85±0.84 vs.3.12±0.93)and SVI(28.62±10.32, 28.77±9.85 vs.25.31±9.09)and decreased SVRI(2 269±615.3, 2 094±542.2 vs.2 946±1 417.0)were observed at 2 h and 24 h after Milrinone infusion, compared with baseline data.
Conclusions
Continuous IV infusion of low dose milrinone can increase cardiac output and decrease systemic vascular resistance in patients with sepsis and low cardiac output.
Key words:
Milrinone; Sepsis; output low cardiac; Hemodynamics
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Mean arterial pressure
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We have reviewed the current data evaluating the effects of intravenous milrinone in patients following cardiac surgery. Milrinone has been shown to be effective in the treatment of acute low output syndrome, and a loading bolus infusion of 50 micrograms kg-1 over 10 min causes an increase in cardiac index and a fall in pulmonary capillary wedge pressure. These effects are easily maintained by a continuous infusion regimen. Other haemodynamic effects are seen, including systemic and pulmonary vasodilatation and an increase in heart rate. These effects are not confined to one patient group, but the increase in cardiac index does appear to be more pronounced in those patients with poor haemodynamics prior to treatment. There is a low incidence of adverse events including arrhythmias and hypotension. Thus milrinone appears to be well tolerated in a broad group of adult patients recovering from cardiac surgery.
Milrinone
Cardiac index
Pulmonary wedge pressure
Bolus (digestion)
Regimen
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Milrinone
Preload
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Milrinone
Cardiac index
Pulmonary wedge pressure
Loading dose
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