INOTROPES IN PCICU,JET,LCOS

1. Dr Rhitajyoti Sengupta
• You receive a neonate from OR after a
switch operation for TGA/VSD on
Epinephrine /dobutamine. would you
like to make changes to inotrope and
if yes why ?

2. TGA/VSD/PAH
ISSUES:
LV DYSFUNCTION--PRIMARY
MYOCARDIAL FAILURE ,CHF
CORONARY
ISSUES(KINKING,STENOSIS,STRETC
HING WITH ST-T CHANGES OR
VENTRICULAR ARRYTHMIAS
PRESENCE OF MR
LV AFTERLOAD MISMATCH
PAH/PVOD
TARGET:
To improve cardiac output with systemic
afterload reduction and to enhance tissue
perfusion and adequate oxygen delivery
Milrinone together with a low
dose of
Dopamine/Dobutamine or
Epinephrine
GTN FOR CORONARY
INSUFFICIENCY/ECG
CHANGES
A
MONITORING
Frequent clinical exam
MAP 35–45 mmHg
LAP--Less than 8–10 mmHg range
SERIAL LACTATE /SCVO2 >60%
Avoid volume boluses -
LEVOSIMENDAN
AS ADD-ON
FOR PAH /RV DYSFUNCTION/HIGH PVR
INHALED NITRIC/SILDENAFIL
Cardiac index (left axis) measured in infants following the arterial switch operation
declined during the first 12 hours and was not the result of any reduction in
inotropic support (right axis).
CALCIUM INFUSION
Noradrenaline/Vasopressin to antagonize over
vasodilation and in Capillary leak syndrome

3. Dr Rhitajyoti Sengupta
• Is JET a concern when choosing an
inotrope?

4. JET
during rewarming on CPB
Dobutamine and Epinephrine used
to augment contractility
--positive chronotropic and
arrhythmogenic effect--more
pronounced in the immature
myocardium of the young child
and in backdrop of postop systolic
and diastolic heart failure --risk
factors for JET
Intensive Care Med., 34, 895-
902, 2008
Dopamine or high inotropic
score(VIS) risk factors for JET
Walsh EP,J Am Coll Cardiol.
1997;29:1046–53
TAKE HOME MESSAGE
1.Increased adrenergic tone--- to
avoid acceleratation of the JET rate
2.Positive inotropic drugs --
arrhythmogenic
used at a dosage as low as possible.
3.Milrinone-- relatively less effect on
the heart rate in comparison to
dobutamine and epinephrine --- acts
independently of the β-adrenergic
receptor.
positive inotropic drug of choice,--
REMEMBER the side effect of severe
hypotension
(Ann Thorac Surg 2002;74:1607–11)
atria and ventricles simultaneously
activated from impulses originating
in the BH,
atria contracts against closed AV
valves.decreased ventricular filling
results in reduced cardiac output
and hypotension
commonly after surgery for TOF ,AV
CANAL,VSD,TGA ,INTERRUPTED
ARCH AND RIGHT ISOMERISM

5. Dr Rhita Jyotisengupta
• Milrinone or Levosimendan ? what is your experience in
managing LCOS in ICUs

6. Milrinone or Levosimendan ?---ANSWER IS ONE OR BOTH DEPENDING ON SITUATION
• nnoo
MILRINONE
vasodilation with afterload
reduction improving diastolic
function leading to improved
cardiac output,minimal increase in
myocardial oxygen consumption
with a high concomitant use of
vasopressors e.g.Noradrenaline /
Vasopressin to prevent
hypotension
routinely for
the
prevention of
LCOS,diastolic
dysfunction in
TOF,JET,PAH
SCENARIO
FIRST CHOICE
INOTROPE
Insufficient evidence of prophylactic milrinone in
preventing death or low cardiac output syndrome in
children undergoing surgery for congenital heart
disease, compared to placebo.
no differences between milrinone and other
inodilators, such as levosimendan or dobutamine, in
the immediate postoperative period, in reducing the
risk of LCOS or death
Cochrane Heart Group,2015
Levosimendan
calcium channel
sensitizer
USES:
as an ADD-ON
long CPB run ,difficulty weaning from
CPB,LCOS despite Milrinone
anticipated severe LV dysfunction in
ALCAPA,SEVERE CO A,INTERRUPTED
ARCH,T-B ANOMALY,COMPLEX TOF
as efficacious as milrinone.
myocardial oxygen demand was
significantly lower,
causes peripheral, coronary, and
pulmonary vasodilatation
INODILATOR

7. Experience in managing LCOS in PCICUs
CHOICE OF INOTROPE(S)
pathophysiology of
the underlying condition, the
severity of the LCOS, and the
medication that is already
being administered from OR
milrinone routinely for the
prevention of LCOS
Adrenaline
Dopamine/Dobutamine
Calcium
Levosimendan
Other medications used
concomitantly Noradrenaline
Vasopressin ,Thyroid supplement
Steroid
NO IDEAL
INOTROPE
Varied heart rate and rhythms,
preload,
afterload or different ventricular
compliance Of
chronically ischemic, pressure-
overloaded or volume overloaded
heart
tachyarrhythmias and increased
myocardial
oxygen consumption,hypotension
Systemic afterload reduction ---
- drugs added to vasodilatory
effect of milrinone; alpha-
blockers on CPB
(Phentolamine,Phenoxybenzam
ine) or GTN/Sodium
Nitroprusside in ICU

8. APPROACH TO MANAGE LCOS---EARLIER DAYS
maintenance of cardiac output
optimizing three factors—preload, cardiac
function, and afterload reduction
Cardiac
function
(1) stimulating contractility
with beta stimulants with
adequate serum
ionized calcium,
(2) prevention of arrhythmias
by adequate serum potassium
and magnesium,
(3) facilitating diastole
(relaxation) with lusitropic
agents.
In diastolic dysfunction, less beta stimulants /more
Milrinone
less tachycardia a beneficial in diastolic dysfunction.
Tachycardia avoided in valvar stenosis.
In valvar regurgitation,tachycardia allowed in
conjunction with inotropic support and
afterload reduction--achieved with dobutamine or
isoproterenol.
Monitored, and dosages adjusted, according to
markers of adequate cardiac output—urine
output, serum lactate levels,
and mixed venous saturations.
Target
increase SVR
BAD FOR MYOCARDIAL
PERFUSION ,DIASTOLIC
FUNCTION AND INCREASED
OXYGEN DEMAND BY BETA
STIMULATION

9. APPROACH TO MANAGE LCOS---NOWADAYS
Target
maintenance of cardiac output
optimizing three contributing factors—preload,
cardiac function, and afterload reduction
Cardiac
function
Minimizes
beta stimulation WITH low dose
Adrenaline or
dopamine,Milrinone as lusitropic
agentsSYSTEMIC VASODILATAION
in every case
adequate serum potassium and
calcium ,magnesium
Dobutamine/Isoprenaline used
nolonger
Target to maintain Perfusion pressure (defined
as MAP minus central venous pressure) and
specifically diastolic pressure
These two pressures maintained more than:
_ 35 mm Hg in premature neonates
_ 40 mm Hg in neonates born at term
_ 50 mm Hg in infants and young children
_ 60 mm Hg in older children and adolescents
Adequate perfusion pressure favors peripheral tissue
perfusion, both directly and by improving systemic venous
return
Afterload reduction achieved with the lusitropic agents and
low-dose dopamine, or more potent vasodilators(SNP/GTN)
norepinephrine should be added to rectify low pressures.
The overall management is a balance between
vasodilatation and vasoconstriction, being guided by
diastolic and perfusion pressures.
CVP/LAP
LACTATE
SCVO2
CLINICAL
EXAM.
more physiologic : good
myocardial perfusion,
LESS metabolic demand
by avoiding beta
stimulation.