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Rahmath MRK, Bhat AN, Lone RA, Kamal RY. Efficacy of nil per oral, total parenteral nutrition, milrinone and non-suction chest tube drainage-based management for chylothorax following pediatric cardiac surgery. Asian Cardiovasc Thorac Ann 2024:2184923241249198. [PMID: 38659299 DOI: 10.1177/02184923241249198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE A single centre experience with chylothorax in post cardiac surgical patients. METHODS Retrospective review. RESULTS Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1-995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011-2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016-2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)]. SUMMARY In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly.
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Affiliation(s)
| | - Akhlaque N Bhat
- Pediatric Cardiac Surgery Division, CT Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Reyaz A Lone
- Pediatric Cardiac Surgery Division, CT Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Reema Y Kamal
- Pediatric Cardiology, Pediatrics, Hamad Medical Corporation, Doha, Qatar
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Cox ZL, Dalia T, Goyal A, Fritzlen J, Gupta B, Shah Z, Sauer AJ, Haglund NA. Novel Nebulized Milrinone Formulation for the Treatment of Acute Heart Failure Requiring Inotropic Therapy: A Phase 1 Study. J Card Fail 2024; 30:329-336. [PMID: 37871843 DOI: 10.1016/j.cardfail.2023.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Nonintravenous inotropic-delivery options are needed for patients with inotropic-dependent heart failure (HF) to reduce the costs, infections and thrombotic risks associated with chronic central venous catheters and home infusion services. METHODS We developed a novel, concentrated formulation of nebulized milrinone for inhalation and evaluated the feasibility, safety and pharmacokinetic profile in a prospective, single-arm, phase I clinical trial. We enrolled 10 patients with stage D HF requiring inotropic therapy during a hospital admission for acute HF. Milrinone 60 mg/4 mL was inhaled via nebulization 3 times daily for 48 hours. The coprimary outcomes were adverse events and pharmacokinetic profiles of inhaled milrinone. Acute changes in hemodynamic parameters were secondary outcomes. RESULTS A concentrated nebulized milrinone formulation was well tolerated, without hypotensive events, arrhythmias or inhalation-related adverse events requiring discontinuation. Nebulized milrinone produced serum concentrations in the goal therapeutic range with a median plasma milrinone trough concentration of 39 (17-66) ng/mL and a median peak concentration of 207 (134-293) ng/mL. There were no serious adverse events. From baseline to 24 hours, mean pulmonary artery saturation increased (60% ± 7%-65 ± 5%; P = 0.001), and mean cardiac index increased (2.0 ± 0.5 mL/min/1.73m2-2.5 ± 0.1 mL/min/1.73m2; P = 0.001) with nebulized milrinone. CONCLUSIONS In a proof-of-concept study, a concentrated, nebulized milrinone formulation for inhalation was safe and produced therapeutic serum milrinone concentrations. Nebulized milrinone was associated with improved hemodynamic parameters of cardiac output in a population with advanced HF. These promising results require further investigation in a longer-term trial in patients with inotrope-dependent advanced HF.
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice and Pharmaceutical Science, Lipscomb University College of Pharmacy, Nashville, TN; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN.
| | - Tarun Dalia
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Amandeep Goyal
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - John Fritzlen
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Bhanu Gupta
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Zubair Shah
- The Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, KS
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Nicholas A Haglund
- Minneapolis Heart Institute, Allina Health at Abbott Northwestern Hospital, Minneapolis, MN
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Abdel-Razek O, Di Santo P, Jung RG, Parlow S, Motazedian P, Prosperi-Porta G, Visintini S, Marbach JA, Ramirez FD, Simard T, Labinaz M, Mathew R, Hibbert B. Efficacy of Milrinone and Dobutamine in Cardiogenic Shock: An Updated Systematic Review and Meta-Analysis. Crit Care Explor 2023; 5:e0962. [PMID: 37649849 PMCID: PMC10465094 DOI: 10.1097/cce.0000000000000962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVES Inotropic support is commonly used in patients with cardiogenic shock (CS). High-quality data guiding the use of dobutamine or milrinone among this patient population is limited. We compared the efficacy and safety of these two inotropes among patients with low cardiac output states (LCOS) or CS. DATA SOURCES MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched up to February 1, 2023, using key terms and index headings related to LCOS or CS and inotropes. DATA EXTRACTION Two independent reviewers included studies that compared dobutamine to milrinone on all-cause in-hospital mortality, length of ICU stay, length of hospital stay, and significant arrhythmias in hospitalized patients. DATA SYNTHESIS A total of eleven studies with 21,084 patients were included in the meta-analysis. Only two randomized controlled trials were identified. The primary outcome, all-cause mortality, favored milrinone in observational studies only (odds ratio [OR] 1.19 (95% CI, 1.02-1.39; p = 0.02). In-hospital length of stay (LOS) was reduced with dobutamine in observational studies only (mean difference -1.85 d; 95% CI -3.62 to -0.09; p = 0.04). There was no difference in the prevalence of significant arrhythmias or in ICU LOS. CONCLUSIONS Only limited data exists supporting the use of one inotropic agent over another exists. Dobutamine may be associated with a shorter hospital LOS; however, there is also a potential for increased all-cause mortality. Larger randomized studies sufficiently powered to detect a difference in these outcomes are required to confirm these findings.
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Affiliation(s)
- Omar Abdel-Razek
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pietro Di Santo
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Vascular Biology and Experimental Medicine Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard G Jung
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Vascular Biology and Experimental Medicine Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Parlow
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pouya Motazedian
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Graeme Prosperi-Porta
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sarah Visintini
- Berkman Library, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jeffrey A Marbach
- Division of Cardiovascular Medicine, Knight Cardiovascular Center, Oregon Health and Science University, Portland, OR
| | - F Daniel Ramirez
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Trevor Simard
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Vascular Biology and Experimental Medicine Laboratory, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Marino Labinaz
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rebecca Mathew
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Beshish AG, Aljiffry A, Aronoff E, Chauhan D, Zinyandu T, Basu M, Shashidharan S, Maher KO. Milrinone for treatment of elevated lactate in the pre-operative newborn with hypoplastic left heart syndrome. Cardiol Young 2023; 33:1691-1699. [PMID: 36184833 DOI: 10.1017/s1047951122003171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND There is a paucity of information reported regarding the use of milrinone in patients with hypoplastic left heart syndrome prior to the Norwood procedure. At our institution, milrinone is initiated in the pre-operative setting when over-circulation and elevated serum lactate levels develop. We aimed to review the responses associated with the administration of milrinone in the pre-operative hypoplastic left heart syndrome patient. Second, we compared patients who received high- versus low-dose milrinone prior to Norwood procedure. METHODS Single-centre retrospective study of patients diagnosed with hypoplastic left heart syndrome between January 2000 and December 2019 who underwent Norwood procedure. Patient characteristics and outcomes were compared. RESULTS During the study period, 375 patients were identified; 79 (21%) received milrinone prior to the Norwood procedure with median lactate 2.55 mmol/l, and SpO2 93%. Patients who received milrinone were older at the time of Norwood procedure (6 vs. 5 days) and were more likely to be intubated and sedated. In a subset analysis stratifying patients to low- versus high-dose milrinone, median lactate decreased from time of initiation (2.39 vs 2.75 to 1.6 vs 1.8 mmol/l) at 12 hours post-initiation, respectively. Repeated measures analysis showed a significant decrease in lactate levels by 4 hours following initiation of milrinone, that persisted over time, with no significant difference in mean arterial pressure. CONCLUSIONS The use of milrinone in the pre-operative over-circulated hypoplastic left heart syndrome patient is well tolerated, is associated with decreased lactate levels, and was not associated with significant hypotension or worsening of excess pulmonary blood flow.
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Affiliation(s)
- Asaad G Beshish
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Alaa Aljiffry
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Dhaval Chauhan
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Tawanda Zinyandu
- Senior Research Coordinator, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mohua Basu
- Qualitative Analyst, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Subhadra Shashidharan
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kevin O Maher
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Lakhal K, Fresco MH, Hivert A, Rozec B, Cadiet J. Cerebral Vasospasm After Subarachnoid Hemorrhage: Respective Short-Term Effects of Induced Arterial Hypertension and its Combination With IV Milrinone: A Proof-of-Concept Study Using Transcranial Doppler Ultrasound. Crit Care Explor 2023; 5:e0973. [PMID: 37720356 PMCID: PMC10503695 DOI: 10.1097/cce.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
OBJECTIVES It is unclear whether IV milrinone relaxes spasmed cerebral arteries and therefore reduces cerebral blood mean velocity (Vmean). In patients treated for cerebral vasospasm, we aimed to assess and delineate the respective impacts of induced hypertension and its combination with IV milrinone on cerebral hemodynamics as assessed with transcranial Doppler. DESIGN Observational proof-of-concept prospective study. SETTING ICU in a French tertiary care center. PATIENTS Patients with aneurysmal subarachnoid hemorrhage who received induced hypertension (mean arterial blood pressure [MBP] of 100-120 mm Hg) and IV milrinone (0.5 µg/kg/min) for moderate-to-severe cerebral vasospasm. We excluded patients who underwent invasive angioplasty or milrinone discontinuation within 12 hours after the diagnosis of vasospasm. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Vmean was measured at vasospasm diagnosis (TDIAGNOSIS), after the induction of hypertension (THTN), and 1 (THTN+MILRINONE_H1) and 12 hours after the adjunction of IV milrinone (THTN+MILRINONE_H12). Thirteen patients were included. Median Vmean was significantly lower (p < 0.01) at THTN+MILRINONE_H1 (99 [interquartile range (IQR) 89; 134] cm.s-1) and THTN+MILRINONE_H12 (85 [IQR 73-127] cm/s) than at TDIAGNOSIS (136 [IQR 115-164] cm/s) and THTN (148 [IQR 115-183] cm/s), whereas TDIAGNOSIS and THTN did not significantly differ. In all patients but one, Vmean at THTN+MILRINONE_H1 was lower than its value at TDIAGNOSIS (p = 0.0005). Vmean-to-MBP and Vmean-to-cardiac output (CO) ratios (an assessment of Vmean regardless of the level of MBP [n = 13] or CO [n = 7], respectively) were, respectively, similar at TDIAGNOSIS and THTN but were significantly lower after the adjunction of milrinone (p < 0.01). CONCLUSIONS The induction of arterial hypertension was not associated with a significant decrease in Vmean, whereas the adjunction of IV milrinone was, regardless of the level of MBP or CO. This suggests that IV milrinone may succeed in relaxing spasmed arteries.
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Affiliation(s)
- Karim Lakhal
- Department of Anesthesia and Critical Care, Laënnec Hospital, University Hospital of Nantes, France
| | - Marion H Fresco
- Department of Anesthesia and Critical Care, Laënnec Hospital, University Hospital of Nantes, France
| | - Antoine Hivert
- Department of Anesthesia and Critical Care, Laënnec Hospital, University Hospital of Nantes, France
| | - Bertrand Rozec
- Department of Anesthesia and Critical Care, Laënnec Hospital, University Hospital of Nantes, France
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, Nantes, France
| | - Julien Cadiet
- Department of Anesthesia and Critical Care, Laënnec Hospital, University Hospital of Nantes, France
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Alkadri J, Hu R, Jeffers MS, Ross J, McIsaac DI, McDonald B. Comparison of milrinone with dobutamine in patients undergoing cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2023; 70:1272-1274. [PMID: 37160823 DOI: 10.1007/s12630-023-02482-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/02/2023] [Accepted: 01/11/2023] [Indexed: 05/11/2023] Open
Affiliation(s)
- Jamal Alkadri
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Richard Hu
- Department of Surgery, Division of General Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Matthew S Jeffers
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - James Ross
- Department of Surgery, Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Bernard McDonald
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Meng SS, Yu YM, Bu FZ, Yan CW, Wu ZY, Li YT. Cocrystallization-Driven Double-Optimized Stratagem toward Directional Self-Assembly for the First Ternary Salt Cocrystal of Cardiotonic Drug Milrinone with Different Phenolic Acids Exhibits Optimal In Vitro/ Vivo Biopharmaceutical Peculiarities. Mol Pharm 2023. [PMID: 37318766 DOI: 10.1021/acs.molpharmaceut.3c00230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The current research leverages the structural features and property superiorities along with benefits in protecting cardiovascular system of gallic acid (GLC) and gentisic acid (HGA) to optimize in vitro/vivo peculiarities of cardiotonic drug milrinone (MIL) through developing a stratagem of cocrystallization-driven double-optimized ternary salt cocrystal. This strategy assembles MIL ternary salt cocrystal by shaping a cocrystallization moiety relying on noncovalent interplays with GLC to obtain permeability advancement and molding a salt segment via the salification of proton transfer between HGA and MIL molecules to facilitate solubility enhancement. While the ameliorative in vitro properties further modulate the in vivo pharmacokinetic behaviors, thus fulfilling a dual optimization of MIL's biopharmaceutical characteristics on both in vitro and in vivo aspects. Along this line, the first MIL ternary salt cocrystal, viz., [HMIL+-GA-]-MIL-GLC-H2O (denoted as MTSC hereinafter), has been satisfactorily constructed and precisely structurally identified by diversified techniques. The single-crystal X-ray diffraction experiment validates that a molecular salt [HMIL+-GA-] species cocrystallizes with one neutral MIL, two GLC, and five solvent water molecules, among which the organic constituents compose laminated hydrogen bond networks, and then are self-assembled by water molecules to a 3D supramolecular structure. The unique structural feature and stacking pattern of MTSC make both the permeability and solubility be respectively enhanced by 9.69 times and 5.17- to 6.03-fold compared with the parent drug per se. The experimental outcomes are powerfully supported by associated calculations based on density functional theory. Intriguingly, these optimal in vitro physicochemical natures of MTSC have been potently converted into strengths of in vivo pharmacokinetics, showcasing the elevated drug plasma concentration, elongated half-life, alongside advanced bioavailability. Consequently, this presentation not just contributes a brand-new crystalline form with utility values, but ushers in a new dimension of ternary salt cocrystals for improving in vitro/vivo limitations of poor drug bioavailability.
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Affiliation(s)
- Su-Su Meng
- School of Medicine and Pharmacy and College of Marine Life Science, Ocean University of China, Qingdao, Shandong 266003, PR China
| | - Yue-Ming Yu
- School of Medicine and Pharmacy and College of Marine Life Science, Ocean University of China, Qingdao, Shandong 266003, PR China
| | - Fan-Zhi Bu
- School of Medicine and Pharmacy and College of Marine Life Science, Ocean University of China, Qingdao, Shandong 266003, PR China
| | - Cui-Wei Yan
- School of Medicine and Pharmacy and College of Marine Life Science, Ocean University of China, Qingdao, Shandong 266003, PR China
| | - Zhi-Yong Wu
- School of Medicine and Pharmacy and College of Marine Life Science, Ocean University of China, Qingdao, Shandong 266003, PR China
| | - Yan-Tuan Li
- School of Medicine and Pharmacy and College of Marine Life Science, Ocean University of China, Qingdao, Shandong 266003, PR China
- Laboratory for Marine Drugs and Bioproducts, Qingdao National Laboratory for Marine Science and Technology, Qingdao 266003, PR China
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8
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Taylor K, Pehora C, Faraoni D, Ferri S, Colantonio D, Laussen P, Schwartz S, Parshuram C. Milrinone therapeutic drug monitoring to reduce low cardiac output syndrome in pediatric patients. Can J Anaesth 2023; 70:922-924. [PMID: 36869196 DOI: 10.1007/s12630-023-02438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 12/05/2022] [Accepted: 12/11/2022] [Indexed: 03/05/2023] Open
Affiliation(s)
- Katherine Taylor
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.
| | - Carolyne Pehora
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - David Faraoni
- Department of Anesthesiology, Perioperative & Pain Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Susan Ferri
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - David Colantonio
- Division of Clinical Biochemistry, The Ottawa Hospital, Ottawa, ON, Canada
| | - Peter Laussen
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Steven Schwartz
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Christopher Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
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9
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Parlow S, Santo PD, Sterling LH, Goodliffe L, Motazedian P, Prosperi-Porta G, Morgan B, Koopman Z, Jung RG, Lepage-Ratte MF, Robinson L, Feagan H, Simard T, Wells GA, Kyeremanteng K, Ainsworth C, Amin F, Marbach JA, Fernando SM, Labinaz M, Belley-Cote EP, Hibbert B, Mathew R. Inotrope versus Placebo Therapy in Cardiogenic Shock: Rationale and Study Design of the CAPITAL DOREMI2 Trial. Am Heart J 2023; 262:83-89. [PMID: 37094667 DOI: 10.1016/j.ahj.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Cardiogenic shock (CS) is a state of end-organ hypoperfusion related to cardiac dysfunction. Current guidelines recommend consideration of inotrope therapy in patients with CS, however no robust data support their use. The purpose of the CAPITAL DOREMI2 trial is to examine the efficacy and safety of inotrope therapy against placebo in the initial resuscitation of patients with CS. METHODS AND DESIGN This is a multi-center, double-blind, randomized, placebo-controlled trial comparing single-agent inotrope therapy to placebo in patients with CS. A total of 346 participants with Society for Cardiovascular Angiography and Interventions class C or D CS will be randomized in a 1:1 fashion to inotrope or placebo therapy, which will be administered over a 12-hour period. After this period, participants will continue open-label therapies at the discretion of the treating team. The primary outcome is a composite of all-cause in-hospital death, and, as measured during the 12-hour intervention period, any of: sustained hypotension or high dose vasopressor requirements, lactate greater than 3.5 mmol/L at 6 hours or thereafter, need for mechanical circulatory support, arrhythmia leading to emergent electrical cardioversion, and resuscitated cardiac arrest. All participants will be followed for the duration of their hospitalization, and secondary outcomes will be assessed at the time of discharge. IMPLICATION This trial will be the first to establish the safety and efficacy of inotrope therapy against placebo in a population of patients with CS and has the potential to alter the standard care provided to this group of patients.
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Affiliation(s)
- Simon Parlow
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pietro Di Santo
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Division of Critical Care Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Lee H Sterling
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Laura Goodliffe
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Pouya Motazedian
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Graeme Prosperi-Porta
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Baylie Morgan
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Zandra Koopman
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Richard G Jung
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Melissa Fay Lepage-Ratte
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Robinson
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Hannah Feagan
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Trevor Simard
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Faizan Amin
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey A Marbach
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Shannon M Fernando
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, Ontario, Canada
| | - Marino Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Emilie P Belley-Cote
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rebecca Mathew
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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10
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Gujja S, Prajapati M, Chuada TR, Gandhi H, Arora V, Kaul V, Patel S. Outcome of obstructed total anamalous pulmonary venous connection (TAPVC) repair patients with milrinone versus milrinone and inhaled nitric oxide (INO): A prospective randomized observational study. Ann Card Anaesth 2023; 26:177-182. [PMID: 37706383 PMCID: PMC10284474 DOI: 10.4103/aca.aca_56_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/10/2022] [Accepted: 10/07/2022] [Indexed: 09/15/2023] Open
Abstract
Background Obstructed total anomalous pulmonary venous connection (TAPVC) typically present with severe cardiovascular decompensation and requires urgent surgical management. Pulmonary arterial hypertension (PAH) is a major risk factor affecting mortality. Perioperative management focuses on providing inotropic support and managing potential pulmonary hypertensive episodes. Milrinone and inhaled nitric oxide (iNO) efficiently reduce pulmonary artery pressure (PAP) and help to improve the outcome. The aim was to determine the outcome of patients with high PAP with milrinone alone and a combination of iNO and milrinone. Material and Method After ethical committee approval, the study was conducted over a period of 3 years in 80 patients with obstructed TAPVC repair. A total of 80 patients having severe PAH (supra systemic arterial pressure) randomly divided into two groups with 40 patients in each (M & MN). Group M (milrinone) patients received milrinone and Group MN (milrinone & iNO) patients received both milrinone (after opening aortic cross clamp) and iNO (post operative ICU). Ventilation time, hospital stay, ICU stay, complications, in hospital mortality were compared between both groups. Result Ventilation time, Intensive Care Unit (ICU) stay, hospital stay for group M was 8.02 ± 5.74 days, 11.25 ± 7.33 day, 14.92 ± 8.55 days, respectively, and for group MN was 5.02 ± 1.78 days, 8.27 ± 3.24 days, 10.3 ± 3.18 days, respectively. In hospital mortality for group M and MN was 10% and 2.5%, respectively. P value for each variable was significant < 0.05 (except mortality). Conclusion Most of the patients with obstructed TAPVC had severe PAH. Management of severe PAH with a combination of milrinone with iNO had a better outcome than milrinone alone.
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Affiliation(s)
- Srikanth Gujja
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Mrugesh Prajapati
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Tanya R Chuada
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Hemang Gandhi
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Varun Arora
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Vivek Kaul
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Sanjay Patel
- Department of Research, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
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11
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Brown S, Nolan O, Poole E, Kidd J, Cassidy J, Botha P, Chaudhari M. Long-term milrinone therapy in children with dilated cardiomyopathy. Acta Paediatr 2023; 112:1298-1303. [PMID: 36867057 DOI: 10.1111/apa.16738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
AIM The aim of this study was to assess the safety and efficacy of long-term milrinone therapy in children with acute decompensated heart failure due to dilated cardiomyopathy (DCM). METHODS A single-centre retrospective study of all children ≤18 years with acute decompensated heart failure and DCM who received continuous long-term (≥7 consecutive days) intravenous milrinone between January 2008 and January 2022. RESULTS The 47 patients had a median age of 3.3 months [interquartile range (IQR) 1.0-18.1], weight of 5.7 kg [IQR 4.3-10.1] and fractional shortening of 11.9% [±4.7]. Idiopathic DCM (n = 19) and myocarditis (n = 18) were the most common diagnoses. The median milrinone infusion duration was 27 days [IQR 10-50, range 7-290]. No adverse events necessitated milrinone termination. Nine patients required mechanical circulatory support. Median follow-up was 4.2 years [IQR 2.7-8.6]. On initial admission, four patients died, six were transplanted and 79% [37/47] were discharged home. The 18 readmissions resulted in five more deaths and four transplantations. Cardiac function recovered in 60% [28/47], as measured by normalised fractional shortening. CONCLUSION Long-term intravenous milrinone is safe and effective in paediatric acute decompensated DCM. Combined with conventional heart failure therapies, it can act as a bridge to recovery and thereby potentially reduce the need for mechanical support or heart transplantation.
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Affiliation(s)
- Samuel Brown
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Oscar Nolan
- Department of Paediatric Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Esther Poole
- Department of Paediatric Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Justine Kidd
- Department of Paediatric Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Jane Cassidy
- Department of Paediatric Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Phil Botha
- Department of Paediatric Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Milind Chaudhari
- Department of Paediatric Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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12
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Valkovec AM, Kram SJ, Henderson JB, Levy JH. Renal Dysfunction and Arrhythmia Association in Patients Receiving Milrinone After Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:353-359. [PMID: 36566129 DOI: 10.1053/j.jvca.2022.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/14/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The altered pharmacokinetics of milrinone in renal impairment could result in an increased risk of cardiac arrhythmias. This study aimed to determine if there is an association between new-onset arrhythmias and renal impairment after cardiac surgery following milrinone administration. DESIGN A retrospective cohort study. SETTING A single-center tertiary care hospital. PARTICIPANTS Adult patients who received a milrinone infusion in the intensive care unit (ICU) setting after coronary artery bypass graft, valvuloplasty, annuloplasty, or a combination of these surgeries from July 1, 2014 to July 1, 2021. Renal impairment was defined using a creatinine clearance <60 mL/min, calculated using the Cockcroft-Gault equation. INTERVENTIONS Patients received a weight-based continuous intravenous infusion of milrinone. MEASUREMENTS AND MAIN RESULTS The primary outcome was the presence of new arrhythmias after the initial administration of a weight-based continuous intravenous infusion of milrinone postcardiac surgery. Of the 197 patients who met inclusion, there was no difference in the presence of new arrhythmias (42.9% v 40.3%, p = 0.76) or in the time to first new arrhythmia from milrinone initiation in those with renal impairment compared to those without renal impairment (29.1 hours v 33.3 hours, p = 0.54). Patients with renal impairment had a longer hospital stay than patients without renal impairment (17.5 days v 13.9 days, p = 0.016). Arrhythmia type, length of ICU stay, ICU mortality, and hospital mortality were not different between the cohorts. CONCLUSIONS There was no association between new arrhythmias, milrinone, and renal impairment in patients postcardiac surgery.
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Affiliation(s)
- Amy M Valkovec
- Department of Pharmacy, Duke University Hospital, Durham, NC.
| | - Shawn J Kram
- Department of Pharmacy, Duke University Hospital, Durham, NC
| | | | - Jerrold H Levy
- Departments of Critical Care and Surgery (Cardiothoracic) Duke University Hospital, Duke University, Durham, NC
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13
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Norman S, Rosenberg J, Sundararajan SH, Al Balushi A, Boddu SR, Ch’ang JH. Management of refractory bacterial meningitis-associated cerebral vasospasm: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22418. [PMID: 36794739 PMCID: PMC10550601 DOI: 10.3171/case22418] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/03/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Cerebral vasospasm is an alarming complication of acute bacterial meningitis with potentially devastating consequences. It is essential for providers to recognize and treat it appropriately. Unfortunately, there is no well-established approach to the management of postinfectious vasospasm, which makes it especially challenging to treat these patients. More research is needed to address this gap in care. OBSERVATIONS Here, the authors describe a patient with postmeningitis vasospasm that was refractory to induced hypertension, steroids, and verapamil. He eventually responded to a combination of intravenous (IV) and intra-arterial (IA) milrinone followed by angioplasty. LESSONS To our knowledge, this is the first report of successfully using milrinone as vasodilator therapy in a patient with postbacterial meningitis-associated vasospasm. This case supports the use of this intervention. In future cases of vasospasm after bacterial meningitis, IV and IA milrinone should be trialed earlier with consideration of angioplasty.
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Affiliation(s)
- Sofya Norman
- Weill Cornell Medical College, Weill Cornell Medicine, New York, New York
| | | | | | | | - Srikanth Reddy Boddu
- Department of Neurological Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
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14
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Pagliara C, Zambaiti E, Brooks G, Bonadies L, Tognon C, Salvadori S, Sgrò A, Leon FF. Congenital Diaphragmatic Hernia: Perinatal Prognostic Factors and Short-Term Outcomes in a Single-Center Series. Children (Basel) 2023; 10. [PMID: 36832444 DOI: 10.3390/children10020315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
Background: Many prognostic factors for CDH patients are described and validated in the current literature: the size of diaphragmatic defects, need for patch repair, pulmonary hypertension and left ventricular dysfunction are recognized as the most influencing outcomes. The aim of this study is to analyze the influence of these parameters in the outcome of CDH patients in our department and identify any further prognostic factors. Methods: An observational retrospective single-center study was conducted including all patients treated at our centre with posterolateral CDH between 01.01.1997 and 12.31.2019. The main outcomes evaluated were mortality and length of hospital stay. A univariate and multivariate analysis was performed. Results: We identified 140 patients with posterolateral CDH; 34.8% died before discharge. The overall median length of stay was 24 days. A univariate analysis confirmed that both outcomes are associated with the size of diaphragmatic defects, need for patch repair and presence of spleen-up (p < 0.05). A multivariate analysis identified that the need for patch repair and maximum dopamine dose used for cardiac dysfunction are independent parameters associated with the length of stay only (p < 0.001). Conclusions: In our series, the duration of hospitalization is longer for newborns with CDH treated with higher doses of dopamine for left ventricular dysfunction or needing patch repair in large diaphragmatic defects.
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15
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Kenneally AM, Agbana P, Gardner B, Bae Y, Mitchell T, Beckman EJ. Compatibility of calcium chloride with milrinone, epinephrine, vasopressin, and heparin via in vitro testing and simulated Y-site administration. Am J Health Syst Pharm 2023; 80:164-170. [PMID: 36282720 DOI: 10.1093/ajhp/zxac306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Indexed: 01/29/2023] Open
Abstract
PURPOSE The purpose of this study is to evaluate calcium chloride (CaCl) compatibility with commercially available and extemporaneously compounded milrinone, vasopressin, epinephrine, and heparin. This report describes 2 clinical scenarios in which patients experienced intravenous catheter precipitation when receiving multiple continuous infusions, including CaCl, and the results of an in vitro simulation of those scenarios. The hypothesis was that one or a combination of the medications would precipitate with CaCl. METHODS CaCl compatibility was tested in 3 stages to simulate clinical situations where line precipitation occurred. Multiple tests were conducted in each stage to determine if precipitation had occurred, including visual assessment, absorbance measurement at 650 nm, and pH measurement. First, milrinone, vasopressin, epinephrine, and heparin were mixed pairwise with CaCl in a test tube. Second, the medications were mixed in different combinations deemed likely to precipitate. Finally, 5 medications were infused via simulated Y-site administration. Incompatibility was defined as observed crystals, haziness, or turbidity upon visual inspection or absorbance of greater than 0.01 absorbance unit (AU). All solutions were tested at time 0 and at 20, 60, 240, and 1,440 minutes. RESULTS Across all tests, only a commercially available formulation of heparin 2 units/mL in 0.9% sodium chloride injection precipitated with CaCl, alone or in combination with other medications. Upon further review, it was found that this specific formulation of heparin contained a monohydrate and dibasic sodium phosphate buffer. CONCLUSION CaCl only precipitated with a commercially available heparin formulation that contained a phosphate buffer. CaCl was deemed to be compatible with all other medications and formulations tested.
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Affiliation(s)
| | - Preye Agbana
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Brian Gardner
- University of Kentucky Healthcare, Lexington, KY.,University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Younsoo Bae
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | | | - Elizabeth J Beckman
- University of Kentucky Healthcare, Lexington, KY.,University of Kentucky College of Pharmacy, Lexington, KY, USA
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Lannon M, Martyniuk A, Sharma S. Intravenous milrinone for delayed cerebral ischaemia in aneurysmal subarachnoid haemorrhage: a systematic review. Br J Neurosurg 2022:1-6. [PMID: 36154769 DOI: 10.1080/02688697.2022.2125160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/10/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a major contributor to mortality worldwide, with delayed cerebral ischaemia (DCI) contributing significantly to morbidity in these patients. There are limited evidence-based therapies for DCI. A 2012 case series first recommended the use of intravenous (IV) milrinone in this patient population, stating the need for formal prospective trials. However, uptake of this therapy into clinical practice has proceeded without adequate studies for efficacy and safety. METHODS We sought to determine the effect of IV milrinone on DCI in patients with aSAH in terms of functional outcome through a systematic review using Embase, MEDLINE, and Cochrane Library databases. Quality assessment was performed using MINORS criteria. RESULTS A total of 2429 studies were screened, with ten studies included in the review. Of these, no randomized trials were identified. Three observational comparative studies were included, and the remaining seven studies were non-comparative in nature, and mainly retrospective. Overall, the quality of evidence for non-comparative studies was poor. CONCLUSIONS This study reveals a paucity of evidence in the literature and highlights the need for high-quality randomized trials to investigate the safety and efficacy of IV milrinone, a commonly utilized treatment in critically ill aSAH patients with DCI. Ultimately, without evidence of efficacy and absence of harm, we caution continued use of intravenous milrinone for the treatment of DCI.
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
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Zhu H, Ma P, Qian Y, Xia J, Gong F, Chen L, Xu L. Spectral Properties Echoing the Tautomerism of Milrinone and Its Application to Fe 3+ Ion Sensing and Protein Staining. Biosensors (Basel) 2022; 12:777. [PMID: 36290915 PMCID: PMC9599543 DOI: 10.3390/bios12100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/16/2022] [Accepted: 09/18/2022] [Indexed: 06/16/2023]
Abstract
Knowledge on the spectral properties of the tautomers of milrinone (MLR) in solvents and solid-state, as well as under light conditions is of critical importance from both theoretical and practical points of view. Herein, we investigated the spectral properties of MLR in different conditions using UV-Vis and fluorescence spectroscopies. The experimental results demonstrated that MLR can undergo the tautomerization reaction induced by solvent polarity, light and pH, eliciting four tautomeric structures (enol, keto, anion, and cation forms). The interesting multi-functional groups in MLR enable it to coordinate with metal ions or to recognize gust molecules by H-bonding. In the use of MLR as an excited-state intermolecular proton transfer (inter-ESPT) fluorescent probe, a highly sensitive and selective analysis of Fe3+ was developed, which offered a sensitive detection of Fe3+ with the detection limit of 3.5 nM. More importantly, MLR exhibited the ability of anchoring proteins and led to the recognition-driven turn-on inter-ESPT process, highlighting the potential for the probe to image proteins in electrophoresis gels. The spectral experimental results revealed the possible degradation mechanism, so that we can better understand the side effects of oral preparations. The use of the available drug as an inter-ESPT fluorescent probe is simple and accurate, providing a good method for Fe3+ ion sensing and protein staining.
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Prajapati M, Patel J, Patel H, Gandhi H, Singh G, Patel P. Assessment of the effect of two regimens of milrinone infusion in paediatric patients with pulmonary artery hypertension undergoing corrective cardiac procedure: A prospective observational study. Ann Pediatr Cardiol 2022; 15:358-363. [PMID: 36935828 PMCID: PMC10015397 DOI: 10.4103/apc.apc_230_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/25/2022] [Accepted: 06/12/2022] [Indexed: 01/09/2023] Open
Abstract
Background The aim of the study was to compare the effect of two different regimens of milrinone in pediatric patients with pulmonary artery hypertension (PAH) undergoing corrective procedure. Materials and Methods This randomized prospective study included 100 pediatric patients undergoing corrective cardiac surgeries. Group E: Milrinone was started as infusion 0.5 μg/kg/min without a loading dose after induction of anesthesia and continued as infusion 0.5-0.75 μg/kg/min in the pediatric cardiac surgical intensive care unit (PSICU). Group L: Milrinone was started as a loading dose 50 μg/kg over 10 min before weaning from cardiopulmonary bypass (CPB) followed by infusion 0.5-0.75 μg/kg/min in the PSICU. We compared heart rate, mean arterial blood pressure, central venous pressure, cardiac index (CI), mean pulmonary arterial pressure (MPAP), serum lactate level, urine output, vasoactive inotropic score, mechanical ventilation duration, and intensive care unit (ICU)- and hospital length of stay between the groups. Results There was an increase in mean arterial blood pressure, CI, and urine output in Group E compared to Group L (P < 0.05). MPAP, serum lactate level, and requirement of inotropes and vasopressors were lower in Group E compared to Group L (P < 0.05). Mechanical ventilation duration, ICU, and hospital length of stay were shorter in Group E than Group L (P < 0.05). Conclusions Early use of milrinone in patients with PAH undergoing corrective cardiac surgeries improved CI and mean arterial pressure, decreased MPAP, improved urine output, decreased serum lactate level, and decreased requirement of inotropes and vasopressors after weaning from CPB compared to the milrinone bolus group.
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Affiliation(s)
- Mrugesh Prajapati
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Ahmadabad, Gujarat, India
| | - Jigar Patel
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Ahmadabad, Gujarat, India
| | - Hasmukh Patel
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Ahmadabad, Gujarat, India
| | - Hemang Gandhi
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Ahmadabad, Gujarat, India
| | - Guriqbal Singh
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Ahmadabad, Gujarat, India
| | - Pravin Patel
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Ahmadabad, Gujarat, India
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19
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Baulier C, Lessert M, Chauvet JL, Garel P, Bergis A, Burdeau J, Clavier T. Left Ventricular Outflow Tract Obstruction in Patients Treated With Milrinone for Cerebral Vasospasm: Case Report and Literature Review. JMIRx Med 2022; 3:e31019. [PMID: 37463041 PMCID: PMC10337478 DOI: 10.2196/31019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/05/2021] [Accepted: 01/27/2022] [Indexed: 07/20/2023]
Abstract
Subarachnoid hemorrhage is associated with high morbidity and mortality, and cerebral arterial vasospasm is one of its main complications that determines neurological prognosis. The use of intravenous milrinone is becoming more common in the treatment of vasospasm. This molecule has positive inotropic and vasodilating properties by inhibiting phosphodiesterase-3. Its most described side effects are cardiac arrhythmias and arterial hypotension. In this paper, we raise a new issue concerning milrinone and discuss an undescribed side effect of this treatment, left ventricular outflow tract obstruction (LVOTO). Dynamic LVOTO is a clinical situation favored by hypovolemia, decreased left ventricular afterload, and excessive inotropism that can lead to severe hemodynamic failure and pulmonary edema. To our knowledge, this is the first study describing milrinone-induced LVOTO. This could compromise cerebral perfusion and therefore the neurological prognosis of patients. While it is known that catecholamines may induce LVOTO, milrinone-induced LVOTO appears to be a new pathophysiological entity of which neurosurgical intensivists should be aware.
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Affiliation(s)
- Charles Baulier
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Marc Lessert
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | | | - Pauline Garel
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Alexandre Bergis
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
| | - Julie Burdeau
- Cardiology Department Rouen University Hospital Rouen France
| | - Thomas Clavier
- Anesthesia and Intensive Care Department Rouen University Hospital Rouen France
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Laufer‐Perl M, Sadon S, Zahler D, Milwidsky A, Sadeh B, Sapir O, Granot Y, Korotetski L, Ketchker L, Rosh M, Banai S, Havakuk O. Repetitive milrinone therapy in ambulatory advanced heart failure patients. Clin Cardiol 2022; 45:488-494. [PMID: 35243658 PMCID: PMC9045071 DOI: 10.1002/clc.23802] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Advanced heart failure (HF) patients usually poorly tolerate guideline-directed HF medical therapy (GDMT) and suffer high rates of morbidity and mortality. The use of continuous inotropes in the outpatient settings is hampered by previous data showing excess morbidity. We aimed to assess the safety and efficacy of repetitive, intermittent, short-term intravenous milrinone therapy in advanced HF patients with an intention to introduce and up-titrate GDMT and improve functional class. HYPOTHESIS Repetitive, intermittent milrinone therapy may assist with the stabilization of advanced HF patients. METHODS Advanced HF patients treated with beta-blockers and implanted with defibrillators were initiated with repetitive, intermittent short-term intravenous milrinone therapy at our HF outpatient unit. Patients were prospectively followed with defibrillator interrogation, functional class assessment, B-natriuretic peptide (BNP) levels, and echocardiography parameters. RESULTS The cohort included 24 patients with a mean 330 ± 240 days of milrinone therapy exposure. Mean age was 73 ± 6 years with male predominance (96%). Following milrinone therapy, median BNP levels decreased significantly (882 [286-3768] to 631 [278-1378] pg/ml, p = .017) with a significant reduction in the number of patients with New York Heart Association (NYHA) Class III and IV (p = .012, 0.013) and an increase in number of patients on GDMT. Importantly, the number of total sustained ventricular tachycardia events and HF hospitalizations did not change. CONCLUSIONS In this small cohort of advanced HF, repetitive, intermittent, short-term milrinone therapy was found to be safe and potentially efficacious.
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Affiliation(s)
- Michal Laufer‐Perl
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Sapir Sadon
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - David Zahler
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Assi Milwidsky
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Ben Sadeh
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Orly Sapir
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Yoav Granot
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Liuba Korotetski
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Liora Ketchker
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Maayan Rosh
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Shmuel Banai
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Ofer Havakuk
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
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21
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Keskin H, Tavaci T, Halici H, Yuksel TN, Ozkaraca M, Bilen A, Kose D, Mendil AS, Halici Z. Early administration of milrinone ameliorates lung and kidney injury during sepsis in juvenile rats. Pediatr Int 2022; 64:e14917. [PMID: 34242458 DOI: 10.1111/ped.14917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/08/2021] [Accepted: 07/07/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND A sepsis model was created, induced by cecal ligation and puncture (CLP), in juvenile rat groups. Milrinone (MIL), which is known to have a modulatory effect on pro-inflammatory cytokines, was administered to the designated rat groups in the early period before severe sepsis developed. The study was aimed at investigating the possible protective effects of milrinone on the lung and kidney tissues of rats in the late phase of sepsis. METHODS The rat pups were divided into seven groups with six animals in each group: (1) healthy rats who received no drug; (2) CLP-S12 (sacrificed at hour 12); (3) CLP-S24 (sacrificed at hour 24); (4) CLP-MIL1-S12 (administered with 0.5 mg/kg milrinone at hour 1 and sacrificed at hour 12); (5) CLP-MIL1-S24 (administered with 0.5 mg/kg milrinone at hour 1 and sacrificed at hour 24): (6) CLP-MIL12-S24 (administered with 0.5 mg/kg milrinone at hour 12 and sacrificed at hour 24), (7) and CLP-MIL1,12-S24 (administered with 0.5 mg/kg milrinone at hours 1 and 12 and sacrificed at hour 24). RESULTS Significant differences were found between the early and late administration of milrinone in terms of both molecular and histopathological results. The results showed that the tissues were significantly preserved in the groups in which milrinone had been started in the early period compared to the sepsis control groups and the groups in which milrinone had been started in the late period. CONCLUSIONS In addition to the positive inotropic effects of milrinone, its immunomodulatory properties that result in decreased cytokine storm can be beneficial during early period of sepsis.
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Affiliation(s)
- Halil Keskin
- Division of Pediatric Intensive Care Unit, Department of Pediatrics, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Taha Tavaci
- Department of Pharmacology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Hamza Halici
- Department of Pharmacology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Tugba Nurcan Yuksel
- Department of Pharmacology, Namik Kemal University Faculty of Medicine, Tekirdag, Turkey
| | - Mustafa Ozkaraca
- Department of Pathology, Cumhuriyet University Faculty of Veterinary, Sivas, Turkey
| | - Arzu Bilen
- Division of Endocrinology, Department of Internal Medicine, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Duygu Kose
- Department of Pharmacology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Ali Sefa Mendil
- Department of Pathology, Cumhuriyet University Faculty of Veterinary, Sivas, Turkey
| | - Zekai Halici
- Department of Pharmacology, Ataturk University Faculty of Medicine, Erzurum, Turkey.,Clinical Research, Development and Design Application and Research Center, Ataturk University, Erzurum, Turkey
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22
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Lomis N, Sarfaraz ZK, Alruwaih A, Westfall S, Shum-Tim D, Prakash S. Albumin Nanoparticle Formulation for Heart-Targeted Drug Delivery: In Vivo Assessment of Congestive Heart Failure. Pharmaceuticals (Basel) 2021; 14:697. [PMID: 34358122 DOI: 10.3390/ph14070697] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 01/14/2023] Open
Abstract
Congestive heart failure is a fatal cardiovascular disease resulting in tissue necrosis and loss of cardiac contractile function. Inotropic drugs such as milrinone are commonly used to improve the myocardial contractility and heart function. However, milrinone is associated with severe side effects and lower circulation time. In this article, a novel protein nanoparticle formulation for heart-targeted delivery of milrinone has been designed and tested. The formulation was prepared using albumin protein conjugated with the targeting ligand, angiotensin II peptide to form nanoparticles following the ethanol desolvation method. The formulation was characterized for size, charge, and morphology and tested in a rat model of congestive heart failure to study pharmacokinetics, biodistribution, and efficacy. The overall cardiac output parameters were evaluated comparing the formulation with the control non-targeted drug, milrinone lactate. This formulation exhibited improved pharmacokinetics with a mean retention time of 123.7 min, half-life of 101.3 min, and clearance rate of 0.24 L/(kg*h). The targeted formulation also significantly improved ejection fraction and fractional shortening parameters thus improving cardiac function. This study demonstrates a new approach in delivering inotropic drugs such as milrinone for superior treatment of congestive heart failure.
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23
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Gottlieb SS, Psotka MA, Desai N, Lindenfeld J, Russo P, Allen LA. Use of Outpatient Intravenous Calcitropes for Heart Failure in the United States. J Card Fail 2021; 27:1276-1279. [PMID: 34265464 DOI: 10.1016/j.cardfail.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Outpatient calcitrope infusions-that is, the cardiac inotropes milrinone and dobutamine-are often used for bridge to transplantation and palliation in advanced heart failure, but few data exist about the real-world use of these agents. METHODS AND RESULTS We used the Symphony Integrated DataVerse of commercial, managed Medicare, and Medicaid insurance claims of approximately 280 million people (2012-2020) to determine the incidence and characteristics of ambulatory calcitrope use. Demographics were calculated, including geographic densities at the metropolitan statistical area level. A population projection normalized for age, sex, and location was extrapolated to the total US population. Ambulatory dispensing of milrinone was found in 10,533 outpatients, 1867 in 2019. Ambulatory dobutamine use was found in 4967 outpatients, 836 in 2019. The 2019 total US projection was 3411 for milrinone and 1281 for dobutamine. The mean age was 62 years for milrinone and 68 for dobutamine. Males represented 70% of use. There were differences between drugs in geographic distribution, with more milrinone use in the Northeast and South and more dobutamine use in the Midwest. Duration of use was 4.6 ± 7.2 months for milrinone and 1.8 ± 4.0 months for dobutamine. Of the patients receiving milrinone, 30.6% subsequently underwent cardiac transplantation or left ventricular assist device placement, whereas 10% receiving dobutamine went on to advanced therapies. Less than 0.5% of patients received calcitropes while enrolled in hospice care. CONCLUSIONS More than 4000 patients receive outpatient infusion of calcitropes annually in the outpatient setting. Men are much more likely to receive these medications. A minority of the use is as a bridge to advanced therapies. Geographic variability in use suggests better evidence and consistent guidelines may be helpful.
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Affiliation(s)
- Stephen S Gottlieb
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, Maryland.
| | | | | | | | - Pierantonio Russo
- Spring Hills-Population Health, Edison, NJ and Eversana Analytics, Milwaukee, WI
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado
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24
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Bernier TD, Schontz MJ, Izzy S, Chung DY, Nelson SE, Leslie-Mazwi TM, Henderson GV, Dasenbrock H, Patel N, Aziz-Sultan MA, Feske S, Du R, Abulhasan YB, Angle MR. Treatment of Subarachnoid Hemorrhage-associated Delayed Cerebral Ischemia With Milrinone: A Review and Proposal. J Neurosurg Anesthesiol 2021; 33:195-202. [PMID: 33480639 PMCID: PMC8192346 DOI: 10.1097/ana.0000000000000755] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022]
Abstract
Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage continues to be associated with high levels of morbidity and mortality. This complication had long been thought to occur secondary to severe cerebral vasospasm, but expert opinion now favors a multifactorial etiology, opening the possibility of new therapies. To date, no definitive treatment option for DCI has been recommended as standard of care, highlighting a need for further research into potential therapies. Milrinone has been identified as a promising therapeutic agent for DCI, possessing a mechanism of action for the reversal of cerebral vasospasm as well as potentially anti-inflammatory effects to treat the underlying etiology of DCI. Intra-arterial and intravenous administration of milrinone has been evaluated for the treatment of DCI in single-center case series and cohorts and appears safe and associated with improved clinical outcomes. Recent results have also brought attention to the potential outcome benefits of early, more aggressive dosing and titration of milrinone. Limitations exist within the available data, however, and questions remain about the generalizability of results across a broader spectrum of patients suffering from DCI. The development of a standardized protocol for milrinone use in DCI, specifically addressing areas requiring further clarification, is needed. Data generated from a standardized protocol may provide the impetus for a multicenter, randomized control trial. We review the current literature on milrinone for the treatment of DCI and propose a preliminary standardized protocol for further evaluation of both safety and efficacy of milrinone.
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Affiliation(s)
- Thomas D. Bernier
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David Y. Chung
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah E. Nelson
- Departments of Neurology and Anesthesiology & Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thabele M. Leslie-Mazwi
- Harvard Medical School, Boston, MA, USA
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Galen V. Henderson
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Hormuzdiyar Dasenbrock
- Department of Neurosurgery, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Nirav Patel
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mohammad Ali Aziz-Sultan
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Steven Feske
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rose Du
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Yasser B. Abulhasan
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
- Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait
| | - Mark R. Angle
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
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25
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Vogel DJ, Brame A, Hanks F, Remmington C, Chung N, Camporota L. Improved oxygenation with inhaled milrinone in mechanically ventilated patients with severe COVID-19. Br J Anaesth 2021; 127:e111-e113. [PMID: 34218906 PMCID: PMC8185181 DOI: 10.1016/j.bja.2021.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/17/2021] [Accepted: 06/02/2021] [Indexed: 10/27/2022] Open
Affiliation(s)
- Dominik J Vogel
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Aimee Brame
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fraser Hanks
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK; Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Chris Remmington
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK; Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Natali Chung
- Adult Congenital Heart Disease Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK; Centre of Human Applied Physiological Sciences, King's College London, London, UK
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26
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Kölükçü E, Atılgan D, Uluocak N, Deresoy FA, Katar M, Unsal V. Milrinone ameliorates ischaemia-reperfusion injury in experimental testicular torsion/detorsion rat model. Andrologia 2021; 53:e14128. [PMID: 34091938 DOI: 10.1111/and.14128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/07/2021] [Accepted: 05/09/2021] [Indexed: 01/02/2023] Open
Abstract
This experimental study aims to evaluate the efficacy of milrinone against ischaemia-reperfusion injury due to testicular torsion/detorsion. Group 1 was defined as the control group. Testicular torsion/detorsion model was performed in Group 2. Group 3 had similar procedures to the rats in Group 2. In addition, 0.5 mg/kg of milrinone was administered intraperitoneally immediately after testicular torsion in Group 3. Histopathological examinations indicated a dramatic improvement in terms of inflammation, haemorrhage, oedema, congestion, Cosentino and Johnson scores in Group 3 compared to Group 2 (p = .037, p = .045, p = .018, p = .040, p = .033 and p = .03 respectively). Blood biochemical analyses, superoxide dismutase (SOD), glutathione peroxidase (GSH-px) activity and total antioxidant status (TAS) levels increased significantly in Group 3 compared to Group 2 (p = .001, p = .024 and p < .001). Malondialdehyde (MDA), protein carbonyl (PC), interleukin 1beta (IL-1beta), tumour necrosis factor-alpha (TNF-alpha) and total oxidant status (TOS) levels decreased in Group 3 compared to Group 2 (p = .001, p = .018, p < .001, p = .036 and p = .002 respectively). Tissue biochemical analyses determined an increase in SOD and GSH-px activity in Group 3 compared to Group 2, while PC and MDA levels were reduced (p = .001, p < .001, p = .038 and p < .001 respectively). Milrinone attenuates ischaemia-reperfusion injury that causes highly harmful effects due to testicular torsion/detorsion.
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Affiliation(s)
- Engin Kölükçü
- Department of Urology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Doğan Atılgan
- Department of Urology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Nihat Uluocak
- Department of Urology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Faik Alev Deresoy
- Department of Pathology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Muzaffer Katar
- Department of Biochemistry, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Velid Unsal
- Faculty of Health Sciences and Central Research Laboratory, Mardin Artuklu University, Mardin, Turkey
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27
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Roy PK, Qamar AY, Tanga BM, Fang X, Kim G, Bang S, Cho J. Enhancing Oocyte Competence With Milrinone as a Phosphodiesterase 3A Inhibitor to Improve the Development of Porcine Cloned Embryos. Front Cell Dev Biol 2021; 9:647616. [PMID: 33996810 PMCID: PMC8120234 DOI: 10.3389/fcell.2021.647616] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/22/2021] [Indexed: 11/25/2022] Open
Abstract
The objective of this study was to investigate the effect of milrinone supplementation as a phosphodiesterase 3A inhibitor during in vitro maturation (IVM) to coordinate the cytoplasmic and nuclear maturation of porcine oocytes and subsequent development of porcine cloned embryos. Brilliant cresyl blue (BCB)-stained (BCB +) oocytes, classified as well-developed, and BCB− oocytes were used in parthenogenesis (PA) and cloning, and their preimplantation development was compared. In PA embryos, BCB + oocytes had significantly higher rates of development than BCB− oocytes in terms of maturation (87.5 vs. 71.3%), cleavage (88.6 vs. 76.3%), and blastocyst development (34.3 vs. 25.3%) and also had higher cell numbers (46.9 vs. 38.9%), respectively (p < 0.05). In cloned embryos, the BCB + group also had a significantly higher blastocyst formation rate than the BCB− group (30.6 vs. 20.1%; p < 0.05). Supplementation with 75 μM milrinone during IVM of BCB− oocytes showed improvement in maturation and blastocyst development rates, which may be due to the coordinated maturation of the cytoplasm with the nucleus as an effect of milrinone. Moreover, the analysis of nuclear reprogramming via the examination of the expression levels of the reprogramming-related genes POU5F1, DPPA2, and NDP52IL in milrinone-supplemented BCB− oocytes showed higher expression levels than that in non-treated BCB− oocytes. These findings demonstrate that milrinone is useful in improving developmental competence in less competent oocytes during IVM and for proper nuclear reprogramming in the production of porcine cloned embryos by coordinating cytoplasmic and nucleus maturation.
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Affiliation(s)
- Pantu Kumar Roy
- Laboratory of Theriogenology, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Ahmad Yar Qamar
- Laboratory of Theriogenology, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea.,College of Veterinary and Animal Sciences, Jhang, Sub-campus of University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Bereket Molla Tanga
- Laboratory of Theriogenology, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea.,Faculty of Veterinary Medicine, Hawassa University, Hawassa, Ethiopia
| | - Xun Fang
- Laboratory of Theriogenology, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Ghangyong Kim
- Laboratory of Theriogenology, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Seonggyu Bang
- Laboratory of Theriogenology, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Jongki Cho
- Laboratory of Theriogenology, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
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28
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Uriel N, Burkhoff D, Kim G, Silverstein T, Juricek C, Kaye DM, Sayer G. Oral Milrinone for the Treatment of Chronic Severe Right Ventricular Failure in Left Ventricular Assist Device Patients. Circ Heart Fail 2021; 14:e007286. [PMID: 33736460 DOI: 10.1161/circheartfailure.120.007286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (N.U., D.B., G.S.)
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (N.U., D.B., G.S.)
| | - Gene Kim
- Section of Cardiology (G.K., T.S.), University of Chicago Medicine, IL
| | | | - Colleen Juricek
- Department of Surgery (C.J.), University of Chicago Medicine, IL
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (D.M.K.)
| | - Gabriel Sayer
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (N.U., D.B., G.S.)
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29
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Kanazawa T, Shimizu K, Iwasaki T, Baba K, Otsuki S, Kotani Y, Kasahara S, Morimatsu H. Perioperative Milrinone Infusion Improves One-Year Survival After the Norwood-Sano Procedure. J Cardiothorac Vasc Anesth 2021; 35:2073-2078. [PMID: 33736911 DOI: 10.1053/j.jvca.2021.02.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/19/2021] [Accepted: 02/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether milrinone infusion improved one-year survival in patients who underwent the Norwood-Sano procedure. DESIGN A retrospective observational study. SETTING A single-institution university hospital. PARTICIPANTS Children who underwent the Norwood-Sano procedure from January 2008 to December 2014. INTERVENTIONS Patients were categorized into two groups: group E+D, who received routine epinephrine and dopamine infusion, and group M, who received routine milrinone infusion for intra- and postoperative inotropic support. MEASUREMENTS AND MAIN RESULTS The primary outcome of this study was one-year survival after the Norwood-Sano procedure. A total of 45 patients were included (group E+D, 22; group M, 23). One-year survival in group M was significantly higher than that in group E+D (95.7% [22/23] v 72.7% [16/22], p = 0.03). A Kaplan-Meier curve also showed that one-year survival in group M was significantly higher than that in group E+D (p = 0.04), from the result of the log-rank test. The number of patients who had any arrhythmias in the intensive care unit (ICU) was significantly lower in group M than in group E+D (21.7% [5/23] v 50% [11/22], p = 0.03). The duration of ICU stay did not have statistical difference between groups (group M 19; interquartile range [IQR], 15-28) v group E+D 19.5 (IQR, 16.3-35.5) days, p = 0.57). CONCLUSIONS Perioperative milrinone infusion improved the mortality after the Norwood-Sano procedure. Potential advantages of milrinone compared with epinephrine are fewer arrhythmias and better systemic perfusion, which could decrease lethal cardiac events in the ICU.
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Affiliation(s)
- Tomoyuki Kanazawa
- Anesthesiology and Resuscitology, Okayama University Hospital, Kitaku, Okayama, Japan.
| | - Kazuyoshi Shimizu
- Anesthesiology and Resuscitology, Okayama University Hospital, Kitaku, Okayama, Japan
| | - Tatsuo Iwasaki
- Anesthesiology and Resuscitology, Okayama University Hospital, Kitaku, Okayama, Japan
| | - Kenji Baba
- Pediatric Cardiology, Okayama University Hospital, Kitaku, Okayama, Japan
| | - Shinichi Otsuki
- Pediatric Cardiology, Okayama University Hospital, Kitaku, Okayama, Japan
| | - Yasuhiro Kotani
- Cardiovascular Surgery, Okayama University Hospital, Kitaku, Okayama, Japan
| | - Shingo Kasahara
- Cardiovascular Surgery, Okayama University Hospital, Kitaku, Okayama, Japan
| | - Hiroshi Morimatsu
- Anesthesiology and Resuscitology, Okayama University Hospital, Kitaku, Okayama, Japan
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30
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Chen Q, Yin Y, Li L, Zhang Y, He W, Shi Y. Milrinone Ameliorates the Neuroinflammation and Memory Function of Alzheimer's Disease in an APP/PS1 Mouse Model. Neuropsychiatr Dis Treat 2021; 17:2129-2139. [PMID: 34234439 PMCID: PMC8256386 DOI: 10.2147/ndt.s312648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Alzheimer's disease (AD) is a complex neurodegenerative disorder, which is characterized by memory loss and cognitive deficits. The neuroprotective role of milrinone on the injury of spinal cord or cerebral ischemia-reperfusion has been confirmed. However, the accurate function of milrinone on AD pathogeny is still unclear. METHODS APP/PS1 transgenic mouse was used to explore the role of milrinone in behaviour tests, and the effects on histopathologic features of AD such as the formation of neuronal amyloid-β (Aβ) plaque, microglial activation, tau protein hyperphosphorylation, oxidative stress, and neuroinflammation. Lipopolysaccharide (LPS)/Aβ-treated BV-2 cells were used to understand the anti-inflammation mechanism of milrinone on AD in vitro. RESULTS Our in vivo results showed that milrinone ameliorates the memory functions of AD mice. Meanwhile, milrinone reduced Aβ deposits, repressed microglial activation and tau protein hyperphosphorylation, attenuated the oxidative stress, and decreased the levels of inflammatory cytokines. The in vitro results demonstrated that milrinone could inhibit the secretion of interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α via regulation of NLRP3 inflammasomes and TLR4/MyD88/NF-κB signalling pathway. CONCLUSION Overall, milrinone could ameliorate the memory loss and cognitive deficits through repressing the multiple pathological processes of AD, suggesting that milrinone may be an underlying and effective drug for treating AD clinically.
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Affiliation(s)
- Qingyou Chen
- Department of Neurology, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar City, Heilongjiang Province, 161000, People's Republic of China
| | - Yue Yin
- Department of Science and Education, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar City, Heilongjiang Province, 161000, People's Republic of China
| | - Li Li
- Department of Neurology, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar City, Heilongjiang Province, 161000, People's Republic of China
| | - Yanjiao Zhang
- Department of Neurology, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar City, Heilongjiang Province, 161000, People's Republic of China
| | - Wei He
- Department of Neurology, The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar City, Heilongjiang Province, 161000, People's Republic of China
| | - Yan Shi
- College of Medical Technology, Qiqihar Medical University, Qiqihar City, Heilongjiang Province, 161000, People's Republic of China
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31
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Griffith SN, Stapleton E, Padilla S, Mruk A, Thomas CA. Physical compatibility of milrinone 1 mg/mL with select cardiovascular medications during simulated Y-site administration. Am J Health Syst Pharm 2020; 77:1938-1940. [PMID: 32991671 DOI: 10.1093/ajhp/zxaa296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Stacy Padilla
- Department of Pharmacy Phoenix Children's Hospital, Phoenix, AZ
| | - Allison Mruk
- Department of Pharmacy Phoenix Children's Hospital, Phoenix, AZ
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32
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Choi H, Huh J, Koo J, Lee J, Hwang W. Effects of milrinone on cerebral perfusion and postoperative cognitive function in spine surgery: Secondary analysis of a CONSORT-compliant randomized controlled trial. Medicine (Baltimore) 2020; 99:e21717. [PMID: 33181634 PMCID: PMC7668439 DOI: 10.1097/md.0000000000021717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To compare the effects of milrinone, sodium nitroprusside (SNP), and nitroglycerin (NTG) on induced hypotension, cerebral perfusion, and postoperative cognitive function in elderly patients undergoing spine surgery. METHODS Sixty patients >60 years scheduled for lumbar fusion surgery were assigned to receive milrinone (group M), SNP (group S), or NTG (group N). The administration of the study drug was initiated immediately after perivertebral muscle retraction and was stopped after completion of interbody fusion. Target blood pressure was a decrease of 30% in systolic blood pressure from baseline or mean blood pressure of 60 to 65 mm Hg. The regional cerebral venous oxygen saturation (rSVO2), as a measure of cerebral perfusion, and the change in perioperative Mini-Mental State Examination (MMSE) score, as a measure of postoperative cognitive function, were assessed. RESULTS During the administration of the study drug, the overall and lowest intraoperative rSVO2 values were significantly higher (P = .01 and P = .01, respectively), and the duration of rSVO2 <60% was shorter in group M than in the other groups (P = .03). In group M, intraoperative rSVO2 was not different from the basal value, whereas in groups S and N, rSVO2 was significantly lower than the basal value during the administration of the study drug, but then returned to the basal value after terminating the study drug. Basal MMSE scores were comparable among the 3 groups. The MMSE score on postoperative day 5 was higher in group M than the other groups. CONCLUSIONS Milrinone used to induce hypotension resulted in better intraoperative cerebral perfusion and postoperative cognitive function compared to SNP and nitroglycerin.
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Abstract
OBJECTIVE To evaluate and compare the hemodynamic effects of intraoperative intravenous milrinone versus inhalational milrinone at two timepoints in patients with severe pulmonary hypertension undergoing mitral valve surgery. METHODS A prospective observational study was performed in 100 patients with severe rheumatic mitral stenosis (with/without regurgitation) and right ventricular systolic pressure > 50 mm Hg. They were divided into two groups based on the strategy used to reduce pulmonary hypertension. Fifty patients had inhalational milrinone after sternotomy until initiation of cardiopulmonary bypass and after release of the aortic crossclamp until weaning off cardiopulmonary bypass. The other 50 patients received an intravenous loading dose of milrinone 50 µg·kg-1 over 10 min on release of the aortic crossclamp. Both groups received intravenous milrinone 0.5 µg·kg-1 during weaning from cardiopulmonary bypass. Hemodynamic data were evaluated at the 3 timepoints. RESULTS Pulmonary artery pressures, central venous pressure, and pulmonary capillary wedge pressure decreased significantly in the inhalational milrinone group compared to the intravenous milrinone group. Systemic vascular resistance index and cardiac index were significantly higher and pulmonary vascular resistance index was significantly lower in the inhalational milrinone group. The mean arterial pressure-to-mean pulmonary artery pressure ratio was significantly lower in the intravenous milrinone group. Tricuspid annular plane systolic excursion and right ventricular fractional area change were increased significantly in the inhalational milrinone group. CONCLUSION Intraoperative inhalational milrinone before and after cardiopulmonary bypass is safe, easy to administer, and results in significant improvements in right ventricular hemodynamics, right ventricular function, and systemic hemodynamics.
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Affiliation(s)
- Jigar Patel
- Department of Cardiac Anaesthesia, UN Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Kartik Patel
- Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Pankaj Garg
- Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Sanjay Patel
- Department of Research, UN Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
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Abulhasan YB, Ortiz Jimenez J, Teitelbaum J, Simoneau G, Angle MR. Milrinone for refractory cerebral vasospasm with delayed cerebral ischemia. J Neurosurg 2020; 134:971-982. [PMID: 32217799 DOI: 10.3171/2020.1.jns193107] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intravenous (IV) milrinone is a promising option for the treatment of cerebral vasospasm with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). However, data remain limited on the efficacy of treating cases that are refractory to standard therapy with IV milrinone. The aim of this study was to determine predictors of refractory vasospasm/DCI despite treatment with IV milrinone, and to analyze the outcome of rescue therapy with intraarterial (IA) milrinone and/or mechanical angioplasty. METHODS The authors conducted a retrospective cohort study of all patients with aSAH admitted between 2010 and 2016 to the Montreal Neurological Institute and Hospital. Patients were stratified into 3 groups: no DCI, standard therapy, and rescue therapy. The primary outcome was frequency of DCI-related cerebral infarction identified on neuroimaging before hospital discharge. Secondary outcomes included functional outcome reported as modified Rankin Scale (mRS) score, and segment reversal of refractory vasospasm. RESULTS The cohort included 322 patients: 212 in the no DCI group, 89 in the standard therapy group, and 21 in the rescue therapy group. Approximately half (52%, 168/322) were admitted with poor-grade aSAH at treatment decision (World Federation of Neurosurgical Societies grade III-V). Among patients with DCI and imaging assessing severity of vasospasm, 62% (68/109) had moderate/severe radiological vasospasm on DCI presentation. Nineteen percent (21/110) of patients had refractory vasospasm/DCI and were treated with rescue therapy. Targeted rescue therapy with IA milrinone reversed 32% (29/91) of the refractory vasospastic vessels, and 76% (16/21) of those patients experienced significant improvement in their neurological status within 24 hours of initiating therapy. Moderate/severe radiological vasospasm independently predicted the need for rescue therapy (OR 27, 95% CI 8.01-112). Of patients with neuroimaging before discharge, 40% (112/277) had developed new cerebral infarcts, and only 21% (23/112) of these were vasospasm-related. Overall, 65% (204/314) of patients had a favorable functional outcome (mRS score 0-2) assessed at a median of 4 months (interquartile range 2-8 months) after aSAH, and there was no difference in functional outcome between the 3 groups (p = 0.512). CONCLUSIONS The aggressive use of milrinone was safe and effective based on this retrospective study cohort and is a promising therapy for the treatment of vasospasm/DCI after aSAH.
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Affiliation(s)
- Yasser B Abulhasan
- 1Neurological Intensive Care Unit and.,2Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait; and
| | - Johanna Ortiz Jimenez
- 3Department of Radiology, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Gabrielle Simoneau
- 4Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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Fredholm M, Jörgensen K, Houltz E, Ricksten S. Levosimendan or milrinone for right ventricular inotropic treatment?-A secondary analysis of a randomized trial. Acta Anaesthesiol Scand 2020; 64:193-201. [PMID: 31556095 DOI: 10.1111/aas.13486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aim of the present study was to compare the effects of milrinone and levosimendan on right ventricular (RV) inotropy and lusitropy in patients after aortic valve replacement (AVR) for aortic stenosis, a procedure in which an abnormal postoperative RV function may be seen. METHODS In a prospective, blinded trial, 31 patients were randomized to receive either milrinone (0.4 and 0.8 µg/kg/min, n = 16) or levosimendan (0.1 and 0.2 µg/kg/min, n = 15) after AVR for aortic stenosis. RV performance, afterload (pulmonary arterial elastance), RV strain, systolic (SR-S) and early diastolic (SR-E) strain rate were measured by pulmonary artery thermodilution catheterization and transoesophageal two-dimensional speckle tracking echocardiography. To circumvent the indirect effects of inodilator-induced hemodynamic changes on RV systolic and diastolic deformation, pulmonary arterial elastance, central venous pressure and heart rate were maintained constant by atrial pacing, plasma volume expansion with colloids and phenylephrine-induced vasoconstriction during treatment with the inotropes. RESULTS A dose-dependent increase in stroke volume index and cardiac index by approximately 20% were seen with both agents at the highest doses, with no difference between groups (P = .792 and 0.744, respectively). In both groups, RV strain and SR-S dose-dependently increased by 20% and 15%-19%, respectively, at the highest doses (P = .742 and 0.259, respectively) with no difference between groups. SR-E improved by both agents 20%-24% at the highest dose with no difference between groups (P = .714). CONCLUSIONS The direct RV inotropic and lusitropic effects of levosimendan and milrinone were comparable at clinically relevant infusion rates.
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Affiliation(s)
- Martin Fredholm
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Kirsten Jörgensen
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Erik Houltz
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Sven‐Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
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Abstract
Milrinone is a drug frequently used for hemodynamic support in children during critical illness. Although the hemodynamic changes induced by milrinone in children may appear similar to those of adults, the physiologic contributors of these changes remain vastly unknown. A systematic review was conducted to identify studies characterising the hemodynamic effects of milrinone in children during critical illness for hemodynamic support for various medical conditions. Studies were assessed for quality and those of satisfactory quality with pre- and post-operative hemodynamics for each patient were included in the final analyses. Those not limited to children and those not limited to patients with critical illness were excluded from the final analyses. A total of six studies with 791 patients were included in the final analyses. Milrinone infusion doses ranged from 0.3 to 0.75 mcg/kg/minute with the mean infusion dose being 0.5 mcg/kg/minute. Patients whom received milrinone infusion had greater cardiac output, greater left ventricle shortening fraction, lower right ventricular systolic pressure, and lower serum lactate levels. Systolic blood pressure mean arterial blood pressure and arterial oxygen concentration did not significantly change with administration of milrinone. These results were irrespective of milrinone infusion dose, infusion duration, and study size. Milrinone was found to have several beneficial hemodynamic effects in children during critical illness when used at usual clinical doses.
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Sato R, Ariyoshi N, Hasegawa D, Crossey E, Hamahata N, Ishihara T, Nasu M, Devendra G. Effects of Inotropes on the Mortality in Patients With Septic Shock. J Intensive Care Med 2019; 36:211-219. [PMID: 31793373 DOI: 10.1177/0885066619892218] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although surviving sepsis campaign guidelines recommend the use of inotropes in the presence of myocardial dysfunction, the effects of inotropes, including epinephrine, dobutamine, and milrinone, on in-hospital mortality in patients with septic shock remains unclear. MATERIALS AND METHODS We conducted an international,2-center, retrospective cohort study. The Cox proportional hazards regression model with time-varying covariates was used to investigate whether epinephrine, milrinone, or dobutamine reduces in-hospital mortality in patients with septic shock. Sensitivity analysis was performed using propensity score matching. The primary outcome was in-hospital mortality. The secondary outcome included atrial fibrillation (Afib) with a rapid ventricular response (RVR) in the intensive care unit (ICU) and ICU-free days. RESULTS A total of 417 patients with septic shock were included, 72 (17.3%) of whom received inotropes. The use of epinephrine and dobutamine was associated with significantly higher in-hospital mortality (epinephrine, hazard ratio [HR]: 4.79, 95% confidence interval [CI]: 2.12-10.82, P = .001; dobutamine, HR: 2.53, 95% CI: 1.30-4.95, P = .046). The effects of epinephrine and dobutamine were time- and dose-dependent. The use of milrinone was not associated with increased mortality (HR: 1.07, 95% CI: 0.42-2.68, P = .345). The use of epinephrine, dobutamine, and milrinone was associated with significantly increased odds of Afib with RVR (epinephrine, odds ratio [OR]: 3.88, 95% CI: 1.11-13.61, P = .034; dobutamine, OR: 3.95, 95% CI: 1.14-13.76; and milrinone, OR: 3.77, 95% CI: 1.05-13.59). On the other hand, the use of epinephrine, dobutamine, and milrinone was not associated with less ICU-free days (epinephrine, adjusted OR: 0.30, 95% CI: 0.09-1.01, P = .053; dobutamine, adjusted OR: 0.91, 95% CI: 0.29-2.84; and milrinone, adjusted OR: 0.60, 95% CI: 0.19-1.87). CONCLUSION The present study showed that the use of epinephrine and dobutamine was associated with significantly increased in-hospital mortality in patients with septic shock. These effects were both time- and dose-dependent. On the other hand, the use of milrinone was not associated with increased in-hospital mortality.
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Affiliation(s)
- Ryota Sato
- Department of Internal Medicine, John A. Burns School of Medicine, 50677University of Hawaii at Manoa, Honolulu, HI, USA
| | - Nobuhiro Ariyoshi
- Hospitalist Program, 24797The Queen's Medical Center, Honolulu, HI, USA
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Erin Crossey
- Department of Internal Medicine, John A. Burns School of Medicine, 50677University of Hawaii at Manoa, Honolulu, HI, USA
| | - Natsumi Hamahata
- Department of Internal Medicine, John A. Burns School of Medicine, 50677University of Hawaii at Manoa, Honolulu, HI, USA
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, 12785Gifu University Hospital, Gifu, Japan
| | - Michitaka Nasu
- Department of Emergency and Critical Care, 74101Urasoe General Hospital, Okinawa, Japan
| | - Gehan Devendra
- Department of Pulmonary and Critical Care, John A. Burns School of Medicine, 50677University of Hawaii at Manoa, Honolulu, HI, USA
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Hornik CP, Yogev R, Mourani PM, Watt KM, Sullivan JE, Atz AM, Speicher D, Al-Uzri A, Adu-Darko M, Payne EH, Gelber CE, Lin S, Harper B, Melloni C, Cohen-Wolkowiez M, Gonzalez D. Population Pharmacokinetics of Milrinone in Infants, Children, and Adolescents. J Clin Pharmacol 2019; 59:1606-1619. [PMID: 31317556 PMCID: PMC6813877 DOI: 10.1002/jcph.1499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/03/2019] [Indexed: 11/09/2022]
Abstract
Milrinone is a type 3 phosphodiesterase inhibitor used to improve cardiac output in critically ill infants and children. Milrinone is primarily excreted unchanged in the urine, raising concerns for toxic accumulation in the setting of renal dysfunction of critical illness. We developed a population pharmacokinetic model of milrinone using nonlinear mixed-effects modeling in NONMEM to perform dose-exposure simulations in children with variable renal function. We included children aged <21 years who received intravenous milrinone per clinical care. Plasma milrinone concentrations were measured using a validated liquid chromatography-tandem mass spectrometry assay (range 1-5000 ng/mL). We performed dose-exposure simulations targeting steady-state therapeutic concentrations of 100-300 ng/mL previously established in adults and children with cardiac dysfunction. We simulated concentrations over 48 hours in typical subjects with decreasing creatinine clearance (CrCl), estimated using the updated bedside Schwartz equation. Seventy-four patients contributed 111 plasma samples (concentration range, 4-634 ng/mL). The median (range) postmenstrual age (PMA) was 3.7 years (0-18), and median weight (WT) was 13.1 kg (2.6-157.7). The median serum creatinine and CrCl were 0.5 mg/dL (0.1-3.1) and 117.2 mL/min/1.73 m2 (13.1-261.3), respectively. A 1-compartment model characterized the pharmacokinetic data well. The final model parameterization was: Clearance (L/h) = 15.9*(WT [kg] / 70)0.75 * (PMA1.12 / (67.71.12 +PMA1.12 )*(CrCl / 117)0.522 ; and Volume of Distribution (L) = 32.2*(WT [kg] / 70). A loading dose of 50 µg/kg followed by a continuous infusion of 0.5 µg/kg/min resulted in therapeutic concentrations, except when CrCl was severely impaired at ≤30 mL/min/1.73 m2 . In this setting, a 25 µg/kg loading dose and 0.25 µg/kg/min continuous infusion resulted in therapeutic exposures.
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Affiliation(s)
- Christoph P. Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Ram Yogev
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | | | - Kevin M. Watt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Janice E. Sullivan
- University of Louisville Norton Children’s Hospital, Louisville, KY, USA
| | - Andrew M. Atz
- Medical University of South Carolina Children’s Hospital, Charleston, SC, USA
| | - David Speicher
- Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, USA
| | | | | | | | - Susan Lin
- The EMMES Corporation, Rockville, MD, USA
| | - Barrie Harper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Benjamin MM, Sundararajan S, Sulaiman S, Kindel T, Joyce D, Mohammed AA. Testing the obesity paradox in patients on long-term milrinone infusion for end-stage heart failure. Am J Cardiovasc Dis 2019; 9:59-64. [PMID: 31516764 PMCID: PMC6737350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/16/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Obese patients with chronic HF have a lower mortality than do non-obese patients with heart failure (HF) i.e. "obesity paradox". We sought to determine the relationship between obesity (defined by body-mass index; BMI) and survival in inotrope-dependent patients with Stage D HF. METHODS AND RESULTS We screened the medical records of adults with ACC/AHA stage D HF who were admitted to our institution between January, 2010 and July, 2018 who were both initiated and discharged on continuous intravenous milrinone. Patients were divided into three groups: non-obese patients (Nob-BMI < 30 kg/m2), Class 1 obese patients (Ob1-BMI 30 to 34.9 kg/m2), and class 2/3 obese patients (Ob2/3-BMI ≥ 35 kg/m2). The primary endpoint was all-cause mortality. Of the 233 patients included in the study, 154 were NOb, 39 were Ob1, and 40 were OB2/3. Age and baseline comorbidities did not differ significantly among the groups. Mean follow up was 21.8 months (Median: 12.4, IQ range: 3.6-31.3). Compared to the NOb, relative mortality (HR) was 0.68 for Ob1 patients and 1.21 for Ob2/3 patients (P = 0.30). Adjusting for age, sex, race, and medical comorbidities, relative mortality was 0.85 in the Ob1 and 1.77 in the Ob2/3 (P = 0.08). CONCLUSION In this retrospective study of stage D inotrope-dependent HF patients, there was trend of an "obesity paradox" with higher survival in the Ob1 group patients compared to NOb and Ob2/3 patients. Ob2/3 patients had the worst survival.
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Affiliation(s)
- Mina M Benjamin
- Division of General Internal Medicine, Department of Medicine, Froedtert & The Medical College of Wisconsin 9200 West Wisconsin AvenueMilwaukee, WI 53226-3596, USA
| | - Sakthi Sundararajan
- Division of General Internal Medicine, Department of Medicine, Froedtert & The Medical College of Wisconsin 9200 West Wisconsin AvenueMilwaukee, WI 53226-3596, USA
| | - Samian Sulaiman
- Division of General Internal Medicine, Department of Medicine, Froedtert & The Medical College of Wisconsin 9200 West Wisconsin AvenueMilwaukee, WI 53226-3596, USA
| | - Tammy Kindel
- Department of Surgery, Froedtert & The Medical College of Wisconsin 9200 West Wisconsin AvenueMilwaukee, WI 53226-3596, USA
| | - David Joyce
- Department of Surgery, Froedtert & The Medical College of Wisconsin 9200 West Wisconsin AvenueMilwaukee, WI 53226-3596, USA
| | - Asim A Mohammed
- Division of Cardiovascular Medicine, Department of Medicine, Froedtert & The Medical College of Wisconsin 9200 West Wisconsin AvenueMilwaukee, WI 53226-3596, USA
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Raupach A, Reinle J, Stroethoff M, Mathes A, Heinen A, Hollmann MW, Huhn R, Bunte S. Milrinone-Induced Pharmacological Preconditioning in Cardioprotection: Hints for a Role of Mitochondrial Mechanisms. J Clin Med 2019; 8:jcm8040507. [PMID: 31013843 PMCID: PMC6517902 DOI: 10.3390/jcm8040507] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/29/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023] Open
Abstract
The activation of mitochondrial calcium-sensitive potassium (mBKCa) channels is crucially involved in cardioprotection induced by preconditioning. For milrinone (Mil)-induced preconditioning, the involvement of mBKCa-channels and further mitochondrial signaling is unknown. We hypothesize that (1) Mil-induced preconditioning is concentration-dependent and (2) that the activation of mBKCa-channels, release of reactive oxygen species (ROS), and the mitochondrial permeability transition pore (mPTP) could be involved. Isolated hearts of male Wistar rats were perfused with Krebs-Henseleit buffer and underwent 33 min of ischemia followed by 60 min of reperfusion. For determination of a concentration-dependent effect of Mil, hearts were perfused with different concentrations of Mil (0.3–10 µM) over 10 min before ischemia. In a second set of experiments, in addition to controls, hearts were pretreated with the lowest protective concentration of 1 µM Mil either alone or combined with the mBKCa-channel blocker paxilline (Pax + Mil), or paxilline alone (Pax). In additional groups, Mil was administered with and without the ROS scavenger N-2-mercaptopropionylglycine (MPG + Mil, MPG) or the mPTP inhibitor cyclosporine A (MPG + Mil + CsA, CsA + Mil), respectively. Infarct sizes were determined by triphenyltetrazolium chloride (TTC) staining. The lowest and most cardioprotective concentration was 1 µM Mil (Mil 1: 32 ± 6%; p < 0.05 vs. Con: 63 ± 8% and Mil 0.3: 49 ± 6%). Pax and MPG blocked the infarct size reduction of Mil (Pax + Mil: 53 ± 6%, MPG + Mil: 59 ± 7%; p < 0.05 vs. Mil: 34 ± 6%) without having an effect on infarct size when administered alone (Pax: 53 ± 7%, MPG: 58 ± 5%; ns vs. Con). The combined administration of CsA completely restored the MPG-inhibited cardioprotection of Mil (MPG + Mil + CsA: 35 ± 7%, p < 0.05 vs. MPG + Mil). Milrinone concentration-dependently induces preconditioning. Cardioprotection is mediated by the activation of mBKCa-channels, release of ROS and mPTP inhibition.
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Affiliation(s)
- Annika Raupach
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Julia Reinle
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Martin Stroethoff
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Alexander Mathes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
| | - André Heinen
- Institute of Cardiovascular Physiology, Heinrich-Heine-University Duesseldorf, Universitaetsstr. 1, 40225 Duesseldorf, Germany.
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Meiberdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Ragnar Huhn
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Sebastian Bunte
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
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Santos‐Teles AG, Passos RH, Panerai RB, Ramalho C, Farias S, Rosa JG, Gobatto A, Benigno P, Caldas JR. Intravenous administration of Milrinone, as an alternative approach to treat vasospasm in subarachnoid hemorrhage: A case report of transcranial Doppler monitoring. Clin Case Rep 2019; 7:648-652. [PMID: 30997055 PMCID: PMC6452455 DOI: 10.1002/ccr3.2034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/16/2018] [Accepted: 12/18/2018] [Indexed: 01/03/2023] Open
Abstract
This case illustrates the importance and potential of having TCD monitoring in intensive care. This easy-to-use, safe, low-cost, and bedside tool allows evaluation of the safety and feasibility of an alternative treatment of VSP in SCH and demonstrates the potential to avoid the use of angiography, a high cost, invasive procedure.
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Affiliation(s)
- Alex Goes Santos‐Teles
- Critical Care UnitHospital São RafaelSalvadorBrazil
- Escola Bahiana de Medicina e Saúde PúblicaSalvadorBrazil
| | | | - Ronney B. Panerai
- Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUK
- NIHR Leicester Biomedical Research CentreGlenfield HospitalLeicesterUK
| | | | | | - João G Rosa
- Critical Care UnitHospital São RafaelSalvadorBrazil
| | | | | | - Juliana Ribeiro Caldas
- Critical Care UnitHospital São RafaelSalvadorBrazil
- Escola Bahiana de Medicina e Saúde PúblicaSalvadorBrazil
- University of Salvador (UNIFACS)SalvadorBrazil
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Bunte S, Lill T, Falk M, Stroethoff M, Raupach A, Mathes A, Heinen A, Hollmann MW, Huhn R. Impact of Anesthetics on Cardioprotection Induced by Pharmacological Preconditioning. J Clin Med 2019; 8:jcm8030396. [PMID: 30901956 PMCID: PMC6462902 DOI: 10.3390/jcm8030396] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/07/2019] [Accepted: 03/15/2019] [Indexed: 12/12/2022] Open
Abstract
Anesthetics, especially propofol, are discussed to influence ischemic preconditioning. We investigated whether cardioprotection by milrinone or levosimendan is influenced by the clinically used anesthetics propofol, sevoflurane or dexmedetomidine. Hearts of male Wistar rats were randomised, placed on a Langendorff system and perfused with Krebs–Henseleit buffer (KHB) at a constant pressure of 80 mmHg. All hearts underwent 33 min of global ischemia and 60 min of reperfusion. Three different anesthetic regimens were conducted throughout the experiments: propofol (11 μM), sevoflurane (2.5 Vol%) and dexmedetomidine (1.5 nM). Under each anesthetic regimen, pharmacological preconditioning was induced by administration of milrinone (1 μM) or levosimendan (0.3 μM) 10 min before ischemia. Infarct size was determined by TTC staining. Infarct sizes in control groups were comparable (KHB-Con: 53 ± 9%, Prop-Con: 56 ± 9%, Sevo-Con: 56 ± 8%, Dex-Con: 53 ± 9%; ns). Propofol completely abolished preconditioning by milrinone and levosimendan (Prop-Mil: 52 ± 8%, Prop-Lev: 52 ± 8%; ns versus Prop-Con), while sevoflurane did not (Sevo-Mil: 31 ± 9%, Sevo-Lev: 33 ± 7%; p < 0.05 versus Sevo-Con). Under dexmedetomidine, results were inconsistent; levosimendan induced infarct size reduction (Dex-Lev: 36 ± 6%; p < 0.05 versus Dex-Con) but not milrinone (Dex-Mil: 51 ± 8%; ns versus Dex-Con). The choice of the anesthetic regimen has an impact on infarct size reduction by pharmacological preconditioning.
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Affiliation(s)
- Sebastian Bunte
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Tobias Lill
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Maximilian Falk
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Martin Stroethoff
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Annika Raupach
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Alexander Mathes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
| | - André Heinen
- Institute of Cardiovascular Physiology, Heinrich-Heine-University Duesseldorf, Universitaetsstr. 1, 40225 Duesseldorf, Germany.
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Meiberdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Ragnar Huhn
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.
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Mehanna OM, El Askary A, Al-Shehri S, El-Esawy B. Effect of phosphodiesterase inhibitors on renal functions and oxidant/antioxidant parameters in streptozocin-induced diabetic rats. Arch Physiol Biochem 2018; 124:424-429. [PMID: 29271249 DOI: 10.1080/13813455.2017.1419267] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The goal of this study was to investigate the effect of different phosphodiesterase inhibitors (PDEIs), on renal oxidant/antioxidant balance in diabetic rats. Our study was conducted on 125 rats, diabetes was induced in 100 rats by a single administration of streptozocin (STZ). Diabetic rats were divided into four equal groups. The first group was assigned as diabetic control, the remaining three groups were treated with pentoxifylline, sildenafil and milrinone via drinking water for 15 successive days, another group of 25 normal rats was assigned as non-diabetic control. Significant increase in plasma levels of glucose, urea, creatinine, malondialdehyde (MDA), and nitric oxide (NO) with a concomitant decrease in the levels of insulin, reduced glutathione (GSH), glutathione peroxidase (Gpx), superoxide dismutase (SOD), catalase (CAT), and total antioxidant capacity (TAC) were observed in diabetic rats. These alterations were reverted back to near normal level after treatment with PDEIs. Our data seem to suggest a potential role of PDEIs in maintaining health in diabetes by reducing the progression of diabetic nephropathy.
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Affiliation(s)
- Osama Mahmoud Mehanna
- a Department of Medical Physiology, Faculty of Medicine , Taif University , Taif , KSA
- b Department of Medical Physiology, Faculty of Medicine (New Damietta) , Al-Azhar University , Cairo , Egypt
| | - Ahmad El Askary
- c Department of Clinical Laboratory Sciences, College of Applied Medical Sciences , Taif University , Taif , KSA
- d Department of Medical Biochemistry, Faculty of Medicine (New Damietta) , Al-Azhar University , Cairo , Egypt
| | - Saad Al-Shehri
- c Department of Clinical Laboratory Sciences, College of Applied Medical Sciences , Taif University , Taif , KSA
| | - Basem El-Esawy
- c Department of Clinical Laboratory Sciences, College of Applied Medical Sciences , Taif University , Taif , KSA
- e Department of Pathology, Faculty of medicine , Mansoura University , Mansoura , Egypt
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Soliman R, Ragheb A. Assessment of the effect of two regimens of milrinone infusion in pediatric patients undergoing fontan procedure: A randomized study. Ann Card Anaesth 2018; 21:134-140. [PMID: 29652273 PMCID: PMC5914212 DOI: 10.4103/aca.aca_160_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective: The aim of the study was to compare the effect of two different regimens of milrinone on hemodynamics and oxygen saturation in pediatric patients undergoing Fontan procedure. Design: This was a randomized study. Setting: Cardiac centers. Patients: This study included 116 patients undergoing Fontan procedure. Material and Methods: Group E: Milrinone was started as infusion 0.5 μg/kg/min without a loading dose at the beginning of cardiopulmonary bypass (CPB) followed by infusion 0.5–0.75 μg/kg/min in the pediatric cardiac surgical intensive care unit (PSICU). Group L: Milrinone was started as a loading dose 50 μg/kg over 10 min before weaning from CPB followed by infusion 0.5–0.75 μg/kg/min in the PSICU. Measurements: Heart rate, mean arterial blood pressure, central venous pressure, transpulmonary pressure, cardiac index, pharmacological support, lactate level, urine output, oxygen saturation, ICU, and hospital length of stay. Main Results: There were no changes in the heart rate and mean arterial blood pressure (P > 0.05). The increase in the postoperative central venous pressure, transpulmonary pressure and lactate level was lower in Group E than Group L (P < 0.05). The increase in the postoperative cardiac index, oxygen saturation, and urine output was higher in Group E than Group L (P < 0.05). The requirement for pharmacological support was lower in the Group E (P < 0.05). The ICU and hospital length of stay were shorter in the Group E than Group L (P < 0.05). Conclusion: Early use of milrinone during Fontan procedure facilitated the weaning from CPB, decreased the elevation in the central venous pressure, transpulmonary gradient pressure, and the requirement for pharmacological support. Furthermore, it increased the cardiac index and arterial oxygen saturation.
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Affiliation(s)
- Rabie Soliman
- Department of Anesthesia, Cairo University; Prince Sultan Cardiac Centre, Riyadh, Al-Hassa, Saudi Arabia
| | - Adel Ragheb
- Prince Sultan Cardiac Centre, Riyadh; National Heart Institute, Cairo, Egypt, Al-Hassa, Saudi Arabia
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Venakatesh AG, Mathew JJ, Coleman S, Yang L, Liu GL, Li MM, Liu H. Effects of milrinone on inflammatory response-related gene expressions in cultured rat cardiomyocytes. J Biomed Res 2018; 33:258. [PMID: 30449737 PMCID: PMC6813519 DOI: 10.7555/jbr.32.20170085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/22/2017] [Indexed: 11/03/2022] Open
Abstract
Congestive heart failure (CHF) is defined as a cardiac dysfunction leading to low cardiac output and inadequate tissue perfusion. Intravenous positive inotropes are used to increase myocardial contractility in hospitalized patients with advanced heart failure. Milrinone is a phosphodiesterase Ⅲ inhibitor and used most commonly for inotropic effect. The well-known PROMISE study investigated the effects of milrinone on mortality in patients with severe CHF, and concluded that long-term therapy with milrinone increased morbidity and mortality among patients with advanced CHF. Previous studies have suggested that phosphodiesterase inhibitors can have potential effects on inflammatory pathways. Hence, we hypothesized that milrinone may alter inflammatory gene expressions in cardiomyocytes, thus leading to adverse clinical outcomes. We used rat cardiomyocyte cell line H9C2 and studied the impact of exposing cardiomyocytes to milrinone (10 μmol/L) for 24 hours on inflammatory gene expressions. RNA extracted from cultured cardiomyocytes was used for whole rat genome gene expression assay (41,000 genes). The following changes in inflammatory response-related gene expressions were discovered. Genes with increased expressions included: THBS2 (+9.98), MMP2 (+3.47), DDIT3 (+2.39), and ADORA3 (+3.5). Genes with decreased expressions were: SPP1 (-5.28) and CD14 (-2.05). We found that the above mentioned gene expression changes seem to indicate that milrinone may hinder the inflammatory process which may potentially lead to adverse clinical outcomes. However, further in vivo and clinical investigations will be needed to illustrate the clinical relevance of these gene expression changes induced by milrinone.
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Affiliation(s)
- Archana G. Venakatesh
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA 19102, USA
| | - Johann J. Mathew
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA 19102, USA
| | - Scott Coleman
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA 19102, USA
| | - Longqiu Yang
- Department of Anesthesiology, Huangshi Central Hospital, Huangshi, Hubei 435002, China
| | - Geoffrey L. Liu
- Division of Genomic Diagnostics, Department of Pathology & Laboratory Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Marilyn M. Li
- Division of Genomic Diagnostics, Department of Pathology & Laboratory Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Henry Liu
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA 19102, USA
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Fredholm M, Jörgensen K, Houltz E, Ricksten SE. Inotropic and lusitropic effects of levosimendan and milrinone assessed by strain echocardiography-A randomised trial. Acta Anaesthesiol Scand 2018; 62:1246-1254. [PMID: 29926912 DOI: 10.1111/aas.13170] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND We compared the direct inotropic and lusitropic effects of two inodilators, milrinone and levosimendan in patients after aortic valve replacement for aortic stenosis. METHODS In this randomised, blinded study, 31 patients with normal LV function, were randomised to either levosimendan (0.1 and 0.2 μg/kg/min, n = 15) or milrinone (0.4 and 0.8 μg/kg/min, n = 16) after aortic valve replacement. The effects on LV performance, LV strain, systolic (SR-S) and early diastolic (SR-E) strain rate were assessed by a pulmonary artery catheter and transoesophageal two-dimensional speckle tracking echocardiography of the LV inferior wall. To circumvent the inodilator-induced hemodynamic changes on LV systolic and diastolic deformation, central venous pressure (CVP), systolic artery pressure (SAP), and heart rate were maintained constant by colloid infusion, phenylephrine-induced vasoconstriction and atrial pacing, respectively, during drug infusion. RESULTS Both inotropic agents induced a dose-dependent increase in cardiac index and stroke volume index by approximately 20% at the highest infusion rates with no differences between groups (P = .139 and .249, respectively). CVP, pulmonary capillary wedge pressure, SAP and heart rate were maintained constant in both groups. LV strain and SR-S increased with both agents, dose-dependently, by 17%-18% and 25%-30%, respectively, at the highest infusion rates, with no difference between groups (P = .434 and .284, respectively). Both agents improved early LV relaxation with no differences between groups (P = .637). At the higher doses, both agents increased SR-E by 30%. CONCLUSIONS At clinically relevant infusion rates and a certain increase in LV performance the direct inotropic and lusitropic of milrinone and levosimendan were comparable.
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Affiliation(s)
- M. Fredholm
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - K. Jörgensen
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - E. Houltz
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - S.-E. Ricksten
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
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Behmenburg F, Trefz L, Dorsch M, Ströthoff M, Mathes A, Raupach A, Heinen A, Hollmann MW, Berger MM, Huhn R. Milrinone-Induced Postconditioning Requires Activation of Mitochondrial Ca 2+-sensitive Potassium (mBK Ca) Channels. J Cardiothorac Vasc Anesth 2018; 32:2142-2148. [PMID: 29306618 DOI: 10.1053/j.jvca.2017.11.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Cardioprotection by postconditioning requires activation of mitochondrial large-conductance Ca2+-sensitive potassium (mBKCa) channels. The involvement of these channels in milrinone-induced postconditioning is unknown. The authors determined whether cardioprotection by milrinone-induced postconditioning involves activation of mBKCa channels in the rat heart in vitro. DESIGN Randomized, prospective, blinded laboratory investigation. SETTING Experimental laboratory. PARTICIPANTS Male Wistar rats. INTERVENTIONS Hearts of male Wistar rats were randomized, placed on a Langendorff system, and perfused with Krebs-Henseleit buffer at a constant pressure of 80 mmHg. All hearts were subjected to 33 minutes of global ischemia and 60 minutes of reperfusion. At the onset of reperfusion, hearts were perfused with different concentrations of milrinone (0.3-100 μM) for determination of a dose-effect curve. In a second set of experiments, 3 μM milrinone was administered in combination with the mBKCa channel inhibitor paxilline (1 μM). Infarct size was determined by triphenyltetrazoliumchloride staining. MEASUREMENTS AND MAIN RESULTS In control animals, infarct size was 37 ± 7%. Milrinone at a concentration of 3 μM reduced infarct size to 22 ± 7% (p < 0.05 v control). Higher milrinone concentrations did not confer stronger protection. Paxilline completely blocked milrinone-induced cardioprotection whereas paxilline alone had no effect on infarct size. CONCLUSIONS This study shows that activation of mBKCa channels plays a pivotal role in milrinone-induced postconditioning.
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Affiliation(s)
| | - Lara Trefz
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marianne Dorsch
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Martin Ströthoff
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Alexander Mathes
- Department of Anesthesiology, University Hospital Cologne, Cologne, Germany
| | - Annika Raupach
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - André Heinen
- Institute of Cardiovascular Physiology, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Markus W Hollmann
- Department of Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Marc M Berger
- Department of Anesthesiology, Perioperative and General Critical Care Medicine, Salzburg General Hospital, Paracelsus Medical University, Salzburg, Austria; Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ragnar Huhn
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany.
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Shao T, Zhang Y, Tang R, Zhang H, Wang Q, Yang Y, Liu T. Effects of milrinone on serum IL-6, TNF-α, Cys-C and cardiac functions of patients with chronic heart failure. Exp Ther Med 2018; 16:4162-4166. [PMID: 30344692 PMCID: PMC6176130 DOI: 10.3892/etm.2018.6672] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 08/24/2018] [Indexed: 11/06/2022] Open
Abstract
Effects of milrinone on serum interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), cystatin C (Cys-C) and cardiac functions of patients with chronic heart failure were analyzed to investigate the value of milrinone in chronic heart failure. A total of 70 patients diagnosed with chronic heart failure were selected and randomly divided into treatment group (n=35) and control group (n=35). All patients were treated with conventional anti-heart failure therapy, and patients in the treatment group received milrinone on the basis of conventional therapy. The general data of patients, such as age, sex and course of chronic heart failure, were collected; the levels of serum IL-6, TNF-α and Cys-C before and after treatment were compared between the groups, and the cardiac function indexes were also compared, including cardiac output (CO), stroke volume (SV), left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVDd), left ventricular end-systolic diameter (LVSd) and brain natriuretic peptide (BNP) level. Besides, the curative effects and adverse reactions in the two groups were recorded. The results revealed that serum IL-6, TNF-α and Cys-C levels had no significant difference between the two groups before treatment; however, the curative effect in the treatment group was significantly superior to that in control group (p<0.05); after treatment, CO, SV and LVEF in both groups were obviously increased, but LVDd, LVSd and BNP levels were obviously decreased; the curative effect in the treatment group was significantly superior to that in control group (p<0.05); heart rate in both groups was obviously decreased after treatment (p<0.05); the total effective rate in the treatment group was significantly higher than that in control group after treatment (p<0.05). In conclusion, based on the conventional anti-heart failure therapy, the application of milrinone can reduce the serum IL-6, TNF-α and Cys-C levels and improve the cardiac functions of patients effectively.
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Affiliation(s)
- Tingguo Shao
- Department of Cardiology, Dongcheng Branch, Shouguang People's Hospital, Weifang, Shandong 262704, P.R. China
| | - Yuqing Zhang
- Department of Vasculocardiology, Shouguang People's Hospital, Weifang, Shandong 262700, P.R. China
| | - Rubo Tang
- Department of Cardiology, Dongcheng Branch, Shouguang People's Hospital, Weifang, Shandong 262704, P.R. China
| | - Hai Zhang
- Emergency Department, Shouguang People's Hospital, Weifang, Shandong 262700, P.R. China
| | - Quanzheng Wang
- Department of Vasculocardiology, Shouguang People's Hospital, Weifang, Shandong 262700, P.R. China
| | - Ying Yang
- Regular Physical Examination Centre, Shouguang People's Hospital, Weifang, Shandong 262700, P.R. China
| | - Tongxiang Liu
- Emergency Department, Weifang People's Hospital, Weifang, Shandong 261000, P.R. China
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Ross AR, Boddu SHS, Mauro VF, Churchwell MD. Physical compatibility of milrinone with levofloxacin and ceftriaxone injection. Am J Health Syst Pharm 2018; 75:1010-1012. [PMID: 29987058 DOI: 10.2146/ajhp180195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Anthony R Ross
- College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoToledo, OH
| | - Sai H S Boddu
- College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoToledo, OH
| | - Vincent F Mauro
- College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoToledo, OH
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Katyal N, George P, Nattanamai P, Raber LN, Beary JM, Newey CR. Improvement in Sonographic Vasospasm Following Intravenous Milrinone in a Subarachnoid Hemorrhage Patient with Normal Cardiac Function. Cureus 2018; 10:e2916. [PMID: 30186721 PMCID: PMC6122655 DOI: 10.7759/cureus.2916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cerebral vasospasm and delayed cerebral ischemia are well-known complications of an aneurysmal subarachnoid hemorrhage (aSAH), generally occurring days to weeks after hemorrhagic ictus. Management strategies for these complications are controversial and vary in efficacy. There is a growing interest in supporting the use of intravenous (IV) milrinone to manage vasospasm. A 31-year-old male presented to the hospital after being found down outside his home. Computed tomography (CT) of the head and subsequent CT angiogram revealed a Fisher Grade 4 aneurysmal subarachnoid hemorrhage (aSAH). Six hours after admission, he became hypotensive and his neurological examination declined. A repeat CT head showed a new, left frontoparietal intracerebral hemorrhage (ICH) along with increasing SAH. He was stabilized with vasopressors and underwent emergent decompressive hemicraniectomy with subsequent clipping of the aneurysm. Approximately one week later, transcranial Doppler (TCD) showed increasing mean flow velocities in the bilateral anterior and middle cerebral arteries consistent with cerebral vasospasm. He was treated with intravenous milrinone. Repeat TCD 6.5 hours after the initial TCD showed improved mean flow velocities. His cardiac function by echocardiogram assessment was normal. The decrease in TCD velocity following treatment with milrinone indicates an improvement in the cerebral vasospasm regardless of cardiac output in a patient with subarachnoid hemorrhage. This case suggests that augmenting cardiac output may not be the only mechanism for the therapeutic benefit of milrinone.
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Affiliation(s)
- Nakul Katyal
- Neurology, University of Missouri, Columbia, USA
| | | | | | | | - Jonathan M Beary
- Neurobehavioral Sciences, A. T. Still University, Kirksville, USA
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