Starting milrinone while cross clamped.

[urge]

---

Members do not see this ad.

Let's say starting a milrinone infusion 1 or 2 hours before the cross clamp is expected to come off.

Yes or no, and why?

 

[caligas]

Let's say starting a milrinone infusion 1 or 2 hours before the cross clamp is expected to come off.

Yes or no, and why?

No, Why waste milrinone on arrested myocardium? I only have so much in the bag.

 

[pgg]

No. That doesn't make any sense to me. What are you trying to accomplish? Obviously you're not giving it for the inotropic effects.

I don't often find myself needing or wanting to decrease SVR while on bypass, and in general I prefer drugs with shorter half lives during CPB cases. I don't use a lot of milrinone.

I think it's sometimes useful when given as a bolus +/- infusion toward the end of CPB, in patients with pre-existing LV or RV dysfunction, but I don't see a point in starting it hours early. If anything, it seems kind of foolish to commit to a long acting vasodilator that far in advance.

 

[T-burglar]

it was taught to me that milrinone takes a long time to start acting in fellowship. This is obviously incorrect to anyone whose played around with it. The walls start snapping harder as soon as you give it. You don't need to start it until you want it to take effect.

It's also rarely useful I think. I've tried to use it periodically because it seems like it would be useful in certain situations. But more than half the time I have to turn it off because of hypotension. I believe that you can tell right away if its going to help or hurt by looking at how much the systolic function picks up. The systolic function has to pick up significantly to offset the vasodilation and keep the BP reasonable. I've noticed that when people have a lot of akinetic myocardium pre-op and post bypass, the milrinone will make the remaining functioning wall snap harder, but this doesn't translate into much more output, since its only a small area of myocardium thats snapping harder, and the blood pressure gets really low from the vasodilatory effect.

I sort of think its main use these days is out of the OR tune ups in severe heart failure with a major diastolic component BEFORE coming to the OR for surgery. Mobilizing fluid and dropping LVEDP to deliver perfusion to the kidneys and dry out the lungs / splanchnic bed.

 

[Dexmetaketapropofol]

No, I personally don't use Milrinone during that time frame. If I know the clamp is coming off and I need to improve diastology/lusitrophy I'll start it and use the perfusionists to augment any decrease in SVR.

 

[vector2]

it was taught to me that milrinone takes a long time to start acting in fellowship. This is obviously incorrect to anyone whose played around with it. The walls start snapping harder as soon as you give it. You don't need to start it until you want it to take effect.

It's also rarely useful I think. I've tried to use it periodically because it seems like it would be useful in certain situations. But more than half the time I have to turn it off because of hypotension. I believe that you can tell right away if its going to help or hurt by looking at how much the systolic function picks up. The systolic function has to pick up significantly to offset the vasodilation and keep the BP reasonable. I've noticed that when people have a lot of akinetic myocardium pre-op and post bypass, the milrinone will make the remaining functioning wall snap harder, but this doesn't translate into much more output, since its only a small area of myocardium thats snapping harder, and the blood pressure gets really low from the vasodilatory effect.

I sort of think its main use these days is out of the OR tune ups in severe heart failure with a major diastolic component BEFORE coming to the OR for surgery. Mobilizing fluid and dropping LVEDP to deliver perfusion to the kidneys and dry out the lungs / splanchnic bed.

Most people are probably using doses that are too high. A 12.5 mcg/kg bolus is almost as effective as 50 mcg/kg without the significant hypotension. I also start the infusion at 0.2 to 0.25 instead of 0.375. If I do get hypotension I always have norepi hanging anyway.

Another important point is that milrinone does not have a sole lock on increasing lusitropy. All B1 catecholamines increase inotropy and lusitropy

 

[AdmiralChz]

Sounds like you’re using it for the pulmonary vasodilator effects instead of inotropy? If so, I’d probably consider using an inhaled agent like nitric, Flolan or heck even inhaled milrinone.

 

[Noyac]

I’ve always used it to complement Epi when coming off pump in that sick heart that just refuses to do much. I would give a loading dose (don’t recall what the dose was) for 15 min and then try to come off pump again. For some reason I seem to recall that epi was more synergistic with milrinone. Is that not the case any longer?

 

[drmwvr]

Sounds like you’re using it for the pulmonary vasodilator effects instead of inotropy? If so, I’d probably consider using an inhaled agent like nitric, Flolan or heck even inhaled milrinone.

Spot on...except for the inhaled milrinone...no experience with it but the CC types would riot...at least at my shop.

 

[OB1🤙]

Back in the day I started an infusion a little while before unclamping rather than give a bolus, but nowadays I'll just bolus 0.5mg while weaning if things are not looking great and start start a drip then.

I never start any inotrope until the heart proves to me that it needs it. Most of the time some levophed is all you need.

 

[deleted697535]

I work with a guy that just uses it inhaled. He loves it.
All for the pvr. Inhaled lessens the hypotension a lot apparently but I've not seen the study data on that
We have dob and epi for ionotropy so why use mil iv anyway? First line like

 

[urge]

What if the rationale for starting milrinone early is for the patient to get loaded slowly while on bypass making hypotension negligible?

 

[vector2]

Comparison of two different loading doses of milrinone for weaning from cardiopulmonary bypass. - PubMed - NCBI

Pharmacodynamic effects of milrinone with and without a bolus loading infusion. - PubMed - NCBI

 

[itwasalladream]

Count me in as someone who likes inhaled milrinone (occasionally). The effect isn't large, but there's no real downside either. And it can be combined with inhaled flolan for an additive effect. It has some theoretical benefits on the pulmonary vascular endothelium. Anectdotally, it seems to keep patients with PHTN and a sick RV a bit more stable, on less rocket fuel post-bypass. A guy named Andre Denault has published some studies and spoke at SCA, which I found interesting.

I pretty rarely use IV milrinone - as others have said, mainly because of the hypotension. Haven't found it that useful even when hypotension is not an issue.

 

[DM27]

Inhaled milrinone is great, but I rarely use it. The main times I find myself using milrinone is for VADs where I have a specific concern about RV function. Even in these scenarios though I do not use it 100% of the time. When I do use it though, I tend to start the infusion once we go on bypass, or if it's already going, I don't pause it on bypass.

 

[Noyac]

What if the rationale for starting milrinone early is for the patient to get loaded slowly while on bypass making hypotension negligible?

Nothing wrong with doing it this way.

 

[anes121508]

Back in the day I started an infusion a little while before unclamping rather than give a bolus, but nowadays I'll just bolus 0.5mg while weaning if things are not looking great and start start a drip then.

I never start any inotrope until the heart proves to me that it needs it. Most of the time some levophed is all you need.

how about severe MR with dilated LV and depressed ef?

 

[anes121508]

Comparison of two different loading doses of milrinone for weaning from cardiopulmonary bypass. - PubMed - NCBI

Pharmacodynamic effects of milrinone with and without a bolus loading infusion. - PubMed - NCBI

am i reading this correctly? ....does this second paper say that the group without a bolus achieves rapid improvement of inotropy....and by rapid they mean 30 min?

 

[anes121508]

Count me in as someone who likes inhaled milrinone (occasionally). The effect isn't large, but there's no real downside either. And it can be combined with inhaled flolan for an additive effect. It has some theoretical benefits on the pulmonary vascular endothelium. Anectdotally, it seems to keep patients with PHTN and a sick RV a bit more stable, on less rocket fuel post-bypass. A guy named Andre Denault has published some studies and spoke at SCA, which I found interesting.

I pretty rarely use IV milrinone - as others have said, mainly because of the hypotension. Haven't found it that useful even when hypotension is not an issue.

i've only used flolan or nitric.....how do you add milrinone to the inhaled flolan? I like the idea of additive effect if VAD with bad RV/PA HTN

 

[anes121508]

Let's say starting a milrinone infusion 1 or 2 hours before the cross clamp is expected to come off.

Yes or no, and why?

No, because I don't like the idea of committing to an inotropic medicine that comes along with a drop in SVR. Unless you can accurately predict what will happen after CPB, why use a med with long acting side effects?

 

[anes121508]

I've often seen "let's start milrinone and use vaso if we get a drop in SVR"....what are your thoughts on this?

 

[Twiggidy]

I've often seen "let's start milrinone and use vaso if we get a drop in SVR"....what are your thoughts on this?

If someone has bad pulmonary hypertension I think this is a good cocktail. Vasopressin tends to not cause as much pulmonary vasoconstriction as say, phenylepherine.

 

[urge]

Does anyone have any concerns of starting an inotrope while the heart is potentially becoming ischemic during the clamp time?

Or the opposite. Does milrinone protect against ischemia during the clamp time?

 

[urge]

No, because I don't like the idea of committing to an inotropic medicine that comes along with a drop in SVR. Unless you can accurately predict what will happen after CPB, why use a med with long acting side effects?

Good points.

But what if your surgeon is dead set on this patient needing milrinone? If you don't start it you "don't know what you are doing because you don't manage this patients post op" and they are going to start it in the icu regardless.

We have 2 customers. The patient and the surgeon.

 

[OB1🤙]

how about severe MR with dilated LV and depressed ef?

Even then. If you need stuff it's all right there and easy to start. Sometimes these hearts surprise me and fly off pump. Sometimes they don't. I'm a simpleton- I believe the downsides of inotropes are substantial, and I want to see the heart *need* then before starting them.

Milrinone is pretty weak tea in general. I don't really fear the drop in SVR- it's usually pretty minor and easily overcome. And it's not a jackhammer inotrope either.

I use it here and there, but don't think it helps or hurts very much.

Since it's football season- if the struggling heart is like a struggling football player, milrinone is like some upbeat cheerleading on the sideline in the background. Epi is the rabid coach foaming at the mouth screaming obscenities in your face.

 

[Twiggidy]

Good points.

But what if your surgeon is dead set on this patient needing milrinone? If you don't start it you "don't know what you are doing because you don't manage this patients post op" and they are going to start it in the icu regardless.

We have 2 customers. The patient and the surgeon.

In that case just start the drip if it doesn’t hurt the patient and keeps your “customers” happy.

 

[itwasalladream]

i've only used flolan or nitric.....how do you add milrinone to the inhaled flolan? I like the idea of additive effect if VAD with bad RV/PA HTN

I don't physically mix the meds. If you have ultrasonic nebs you can put them in series and deliver both simultaneously. But usually I just nebulize 3-5mg before coming off pump, then change the neb to flolan if needed. The milrinone should exert its effect for a few hours while flolan is going. Or if you come off pump easily and more stable than expected, no need to start flolan plus you've got some protection against transient post-pump pulm HTN and/or protamine response that sometimes happens. There may be some benefit to nebulization before pump (regarding pulmonary endothelial dysfunction), but it's animal data so probably not too meaningful. It's certainly no magic bullet. I've just found there's no downside, and occasionally very sick people seem more stable post-pump than I would've expected.

 

[drmwvr]

Milrinone and vasopressin is a potent one/two punch that works really well. But, at the shop that the CT surgeons manage the ICU course, it's a non-starter because they don't want to manage the hypotension when we walk out of the unit. If we or the intensivists manage the post op care (different shop, some of the same surgeons) we do it.

 

[anes121508]

Good points.

But what if your surgeon is dead set on this patient needing milrinone? If you don't start it you "don't know what you are doing because you don't manage this patients post op" and they are going to start it in the icu regardless.

We have 2 customers. The patient and the surgeon.

Surgeon is definitely a customer too. I believe that I need to respect the fact that our surgeons are going to be the ones managing the patient post op and fielding the calls over night after the case. I do prefer epi over milrinone (most of the time) in the immediate post CPB period if we are anticipating a need for inotropic support. Mainly because of the SVR drop. I have no problem, however, starting some milrinone after patient shows that they aren't vasoplegic. I'll start the drip without a bolus. By the time the milrinone sets in the patient is typically out of the OR. If it does kick in, then I can wean off the epi and if I need some tone I'll start vaso. This way, milrinone is running per surgeon desire (maybe even mine), and I don't have to deal with unnecessary vasoplegia.

Besides, if the surgeon is telling you "you don't know what you are doing", it's likely not because of milrinone. He is either an unreasonable a**hole or you have proven to him in other circumstances that he shouldn't trust your judgement.

 

[anes121508]

Even then. If you need stuff it's all right there and easy to start. Sometimes these hearts surprise me and fly off pump. Sometimes they don't. I'm a simpleton- I believe the downsides of inotropes are substantial, and I want to see the heart *need* then before starting them.

Milrinone is pretty weak tea in general. I don't really fear the drop in SVR- it's usually pretty minor and easily overcome. And it's not a jackhammer inotrope either.

I use it here and there, but don't think it helps or hurts very much.

Since it's football season- if the struggling heart is like a struggling football player, milrinone is like some upbeat cheerleading on the sideline in the background. Epi is the rabid coach foaming at the mouth screaming obscenities in your face.

I think this is reasonable, and I really do not have anything to support the amount of SVR drop when milrinone does hit. I'd imagine it's variable patient to patient and depends on bolus vs no bolus. I also find myself suprised with some patients flying off pump. I've been decreasing the frequency that I preemptively start inotropic support. Like you said, if you need it, the epi works quick. especially a 4mcg or so bolus

 

[anes121508]

In that case just start the drip if it doesn’t hurt the patient and keeps your “customers” happy.

sort of why I just start the infusion without a bolus when it's time