Carev Mladen, Bulat Cristijan, Karanović Nenad, Lojpur Mihajlo, Jercić Antonio, Nenadić Denis, Marovih Zlatko, Husedzinović Ino, Letica Dalibor
Department of Anesthesiology and Intensive Care, Split University Hospital Center, Split, Croatia.
Coll Antropol. 2010 Sep;34(3):1113-7.
Secondary pulmonary hypertension is a frequent condition after heart valve surgery. It may significantly complicate the perioperative management and increase patients' morbidity and mortality. The treatment has not been yet completely defined principally because of lack of the selectivity of drugs for the pulmonary vasculature. The usage of inhaled milrinone could be the possible therapeutic option. Inodilator milrinone is commonly used intravenously for patients with pulmonary hypertension and ventricular dysfunction in cardiac surgery. The decrease in systemic vascular resistance frequently necessitates concomitant use of norepinephrine. Pulmonary vasodilators might be more effective and also devoid of potentially dangerous systemic side effects if applied by inhalation, thus acting predominantly on pulmonary circulation. There are only few reports of inhaled milrinone usage in adult post cardiac surgical patients. We reported 2 patients with severe pulmonary hypertension after valve surgery. Because of desperate clinical situation, we decided to use the combination of inhaled and intravenous milrinone. Inhaled milrinone was delivered by means of pneumatic medication nebulizer dissolved with saline in final concentration of 0.5 mg/ml. The nebulizer was attached to the inspiratory limb of the ventilator circuit, just before the Y-piece. We obtained satisfactory reduction in mean pulmonary artery pressure in both patients, and they were successfully extubated and discharged. Although it is a very small sample of patients, we conclude that the combination of inhaled and intravenous milrinone could be an effective treatment of secondary pulmonary hypertension in high-risk cardiac valve surgery patient. The exact indications for inhaled milrinone usage, optimal concentrations for this route, and the beginning and duration of treatment are yet to be determined.
继发性肺动脉高压是心脏瓣膜手术后的常见病症。它可能会使围手术期管理显著复杂化，并增加患者的发病率和死亡率。由于缺乏针对肺血管系统的药物选择性，其治疗方法尚未完全明确。吸入米力农的使用可能是一种可行的治疗选择。血管扩张性正性肌力药米力农常用于心脏手术中患有肺动脉高压和心室功能不全的患者。全身血管阻力的降低常常需要同时使用去甲肾上腺素。如果通过吸入给药，肺血管扩张剂可能更有效，并且没有潜在的危险全身性副作用，因此主要作用于肺循环。关于成年心脏手术后患者使用吸入米力农的报道很少。我们报告了2例瓣膜手术后患有严重肺动脉高压的患者。由于临床情况危急，我们决定联合使用吸入和静脉注射米力农。吸入米力农通过气动药物雾化器给药，用生理盐水溶解，最终浓度为0.5mg/ml。雾化器连接到呼吸机回路的吸气支，就在Y形接头之前。我们在两名患者中均获得了满意的平均肺动脉压降低效果，并且他们成功拔管并出院。尽管这只是一个非常小的患者样本，但我们得出结论，吸入和静脉注射米力农联合使用可能是高危心脏瓣膜手术患者继发性肺动脉高压的有效治疗方法。吸入米力农使用的确切适应症、该给药途径的最佳浓度以及治疗的开始时间和持续时间尚待确定。
