Gebhard Caroline E, Rochon Antoine, Cogan Jennifer, Ased Hosham, Desjardins Georges, Deschamps Alain, Gavra Paul, Lebon Jean-Sebastien, Couture Pierre, Ayoub Christian, Levesque Sylvie, Elmi-Sarabi Mahsa, Couture Etienne J, Denault André Y
Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada; Department of Anesthesiology and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada.
J Cardiothorac Vasc Anesth. 2019 Mar;33(3):651-660. doi: 10.1053/j.jvca.2018.09.016. Epub 2018 Sep 13.
To report the authors' 12 years of experience with intratracheal milrinone administration and to assess the efficacy and limitations of intratracheal milrinone bolus administration for the treatment of unexpected acute right ventricular (RV) failure in patients undergoing cardiac surgery.
Retrospective analysis.
Single-center university hospital.
One hundred seventy-six patients (4.6%) undergoing on-pump cardiac surgery.
Endotracheal tube administration of milrinone (5-mg bolus) after unexpected acute RV failure during separation from cardiopulmonary bypass (CPB) weaning. RV failure was defined as the simultaneous presence of all of the following criteria: (1) hemodynamic instability or difficult separation from CPB with associated elevated central venous pressure or abnormal RV pressure waveform, (2) >20% reduction of RV fractional area change from baseline evaluated by transesophageal echocardiography, and (3) anatomical visualization of impaired or absent RV wall motion by direct intraoperative visual inspection.
Intratracheal milrinone administration was found to improve RV failure in 109 patients (61.9%) whereas RV failure persisted in 67 patients (38.1%). Using a multiple logistic regression model, severely decreased left ventricular ejection fraction (<35% v >50%) (adjusted odds ratio [OR] 3.72; 95% confidence interval [CI] 1.2-11.3; p = 0.012), longer CPB time (adjusted OR 1.014; CI 1.01-1.02; p = 0.001) and elevated postoperative fluid balance (adjusted OR 1.39; CI 1.1-1.8; p = 0.02) were found to be significant predictors of persistent RV failure.
Intratracheal instillation of milrinone was associated with clinical improvement of RV failure occurring during separation from CPB in almost two-thirds of patients. Factors limiting its therapeutic efficacy include severe left ventricular dysfunction, increased fluid balance, and long CPB time.
报告作者12年来气管内给予米力农的经验，并评估气管内推注米力农治疗心脏手术患者意外急性右心室（RV）衰竭的疗效和局限性。
回顾性分析。
单中心大学医院。
176例（4.6%）接受体外循环心脏手术的患者。
在体外循环（CPB）撤离过程中出现意外急性RV衰竭后，经气管内导管给予米力农（5mg推注）。RV衰竭定义为同时存在以下所有标准：（1）血流动力学不稳定或CPB撤离困难，伴有中心静脉压升高或RV压力波形异常；（2）经食管超声心动图评估，RV面积变化分数较基线降低>20%；（3）术中直接视觉检查可见RV壁运动受损或消失的解剖学表现。
发现气管内给予米力农可使109例患者（61.9%）的RV衰竭得到改善，而67例患者（38.1%）的RV衰竭持续存在。使用多因素逻辑回归模型，发现严重降低的左心室射血分数（<35%对>50%）（调整后的优势比[OR]3.72；95%置信区间[CI]1.2 - 11.3；p = 0.012）、较长的CPB时间（调整后的OR 1.014；CI 1.01 - 1.02；p = 0.001）和术后液体平衡升高（调整后的OR 1.39；CI 1.1 - 1.8；p = 0.02）是持续性RV衰竭的显著预测因素。
气管内滴注米力农与近三分之二CPB撤离期间发生的RV衰竭患者的临床改善相关。限制其治疗效果的因素包括严重的左心室功能障碍、液体平衡增加和CPB时间延长。
