Abdelazziz Mai Mohsen, Abdelhamid Hadil Magdi
Department of Anesthesia, Ain Shams University, Cairo, Egypt.
Ann Card Anaesth. 2019 Apr-Jun;22(2):136-142. doi: 10.4103/aca.ACA_83_18.
Milrinone at inotropic doses requires the addition of a vasoconstrictive drug. We hypothesized that terlipressin use could selectively recover the systemic vascular hypotension induced by milrinone without increasing the pulmonary vascular resistance (PVR) and mean pulmonary artery pressure (MPAP) as norepinephrine in cardiac surgery patients.
Patients with pulmonary hypertension were enrolled in this study. At the start of rewarming a milrinone 25 μg/kg bolus over 10 min followed by infusion at the rate of 0.25 μg/kg/min. Just after the loading dose of milrinone, the patients were randomized to receive norepinephrine infusion at a dose of 0.1 μg/kg/min (norepinephrine group) or terlipressin infusion at a dose of 2 μg/kg/h (terlipressin group). Heart rate, mean arterial blood pressure (MAP), central venous pressure, MPAP, systemic vascular resistance (SVR), PVR, cardiac output were measured after induction of anesthesia, after loading dose of milrinone, during skin closure, and in the intensive care unit till 24 h.
Milrinone decreased MAP (from 79.56 ± 4.5 to 55.21 ± 2.1 and from 78.46 ± 3.3 to 54.11 ± 1.1) and decreased the MPAP (from 59.5 ± 3.5 to 25.4 ± 2.6 and from 61.3 ± 5.2 to 25.1 ± 2.3) in both groups. After norepinephrine, there was an increase in the MAP which is comparable to terlipressin group (P > 0.05). Terlipressin group shows a significant lower MPAP than norepinephrine group (24.5 ± 1.4 at skin closure vs. 43.3 ± 2.1, than 20.3 ± 2.1 at 24 h vs. 39.8 ± 3.8 postoperatively). There is a comparable increase in the SVR in both group, PVR showed a significant increase in the norepinephrine group compared to the terlipressin group (240.5 ± 23 vs. 140.6 ± 13 at skin closure than 190.3 ± 32 vs. 120.3 ± 10 at 24 h postoperatively).
The use of terlipressin after milrinone will reverse systemic hypotension with lesser effect on the pulmonary artery pressure.
米力农在使用强心剂量时需要加用血管收缩药物。我们假设，在心脏手术患者中，使用特利加压素可选择性纠正米力农引起的体循环低血压，而不会像去甲肾上腺素那样增加肺血管阻力（PVR）和平均肺动脉压（MPAP）。
纳入肺动脉高压患者进行本研究。复温开始时，先静脉推注米力农25μg/kg，持续10分钟，随后以0.25μg/kg/分钟的速度输注。在米力农负荷剂量给药后，患者被随机分为两组，分别接受0.1μg/kg/分钟的去甲肾上腺素输注（去甲肾上腺素组）或2μg/kg/小时的特利加压素输注（特利加压素组）。在麻醉诱导后、米力农负荷剂量给药后、皮肤缝合时以及重症监护病房直至24小时期间，测量心率、平均动脉压（MAP）、中心静脉压、MPAP、体循环血管阻力（SVR）、PVR和心输出量。
两组患者中，米力农均使MAP降低（分别从79.56±4.5降至55.21±2.1以及从78.46±3.3降至54.11±1.1），并使MPAP降低（分别从59.5±3.5降至25.4±2.6以及从61.3±5.2降至25.1±2.3）。使用去甲肾上腺素后，MAP升高，与特利加压素组相当（P>0.05）。特利加压素组的MPAP显著低于去甲肾上腺素组（皮肤缝合时为24.5±1.4，而去甲肾上腺素组为43.3±2.1；术后24小时时为20.3±2.1，而去甲肾上腺素组为39.8±3.8）。两组的SVR升高程度相当，与特利加压素组相比，去甲肾上腺素组的PVR显著升高（皮肤缝合时为240.5±23，而特利加压素组为140.6±13；术后24小时时为190.3±32，而特利加压素组为120.3±10）。
米力农后使用特利加压素可纠正体循环低血压，且对肺动脉压影响较小。
