Abstract
A crucial element for weaning patients from cardiopulmonary bypass (CPB) rests on the selection of an appropriate therapeutic regimen. Amrinone, a phosphodiesterase III inhibitor, combines inotropic support with pulmonary and systemic vasodilatation, without increasing heart rate (HR) or myocardial oxygen consumption. These characteristics should be useful in the failing heart during weaning from CPB. Nineteen patients were included in this prospective, open-labelled, phase IV study when systolic blood pressure (SBP) <80 mmHg, and diastolic pulmonary artery pressure (DPAP) > 15 mmHg or central venous pressure (CVP) > 75 mmHg, during progressive separation from CPB. At that moment, CPB flow was increased to alleviate heart failure and amrinone administered as a bolus (0.75 mg · kg−1) followed by an infusion (10 μg · kg−1 · min−1). Weaning from CPB was then resumed and haemodynamic variables (SBP, DPAP, CVP and HR) were compared with those measured at CPB flow when failure had first occurred. Failure to wean from CPB occurred at 57 ± 25% of full pump flow. After the amrinone bolus, DPAP and CVP decreased by 20% and 21% respectively. Subsequently, 16 patients required the infusion of norepinephrine (4-8 fig-min−1) to maintain a SBP > 80 mmHg. Heart rate remained unchanged after the bolus of amrinone, after separation from CPB, and no arrhythmias were noted. Successful weaning from CPB was possible 12 ± 8 min after the amrinone bolus. Weaning resulted in a cardiac index similar to that measured pre-bypass. Amrinone is rapidly effective during weaning from CPB and, in combination with norepinephrine, provides the necessary inotropic support during this unstable period.
Résumé
Lorsque le sevrage de la circulation extracorporelle (CEC) s’avère difficile, le choix d’un régime thérapeutique approprié est d’une importance capitale. L’amrinone, un inhibiteur de la phosphodiestérase de type III, augmente l’inotropie et dilate les circulations pulmonaire et systémique, sans augmenter la fréquence cardiaque ou la consommation d’oxygène du myocarde. Ces caractéristiques pharmacologiques devraient être bénéfiques durant le sevrage de la CEC. Furent inclus dans cette étude prospective de phase IV dix-neuf patients dont la pression artérielle systémique (PAS) était <80 mmHg alors que la pression diastolique de l’artère pulmonaire (PDAP) > 15 mmHg ou la pression veineuse centrale > 15 mmHg durant le sevrage lent et progressif de la CEC. Lors de l’échec du sevrage, le débit de la CEC était augmenté de façon à soulager la défaillance cardiaque et un bolus damrinone était administré (0.75 mg · kg−1), suivi d’une perfusion (10 μg · kg−1 · min−1). Le sevrage était alors repris et les paramètres hémodynamiques comparés au débit de CEC où l’échec était survenu initialement. L’échec du sevrage survint à 57 ± 25% du plein débit de CEC. Après le bolus d’amrinone, la PDAP et la PVC diminuèrent de 20% et de 21% respectivement. Par la suite, une perfusion de norépinéphrine (4–8 μg · min−1) fut requise chez 16 patients afin de maintenir la PAS > 80 mmHg. Le rythme cardiaque demeura stable après l’administration du bolus d’amrinone et après le sevrage de la CEC, et aucune arythmie ne fut notée. Les patients furent complétement sevrés de la CEC 12 ± 8 min après le bolus d’amrinone et leur index cardiaque après la CEC était superposable à celui mesuré avant la CEC. Ainsi, l’amrinone agit rapidement et efficacement durant le sevrage de la CEC et, en association avec la norépinéphrine, procure au myocarde le support inotrope nécessaire durant cette période de grande instabilité hémodynamique.
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Supported by a grant from Sanofi-Winthrop, Inc., and presented at the Annual Meeting of the Canadian Anaesthetists’ Society, Toronto, Canada, 1992.
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Hardy, JF., Searle, N., Roy, M. et al. Amrinone, in combination with norepinephrine, is an effective first-line drug for difficult separation from cardiopulmonary bypass. Can J Anaesth 40, 495–501 (1993). https://doi.org/10.1007/BF03009729
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DOI: https://doi.org/10.1007/BF03009729