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Are peripherally inserted central catheters associated with increased risk of adverse events in status 1B patients awaiting transplantation on continuous intravenous milrinone?
Haglund NA, Cox ZL, Lee JT, Song Y, Keebler ME, DiSalvo TG, Maltais S, Lenihan DJ, Wigger MA
(2014) J Card Fail 20: 630-7
MeSH Terms: Academic Medical Centers, Cardiotonic Agents, Catheter-Related Infections, Catheterization, Central Venous, Catheterization, Peripheral, Female, Heart Failure, Heart Transplantation, Heart-Assist Devices, Hemorrhage, Humans, Infusions, Intravenous, Intensive Care Units, Male, Middle Aged, Milrinone, Regression Analysis, Retrospective Studies, Tennessee, Venous Thromboembolism, Waiting Lists
Show Abstract · Added February 19, 2015
BACKGROUND - Peripherally inserted central catheters (PICCs) are used to deliver continuous intravenous (IV) milrinone in stage D heart failure (HF) patients awaiting heart transplantation (HT).
METHODS - We retrospectively analyzed PICC adverse events (AEs) and associated cost in 129 status 1B patients from 2005 to 2012. End points were HT, left ventricular assist device (LVAD), and death. Regression analysis was used to identify AE risk factors.
RESULTS - Fifty-three PICC AEs occurred in 35 patients (27%), consisting of 48 infections, 4 thromboses, and 1 bleeding event. Median duration of PICC support was 63 (interquartile range [IQR] 34-131) days, and median time to first PICC infection was 44 (IQR 14-76) days. Among PICC infections, 9% required defibrillator removal and 30% were inactivated on the HT list for a mean of 23 ± 17 days. Rate of HT, LVAD, or death was similar between groups (P > .05). Regression analysis found that a double lumen PICC was associated with a shorter time to first PICC infection (hazard ratio 7.59, 95% CI 1.97-29.23; P = .003). Median cost per PICC infection was $10,704 (IQR $7,401-$26,083).
CONCLUSIONS - PICC infections were the most frequent AEs. PICCs with >1 lumen were associated with increased risk of infection. PICC AEs accounted for increased intensive care unit admissions, HT list inactivations, and overall cost.
Copyright © 2014 Elsevier Inc. All rights reserved.
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21 MeSH Terms
Elevation of plasma milrinone concentrations in stage D heart failure associated with renal dysfunction.
Cox ZL, Calcutt MW, Morrison TB, Akers WS, Davis MB, Lenihan DJ
(2013) J Cardiovasc Pharmacol Ther 18: 433-8
MeSH Terms: Adult, Aged, Cardiac Catheterization, Cardiotonic Agents, Creatinine, Defibrillators, Implantable, Female, Heart Failure, Hemodynamics, Humans, Kidney Diseases, Male, Middle Aged, Milrinone, Renal Dialysis, Retrospective Studies, Severity of Illness Index, Tachycardia, Ventricular
Show Abstract · Added May 27, 2014
PURPOSE - To determine steady state milrinone concentrations in patients with stage D heart failure (HF) with and without renal dysfunction
METHODS - We retrospectively identified patients with stage D HF at a single medical center on continuous milrinonein fusion at the time of plasma collection for entry into a research registry database. Milrinone was prescribed and titrated to improve hemodynamic and clinical status by a cardiologist. Plasma samples were obtained at steady state milrinone concentrations. Patients were stratified by creatinine clearance (CrCl) into 4 groups: group 1 (CrCl >60 mL/min), group 2 (CrCl 60-30 mL/min), group 3 (CrCl <30 mL/min), and group 4 (intermittent hemodialysis). Retrospective chart review was performed to quantify the post milrinone hemodynamic changes by cardiac catheterization and electrophysiologic changes by implantable cardiac defibrillator (ICD) interrogation.
RESULTS - A total of 29 patients were identified: group 1 (n=14), group 2 (n=10), group 3(n=3), and group 4 (n = 2). The mean infusion rate (0.391+0.08 mg/kg/min) did not differ between groups (P=0.14). The mean milrinone concentration was 451+243 ng/mL in group 1, 591+293 ng/mL in group 2, 1575+962 ng/mL in group 3, and 6252+4409 ng/mL in group 4 (P<0.05 compared to groups 1). There was no difference in post milrinone hemodynamic improvements between the groups (P=0.41). The ICD interrogation revealed limited comparisons, but 6 of the 8 post milrinone ventricular tachycardia episodes requiring defibrillation occurred in group 4 patients.
CONCLUSION - Patients with stage D HF having severe renal dysfunction have elevated milrinone concentrations. Future studies of milrinone concentrations are warranted to investigate the potential risk of life-threatening arrhythmias and potential dosing regimens in renal dysfunction.
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18 MeSH Terms
Milrinone use is associated with postoperative atrial fibrillation after cardiac surgery.
Fleming GA, Murray KT, Yu C, Byrne JG, Greelish JP, Petracek MR, Hoff SJ, Ball SK, Brown NJ, Pretorius M
(2008) Circulation 118: 1619-25
MeSH Terms: Adult, Aged, Atrial Fibrillation, Cardiac Surgical Procedures, Cardiotonic Agents, Coronary Disease, Elective Surgical Procedures, Female, Humans, Hypertension, Length of Stay, Logistic Models, Male, Middle Aged, Milrinone, Mitral Valve Insufficiency, Multivariate Analysis, Postoperative Complications, Pulmonary Wedge Pressure, Risk Factors
Show Abstract · Added December 10, 2013
BACKGROUND - Postoperative atrial fibrillation (AF), a frequent complication after cardiac surgery, causes morbidity and prolongs hospitalization. Inotropic drugs are commonly used perioperatively to support ventricular function. This study tested the hypothesis that the use of inotropic drugs is associated with postoperative AF.
METHODS AND RESULTS - We evaluated perioperative risk factors in 232 patients who underwent elective cardiac surgery. All patients were in sinus rhythm at surgery. Sixty-seven patients (28.9%) developed AF a mean of 2.9+/-2.1 days after surgery. Patients who developed AF stayed in the hospital longer (P<0.001) and were more likely to die (P=0.02). Milrinone use was associated with an increased risk of postoperative AF (58.2% versus 26.1% in nonusers; P<0.001). Older age (63.4+/-10.7 versus 56.7+/-12.3 years; P<0.001), hypertension (P=0.04), lower preoperative ejection fraction (P=0.03), mitral valve surgery (P=0.02), right ventricular dysfunction (P=0.03), and higher mean pulmonary artery pressure (27.1+/-9.3 versus 21.8+/-7.5 mm Hg; P=0.001) also were associated with postoperative AF. In multivariable logistic regression, age (P<0.001), ejection fraction (P=0.02), and milrinone use (odds ratio, 4.86; 95% confidence interval, 2.31 to 10.25; P<0.001) independently predicted postoperative AF. When only data from patients with pulmonary artery catheters were analyzed and pulmonary artery pressure was included in the model, age, milrinone use (odds ratio, 4.45; 95% confidence interval, 2.01 to 9.84; P<0.001), and higher pulmonary artery pressure (P=0.02) were associated with an increased risk of postoperative AF. Adding other potential confounders or stratifying analysis by mitral valve surgery did not change the association of milrinone use with postoperative AF.
CONCLUSIONS - Milrinone use is an independent risk factor for postoperative AF after elective cardiac surgery.
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20 MeSH Terms