• Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for inotropic support with phosphodiesterase inhibitors after repair of tetralogy of Fallot. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Mar. 10 p. [17 references]

This is the current release of the guideline.

This guideline updates a previous version Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for inotropic support with phosphodiesterase inhibitors after repair of tetralogy of Fallot. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Jan 25. 9 p. [16 references]

The guideline was reviewed for currency in August 2006, using updated literature searches, and was determined to be current.

Each recommendation is followed by evidence grades (A-X) identifying the type of supporting evidence. Definitions of the evidence grades are presented at the end of the "Major Recommendations" field.

Clinical Assessments

1. It is recommended that cardiac index be supported to maintain normal to minimally elevated right atrial pressure or central venous pressure (CVP) (5 to 15 mm Hg) with evidence of adequate tissue and organ perfusion as defined by physical exam, urine output >1 cc/kg/min, and no ongoing metabolic acidosis or lactic acidemia.

   Note 1: Ongoing metabolic acidosis caused by the continued production of lactic acid has been associated with a poor outcome following cardiac surgery in infants and children (Charpie et al., 2000 [C]; Munoz et al., 2000 [C]).

   Note 2: Continuous monitoring of arterial blood pressure via an arterial line is recommended (Local Expert Consensus) [E].

   Note 3: Continuous monitoring of right and left atrial pressures with transthoracic or internal jugular/subclavian vein catheters is recommended.

Laboratory Studies

2. It is recommended that in order to monitor for metabolic acidosis and lactic acidemia, a renal panel be obtained on arrival to the cardiac intensive care unit (CICU) and every morning (AM) until transfer from the CICU, and arterial blood gas (ABG) and lactate be obtained every 4 hours for first 24 hours, then every AM until transfer.

   Note: Ongoing metabolic acidosis caused by the continued production of lactic acid has been associated with a poor outcome following cardiac surgery in infants and children (Charpie et al., 2000 [C]; Munoz et al., 2000 [C]).

Treatment Recommendations

Medications

3. It is recommended that milrinone be considered for any patient following tetralogy of Fallot (TOF) repair to prevent the occurrence of low cardiac output due to restrictive right ventricular physiology after TOF repair.

   Note: There is no direct evidence to suggest that routine use of milrinone following TOF repair improves outcome, but this recommendation is based on evidence that restrictive right ventricular physiology is associated with increased morbidity after TOF repair and that phosphodiesterase inhibitors (PDEI) improve left ventricular diastolic function (Hoffman et al., 2003 [A]; Hoffman et al., 2002 [A]; Norgard et al., 1996 [C]; Chang et al., 1995 [C]; Cullen, Shore, & Redington, 1995 [C]; Berner et al., 1990 [C]; Werner, Herbertson, & Walley, 1995 [F]; Pagel, Hettrick, & Warltier, 1993 [F]).

4. It is recommended that milrinone be started for any patient with a right atrial pressure >15 mm Hg or with signs or symptoms of low cardiac output. The recommended loading dose of milrinone is 50 mcg/kg over 30 to 60 minutes followed by an infusion at 0.375 to 0.75 mcg/kg/min.

   Note 1: Direct comparison has failed to show any significant hemodynamic differences between inamrinone and milrinone. There are anecdotal reports of less thrombocytopenia with milrinone, so milrinone may be particularly useful for patients in whom phosphodiesterase inhibition is desired, but who are thrombocytopenic or following surgery (Hamada et al., 1999 [B]; Rathmell et al., 1998 [B]).

   Note 2: If hypotension develops, blood pressure support with other inotropic/vasopressor agents may be necessary (Lynn et al., 1993 [C]).

Definitions:

Cincinnati Children's Hospital and Medical Center Grading Scale

M: Meta-analysis
A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
O: Other evidence
S: Review article
E: Expert opinion or consensus
F: Basic laboratory research
L: Legal requirement
Q: Decision analysis
X: No evidence

None provided

The type of evidence is identified and classified for each recommendation (see "Major Recommendations") using the following scheme:

Cincinnati Children's Hospital and Medical Center Grading Scale

M: Meta-analysis
A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
O: Other evidence
S: Review article
E: Expert opinion or consensus
F: Basic laboratory research
L: Legal requirement
Q: Decision analysis
X: No evidence

• Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for inotropic support with phosphodiesterase inhibitors after repair of tetralogy of Fallot. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Mar. 10 p. [17 references]

Not applicable: The guideline was not adapted from another source.

2001 Jan 25 (revised 2006 Mar; reviewed 2006 Aug)

Cincinnati Children's Hospital Medical Center - Hospital/Medical Center

Cincinnati Children's Hospital Medical Center

Members of the Cardiac Clinical Pathway Development Team 2006

CHMC Physicians: Peter Manning , MD, Cardiac Surgery; Catherine Dent, MD, Cardiac Intensive Care; William Border, MD, Cardiology; James Spaeth, MD, Anesthesia; Michael Alice Moga, MD, Cardiology/Fellow

Patient Services: Karen Uzark, PhD, CPNP, Cardiology; Susan Ryckman, MS, CPNP, Cardiac Services; Betsy Adler, MS, PNP, Cardiac Services; Christa Barlow, CNP, Cardiac Surgery; Karen Jones, MS, PNP, Cardiac Surgery;  Melissa Magness, RN, Cardiac ICU; Tammy Lingsch, RN, A6 Central; Cynthia Wedekind, Pharm D, Clinical Pharmacy) Jenni Raake, RRT, Respiratory Care

Division of Health Policy & Clinical Effectiveness Support: Eloise Clark, MPH: Danette Stanko, MA, MPH, Epidemiologist; Kate Rich, Lead Decision Support Analyst; Carol Frese, RN, Medical Reviewer; Eduardo Mendez, RN, MPH, Dir. Evidence-Based Care

Not stated

This is the current release of the guideline.

This guideline updates a previous version Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for inotropic support with phosphodiesterase inhibitors after repair of tetralogy of Fallot. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Jan 25. 9 p. [16 references]

The guideline was reviewed for currency in August 2006, using updated literature searches, and was determined to be current.

None available

This NGC summary was completed by ECRI on August 24, 2004. The information was verified by the guideline developer on October 12, 2004. This NGC summary was updated by ECRI on September 8, 2006. The updated information was verified by the guideline developer on October 10, 2006.