• Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for inotropic support with phosphodiesterase inhibitors after arterial switch operation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Aug. 8 p. [16 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 arterial switch operation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Jan 22. 9 p.

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 left atrial pressure (5 to 15 mmHg) with evidence of adequate tissue and organ perfusion as defined by physical exam, urine output >1cc/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 left atrial pressure with a transthoracic catheter is recommended (Local Expert Consensus [E]).

Treatment Recommendations

2. It is recommended that milrinone be considered for any patient following arterial switch operation to prevent the occurrence of low cardiac output over the first 24 hours following arterial switch operation.

   Note: There is no direct evidence to suggest that routine use of milrinone following arterial switch operation improves outcome, but this recommendation is based on evidence that cardiac output decreases in the 6 to 18 hours following cardiopulmonary bypass (Wernovsky et al., 1995 [A]) and that phosphodiesterase inhibitors are effective in improving cardiac output after cardiopulmonary bypass (Hamada et al., 1999 [B]; Laitinen et al., 1999 [B]; Hoffman et al., 2003 [B]; Berner et al., 1990 [C]; Lynn et al., 1993 [C]; Bailey et al., 1997 [C]; Kikura et al., 1998 [C]).

3. It is recommended that milrinone be started for any patient with a left atrial pressure >15 mmHg 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 (Rathmell et al., 1998 [B]; Hamada et al., 1999 [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:

A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
E: Expert opinion or consensus
F: Basic laboratory research
L: Legal requirement
M: Meta-analysis or systematic review
O: Other evidence
Q: Decision analysis
S: Review article
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:

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

• Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for inotropic support with phosphodiesterase inhibitors after arterial switch operation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Aug. 8 p. [16 references]

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

2001 Jan 22 (revised 2006 Jan 10; reviewed 2006 Aug)

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

Cincinnati Children's Hospital Medical Center

Cardiac Clinical Pathway Development Team 2006

Members of the Cardiac Clinical Pathway Development Team 2006

Children's Hospital Medical Center 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 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; Shawna Kirkendall, RN, Manager, A 6 Central

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; Edward Donovan, MD, Medical Director, Clinical Effectiveness

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 arterial switch operation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Jan 22. 9 p.

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 March 11, 2004. This NGC summary was updated by ECRI on June 21, 2006. The updated information was verified by the guideline developer on June 23, 2006. This NGC summary was updated by ECRI on September 7, 2006. The updated information was verified by the guideline developer on September 19, 2006.