Continuous Intravenous Inotropes in Ward Units: Expanding Therapy Outside Intensive Care using a Safety-Oriented Protocol

Hastenteufel, Laura Caroline Tavares; Clausell, Nadine; Neyeloff, Jeruza Lavanholi; Domingues, Fernanda Bandeira; Caballero, Larissa Gussatschenko; Silva, Eneida Rejane Rabelo da; Goldraich, Lívia Adams

doi:10.5935/abc.20190078

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Brief Communication • Arq. Bras. Cardiol. 112 (5) • May 2019 • https://doi.org/10.5935/abc.20190078 copy

Continuous Intravenous Inotropes in Ward Units: Expanding Therapy Outside Intensive Care using a Safety-Oriented Protocol

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Selected clinically stable patients with heart failure (HF) who require prolonged intravenous inotropic therapy may benefit from its continuity out of the intensive care unit (ICU). We aimed to report on the initial experience and safety of a structured protocol for inotropic therapy in non-intensive care units in 28 consecutive patients hospitalized with HF that were discharged from ICU. The utilization of low to moderate inotropic doses oriented by a safety-focused process of care may reconfigure their role as a transition therapy while awaiting definitive advanced therapies and enable early ICU discharge.

Keywords
Cardiotonic Agents; Dobutamine; Heart Failure/physiopathology; Inotropes; Milrinone

Eligibility
Patients that are clinically stable for more than 24 hours on a stable dose of one continuous intravenous inotrope and able to be discharged from the ICU.
Central venous catheter (preferentially PICC).
Safety procedures
Discharge to a continuous cardiac telemetry ward (except if intended for palliation).
Medical prescription including both inotropic dose (mcg/kg/min) and rate of infusion (mL/min).
Maximal recommended doses for inotropes in the ward: dobutamine = 5 mcg/kg/min; milrinone = 0.5 mcg/kg/min.
Fixed or gradually reduced the dose of inotrope, as clinically appropriate.
No dose increments in the ward (patient preferentially transferred back to ICU for dose augmentation).
Rigorous electrolyte targets (potassium 4.0-4.5 mmol/L; magnesium ≥ 2.0 mmol/L) and bicarbonate monitoring.
Systematic nursing evaluation of the patient and the administered drug according to the ward routines.
Daily patient assessment by the medical team.
Considerations
Exclusive intravenous access line for inotrope infusion.

Characteristic	n = 28
Baseline Characteristics
Age, years	54 ± 16
Male sex	20 (71.5)
Ischemic etiology of HF	16 (57)
Left ventricular ejection fraction, %	23 ± 7.5
History of atrial fibrillation	13 (46)
Implantable cardioverter defibrillator	13 (46)
Chronic kidney disease (GFR < 30 mL/min/1.73 m²)	7 (25)
Inotrope infusion
Intravenous inotrope
Milrinone	24 (86)
Dobutamine	4 (14)
Inotrope dose
Milrinone, mcg/Kg/min	0.25 (0.2 - 0.34)
Dobutamine, mcg/Kg/min	5.7 (4.37 - 6.55)
Total duration of inotropic therapy, days	23.5 (13.75 - 45.5)
Duration of inotropic therapy at ward, days	10.5 (6.75 - 25)
Venous access for drug infusion
Central venous catheter	4 (14)
Peripherally inserted central catheter	22 (79)
Peripheral venous access	2 (7)
Systolic blood pressure, mmHg^* * Blood pressures values at the initiation of inotropic therapy. Data from one patient not available. HF: heart failure; GFR: glomerular filtration rate.	93 ± 14
Diastolic blood pressure, mmHg^* * Blood pressures values at the initiation of inotropic therapy. Data from one patient not available. HF: heart failure; GFR: glomerular filtration rate.	59 ± 10

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E-mail: revista@cardiol.br

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[1] Mailing Address: Lívia Adams Goldraich, Hospital de Clínicas de Porto Alegre - Serviço de Cardiologia - Rua Ramiro Barcelos, 2350. Postal Code 90035-903, Porto Alegre, RS - Brazil. E-mail: lgoldraich@gmail.com