Anaesthesia - paediatric cardiac inotrope use
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To be used in PICU and OR for paediatric cardiac patients
Inotropes - indication and dosage
|Routine cases||< 3 months: Milrinone 0.5mcg/kg/min#|
|> 3 months: Dopamine 5mcg/kg/min|
|Modified Blalock-Taussig Shunt||Milrinone 0.25-0.5mcg/kg/min|
|Bidirectional Glenn procedure||Milrinone 0.25-0.5mcg/kg/min|
|Fontan procedure||Dopamine 5mcg/kg/min|
|+/- Milrinone 0.5mcg/kg/min|
|More complex surgery including Norwood /Sano*||Milrinone 0.25-0.5mcg/kg/min|
|+/- Adrenaline 0.05mcg/kg/min|
|+/- Noradrenaline 0.05mcg/kg/min|
|Tetralogy of Fallot repair||Milrinone 0.25-0.5mcg/kg/min|
# A loading dose of milrinone will NOT be routinely given but the infusion rate may be run at a higher level for several hours initially.
* If this is inadequate then adrenaline may be increased to 0.1mcg/kg/min and noradrenaline added at a similar dose to adrenaline.
Patients who are vasoplegic, i.e. overdilated with good cardiac function but low blood pressure may require a vasopressin infusion. Start in those patients if requiring >0.1mcg/kg/min noradrenaline. Dose is 0.02-0.06U/kg/hr.
For ongoing hypotension/low CO in neonates consider a 10% calcium gluconate infusion at 0.5-1ml/hr targeting an ionised calcium level of 1.3-1.5mmol/L. DO NOT USE in older patients.
If inotropic requirements are increasing inform the cardiac surgeon and consider additional investigations (ECHO) and treatments such as opening the chest and/or mechanical support.
- Dopamine is not a good drug for infants due to increased O2 demand, interference with HPA and inhibition of hypoxic drive.
- Milrinone is a good inodilator and lusitropic agent making it ideal for hearts with diastolic dysfunction but not so good for hypotensive patients.
- Select the inotrope(s) required based on the underlying physiology and what you are trying to achieve.
- Be prepared to alter inotropes if required.
- Neonates/Infants especially can have poor cardiac function and normal or raised MAP. Do not stop inotropes for hypertension unless you are certain that cardiac function is good. If not then add in a vasodilator such as GTN or nitroprusside and continue the inotrope.
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- Date last published: 01 June 2017
- Document type: Clinical Guideline
- Services responsible: Paediatric Anaesthesia
- Author(s): D Buckley
- Editor: Michael Tan
- Review frequency: 2 years
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