The Perspective of the Intensivist on Inotropes and Postoperative Care Following Pediatric Heart Surgery: An International Survey and Systematic Review of the Literature

Abstract

Introduction: Inotropes are frequently being used in children undergoing heart surgery to prevent or treat low cardiac output syndrome (LCOS). There is only limited evidence that inotropes actually positively influence postoperative outcome. Our aim was to describe the current international practice variation in the use of inotropes following congenital heart surgery. Methods: We developed an online survey regarding the postoperative use of inotropes. We sent an invitation to all 197 registered members of the Pediatric Cardiac Intensive Care Society (PCICS) to participate in the survey. We also performed a systematic review of the literature. Results: Ninety-eight people (50%) responded, representing 62 international centers. Milrinone is routinely used perioperatively by 90 respondents (97%). Adrenaline/epinephrine is routinely used by 43%, dopamine by 36%, dobutamine by 11%, and levosimendan by 6%. Steroids are used routinely by 54% before initiating cardiopulmonary bypass. Vasopressin is used by 44% of respondents. The development of LCOS is monitored with lactate in 99% of respondents, physical examination (98%), intermittent mixed venous saturation (76%), continuous mixed venous saturation (13%), echocardiography (53%), core–peripheral temperature gap (29%), near-infrared spectrometry (25%), and 4% use cardiac output monitors (PiCCO, USCOM). To improve cardiac output, 42% add/increase milrinone, 37% add adrenaline, and 15% add dopamine. Rescue therapy is titrated individually, based on the patients’ pathophysiology. A systematic review of the literature failed to show compelling evidence with regard to the benefit of inotropes. Conclusions: Despite the lack of sufficient evidence, milrinone is used by the vast majority of caregivers following congenital heart surgery.