ABC | Volume 112, Nº5, May 2019

Brief Communication Continuous Intravenous Inotropes in Ward Units: Expanding Therapy Outside Intensive Care using a Safety‑Oriented Protocol Laura Caroline Tavares Hastenteufel , Nadine Clausell , Jeruza Lavanholi Neyelof f, Fernanda Bandeira Domingues , Larissa Gussatschenko Caballer o, E neida Rejane Rabelo da Silv a, L ívia Adams Goldraic h Hospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brazil Keywords Cardiotonic Agents; Dobutamine; Heart Failure/ physiopathology; Inotropes; Milrinone. 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 Manuscript received September 07, 2018, revised manuscript November 18, 2019, accepted January 16,2019 DOI: 10.5935/abc.20190078 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. Introduction In advanced heart failure (HF), patients with low output syndrome may benefit from intravenous inotropes to provide symptomatic relief and hemodynamic support with different purposes – stabilization of the acute setting, bridge to more definitive surgical therapies for advanced disease and palliation. Among patients admitted with decompensated HF, around 12 to 14% receive inotropes.¹ However, the safety of inotrope use remains a concerning issue.² In the acute setting, continuous inotropic infusions are usually initiated in intensive care units (ICU), where doses may be titrated with careful monitoring of pro-arrhythmogenic and vasodilatory effects until the patient is stabilized. Some patients may require longer periods of inotropic support, and, depending on their clinical status, may benefit from the continuity of inotropic therapy in a less intensive care setting. Our aim is to report the initial experience of a structured protocol for intravenous inotropic therapy in non-intensive care units, focusing on safety processes and end-points. Methods We retrospectively reviewed all consecutive patients hospitalized with HF that were discharged from ICU on an intravenous inotropic infusion in our tertiary, academic hospital from July, 2015 to December, 2017. The strategy to promote discharge to the ward on inotropic therapy was supported by an institutional protocol, which is summarized in the Table 1. Briefly, stabilized HF patients receiving a low to moderate dose of continuous intravenous inotrope (dobutamine or milrinone) for different indications in the ICU were considered for transition of care to a ward unit equipped with cardiac telemetry, except if inotrope was intended for palliation, in which case telemetry was not used. Adverse events - defined as readmission to ICU due to worsening HF, atrial arrhythmia, ventricular arrhythmia requiring inotropic dose reduction, and infection related to central intravenous access - that occurred while the patient was receiving inotropic infusion in the ward were recorded. In-hospital outcomes (death, heart transplant, left ventricular assist device - LVAD - implant or weaned off inotropes), 30-day hospital readmissions, readmission for transplant and all-cause mortality up to a censoring date on December 31 st , 2017 were recorded. Statistical analysis Categorical variables are presented as absolute numbers and percentages, and quantitative variables as mean ± standard deviation or median and interquartile range, as appropriate. A Kaplan-Meier curve was plotted for survival free from heart transplant or LVAD implant during follow‑up, and cumulative incidence curves were calculated for all‑cause mortality and heart transplant or LVAD using competing risk analysis with the R Software, version 3.4.4 (R Project for Statistical Computing, Vienna, Austria). 3 Results We reviewed 28 patients with HF that were discharged from the ICU to the ward on intravenous inotropes after the protocol was created. Table 2 describes both patient and clinical care data during the inotropic support period. Figure 1A depicts in-hospital outcomes of patients according to intention for inotropic support. The cohort was followed for a median of 154 days. Among those in whom inotropes were discontinued and that had hospital discharge free of heart transplant or LVAD implant (n = 8), two were readmitted for HF within 30 days. Competing outcomes for mortality during the follow-up period are demonstrated in Figure 1B. During the period on inotropic support in the ward, nine patients returned to ICU due to worsening HF - two of those for worsening pre-existing atrial fibrillation or atrial flutter. No episodes of new atrial fibrillation or atrial flutter were observed. Six patients developed recurrent non‑sustained 573