ABC | Volume 112, Nº5, May 2019

Brief Communication Hastenteufel et al Continuous intravenous inotropes in ward units Arq Bras Cardiol. 2019; 112(5):573-576 Table 1 – Standard operating procedures for administration of continuous inotrope infusion in ward units 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. ICU: intensive care unit; PICC: peripherally inserted central catheter. Table 2 – Characteristics of study patients and data pertaining the inotropic support 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 m 2 ) 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* 93 ± 14 Diastolic blood pressure, mmHg* 59 ± 10 Data expressed as number (percentage), mean ± standard deviation or median (interquartile range). * Blood pressures values at the initiation of inotropic therapy. Data from one patient not available. HF: heart failure; GFR: glomerular filtration rate. ventricular arrhythmia, and inotropic dose was reduced; of those, four were hypokalemic (≤ 3.5 mmol/L) when arrhythmias were observed. One patient had a central venous catheter exit-site infection, and one had a peripherally inserted central catheter-related bloodstream infection. Seven events of protocol violation were identified: use of peripheral venous access for drug infusion (n = 2); and, increments in inotropic dose in the ward (n = 5). None of them incurred in clinical adverse events. Discussion In the present report, we described our initial experience with a safety-focused protocol for the use of continuous intravenous inotropes in hospitalized patients with advanced HF outside the ICU. We demonstrated that a subset of clinically stable patients on inotropes may benefit from transition to a less intensive care setting following careful standard operating procedures, without a significant burden of adverse events. These safety measures are aligned with our institutional program for quality improvement. Current guidelines indicate that inotropes can be used in specific clinical settings, especially cardiogenic shock or bridge therapy in patients with refractory HF awaiting heart transplant or LVAD. Also, those not candidates for definitive therapies could be considered for long-term inotrope as palliation. 4 The use of intravenous inotropic agents remains controversial, as many reports have associated its utilization with unfavourable outcomes. A deleterious effect of its use on long-termmortality among patients discharged alive, however, has not been suggested by a recent European registry report.¹ In this study, we describe a selected population of patients with advanced HF that has not been well-documented in most studies evaluating inotropes – mostly clinically stable hospitalized patients intended for inotropic wean or bridge to definite therapies. Concerning safety outcomes, most of the arrhythmogenic events occurred in the context of electrolyte 574