PRESENTERS

Jacqueline Kirui , Caroline Limo

CHALLENGES IN THE USE OF INOTROPES IN THE MANAGEMENT OF DECOMPENSATED HEART FAILURE

THEME: The Role of Critical Care Nurse in promoting Sustainable Development Goals.

INTRODUCTION

• Inotropic agents have been used for many years in the management of decompensated

heart failure and cardiogenic shock: syndromes characterized by reduction in the

contractility of the myocardium.

• Inotropic agents improve myocardial contractility force sustaining blood pressure and

heart rate significant for tissue perfusion. The most commonly used agents are dopamine,

dobutamine, norepinephrine, milrnone, digoxin, phenylephrine and levosmendan among

others.

• Their most common use is among hospitalized patients with signs of end organ

dysfunction in the setting of low cardiac output.

• The use of inotropic agents has however been associated with risks and adverse events.

Among these is dependence, increased mortality and morbidities, arrhythmias, myocardial

ischemia. Some patients get hypo perfusion once weaned off inotropic support,

symptomatic hypotension, and others get signs of multiorgan failure.

• It’s imperative now for physicians and critical care nurses to clearly evaluate the kind of

patients on whom to start inotropic support for short term and long term therapy.

Objectives of the Study

• To identify gaps in the use of inotropic drugs and to develop references in the quest

to promote evidence based practice in our clinical set up.

Methodology

• This study implored case study method on some patients managed in MTRH Cardiac

Care Unit.

• Selection of cases was purposive to patients with acute and chronic decompensated

heart failure and presentation done for 3 cases.

CASE 1. NAME X AGE 16YRS

• DoA- 21/06/2018 DoD- 29/06/2018

• CC and Examination- Left sided chest pain non-radiating, Abdominal pains, Restlessness,

Palpitations worsens Pt had hyperactive precordium, systolic murmur at the mitral valve. Had cold

extremities

• HPI: The left sided chest pain was associated with palpitations and worsened by vomiting. Had also

epigastric pain that was worsened by eating some foods. Had been on follow- up in MTRH for RHD

with Severe MS since 2016.

• Vital Signs: Bps- Unrecordable, HR-172, RR-43, RBS- 1.5, Spo2- 90%.

Investigations:

FHG- hb-12.8, wbc-13.2, BGA- pH- 7.21, Co2- 33, HCO3- 16, Po2- 29, UECS- Norm, Ecg- Atrial

Fibrillation 172b/min, Echo- Severe MS, Severe MR, dilated LA, RV, RA.

Treatment

Loading Amiadorone 200mg stat, 75mg maintenance, Esose 20mg, D50%, Morphine 0.5mg, Calcium

gluconate 1g, Levofloxacin 750mg. Ceftriaxone 1g. NaHco3.

Patient presented as follows Day by Day.

• Day 1: Bps- Unrecordable, HR-172, RR-43, RBS- 1.5, Spo2- 90% I/O 1400/200mls. Amiadorone 200mg stat, 75mg given. Dobutamine started at 5mcg/k/min, titrated to 7.5mcg to 10mcg.

• Day 2. Pt on Amio 75mg, Dobutamine ↓↓to 5mcg. Bps 85/55, HR 156. I/O 1000/700mls.

• Day 3, 4. Dobutamine 5mcg. Bps, 80/70(L), 110/60(H) HR-144, I/O 1100/450mls.

• Day 5. Dobutamine 3mcg, bps 84/60(L), 100/70(H), I/O 1000/1400.

• Day 6, 7, 8: Pt off inotropes support, put on digoxin 0.125mg. Bps 90/65(L), 100/70(H). I/O 1000/550mls.

Day 9.

• 8am-Pt lost consciousness, Bps unrecordable, HR- 49, SPO2 49%, RBS- 6.8. Started on Dopamine 15mcg. After 2hrs bps 80/40

• 10am- Bps still unrecordable, Temp 34.6, added on Dobutamine 5mcg

• 11am- BGAs- 7.5, co2- 33, HCo3- 26, O2- 39%- put on BIPAP NIV.

• 12am- bps 50/30

• 2pm- Bps-unrecordable. Stopped dopamine and started Norepi 5mcg. Dobutamine ↑↑10mcg.

• 5- 7pm: dobutamine 10mcg, ↑↑ Norepi to 10mcg-20mcg-30mcg. Bps Unrecordable

• 8pm- Cardiopulmonary Arrest, Resuscitation.

• 8.30pm-Certified Dead.

CASE 2: MR Y AGE 50YRS

• DOA: 31/5/2018 DOD: 23/6/2018

• Cc: Abdominal Distension, easy fatigability.

• DX: Decompensated HF with 2°Heart Block, LVSD and EF < 10%.

• HPI

A known CCF patient who has been on follow-up in our cardiac clinic. He was well until

1/12ago when he started having abd. distension associated with pain in the RUQ. He reported

easy fatigability on slight exercises and DIB when lying low, relieved by sitting down. The

above symptoms were associated with swelling of the lower limbs on and off.

• Vital signs: Bp 60/40, P-37, RR- 18, Rbs 6.5, Spo2- 98%.

• Investigations

• FHG- WBC 5.2, Hb- 10.1, Plt- 174., Uecs: Urea 48.5, Crt 751, Na+ 127, K+ 8.5 , ECG-

Sinus Brady @37bt/min 2°HB, Left Ventricular Hypertrophy, Echo: LVSD with EF <

10%, dilated chambers non-collapsing IVC, Ltfs: Alb 52.5, Total Proteins: 56., Abd Us

– hepatomegaly + venous congestion + right sided pleural effusion, CXR- Minimal

pleural effusion

• Treatment

Dopamine 5mcg/kg/min, Heparin 5000iu SC BD, Lasix 80mg OD, Metalozone 5 mg

OD, Levofloxacin 500 mg , Esomeprazole 40mg OD , Lactulose 10mg TDS, Resonium

15mg TDS, Calcium Gluconate 1g

Patient presented as follows Day by Day.

• Day 1. Hypotensive of 60/40mmHg Pt started on dopamine 5mcg/kg/min titrated to 8mcg/kg/min.

Achieved Bps90/60mmHg, input/950 and output/ 800mls.

• *Dopamine weaned off after 1day. For the next 10 days the pt. was hypotensive with 60/40mmHg (L)

and 80/40mmHg (N) with normal renal function.

• Day 10. Pt hypotensive and confused, with ↓↓ output (I/O 1000/450mls), worsening renal function: Urea

52, Crt 639. He was started on Dobutamine 5mcg/kg/min.

• Day 13-17-20. Pt hypotensive 60/50(L) 100/60(H), ↓↓ renal function. Dobutamine ↑↑ to 7.5mcg

10mcg/kg/min on the 17th day.

• Day 21. Bps 80/50(L), 102/ 61(H), Urea 24, Crt 180, I/O 900/1450. Weaned off dobut, started on digox

0.125mg. Day 23. Discharged on digoxin 0.125mg. Bps 98/58.

CASE 3. MR. Z AGE 21YRS

DOA: 25/07/2018 DOD 17/07/2018

• Diagnosis: Multivalvular Rheumatic Heart Disease/ Severe MS Severe AR

• CC and Examination: General body weakness, generalized edema Grade 4, DIB, RUQ tenderness,

Vomiting and ↓↓↓ appetite, S3 Markable JVD, S4 Gallops, Diastolic and Systolic Murmurs, Course

crackles in the basal lungs

Vital Signs: Bp 120/70mmHg, P- 99, RR-26, Temp- 36.5, Spo2- 97%, RBS- 8.1

Investigations

• FHG- Wbcs- 5.2, Hb- 11.5, MCV-72, Plt- 71, ECG- Inferior old Infarct, regular PVCS, Echo- Severe

MS, Severe AR, EF < 30%, Lfts- Alb 26, Cardiac Biomarkers -Ⓝ

• Management and Patient presentation Day by Day.

• Day 1. The patient started on the following drugs. (With a target output of -2000mls). Bps stable.

Lasix 120mg, Enalpril 5mg, Clexane 40mg, Digoxin 0.125mg , Iv calcium gluconate 2g

• Day 2. I/O 1100/800mls, Pt in fluid overload. Lasix 120mgs and Metalozone 5mg was added to

the Rx. Bps stable

• Day 3.I/O 1000/3500mls, Pt still in overload. Started on Dobutamine 5mcgs/k/min, Lasix

120mgs Stat

• Day 5. Pt on Dobutamine at 5mcgs with I/O 1180/2300mls. Lasix 80mg given

• Day 8. Pt on Dobutamine at 5mcg with I/O 1580/ 1200, BP 90/43(L) and 150/50(H).. Lasix

160mgs given

• Day 10. Pt I/O 1300/ 5150mls, yet overloaded with very wet chest. Lasix 120mgs stat given

• Day 18. Pt I/O 105/340mls. Edema subsided to Grade 1. Bps holding. Dobutamine was

weaned off put on Digoxin 0.125mg.

• Day 22. Pt was discharged on Lasix 80mg, enalapril 2.5 mg, digoxin 0.125mg.

*Mr. P was on remarkable fluid overload for 18days yet on inotropic support. The clinicians

had to concomitantly use high doses for diuretics to relieve the patient of overload on top of

the inotropic support

DISCUSSION

• This study aimed at identifying some of the challenges encountered with the use of inotropes

in the management of decompensated heart failure. The following is the highlight.

• 1. Tolerance and Dependence.

• Long use of inotropic agents creates tolerance and their overstretched use creates

dependence (Moran 1997).

• Case 1, the patient expressed a level of tolerance to the three inotropic agents used to her:

dopamine, dobutamine and norepinephrine. She had unrecordable blood pressures despite

high doses. Case 2, this was his 4th admission to CCU and in each admission , there is use of

Inotropes, creating a level of tolerance and dependence. He could not achieve a significant

cardiac contractility able to perfuse vital organs thus was constantly hypotensive with

worsening renal functions

• 2. Drug Interaction

• In case 1, Amiodarone was being used to manage the Atrial Fibrillation while

Dobutamine was being used for cardiac contractility to boost blood pressure. Amio is

known to cause drastic hypotension (Naccarelli et al.). Thus concomitant use with

dobutamine pauses challenges in that both drugs counteracts the effect of the other

(Hunt et al., 2009).

• 3. Use of High Doses of Diuretics.

• Diuretics use is a mainstay in fluid management for decompensating heart failure. In the

event of a low cardiac output 2° to decompensation, major organs gets hypo perfused. Renal

hypo perfusion activates RAAS system which leads to retention of sodium and water

worsening the congestion in the heart failure patients (Ahmed et al.). In such cases, use of

very high doses of diuretics have been used to relieve patients of excess fluids. This risks

hypotension, renal dysfunction and electrolyte imbalances which is detrimental to HF

causing arrhythmias and mortalities (Albert, 2012).

• Case 3 is classic example where the patient had almost 2weeks with high doses of diuretics

together with dobutamine support. This lead to constant electrolyte imbalances reflected as

frequent PVCs.

CONCLUSION

• This study concludes that there is still great challenge and dilemmas that have not been

highlighted in the use of contemporary inotropic agents. It’s still debatable on the appropriate

time to start inotropic support and when do you stop support for a heart failure patients.

Differences have been reported also on which agent to start between dopamine and

dobutamine on a patient with signs of end organ failure, hypotension but with a normal WBCs

count.

• Additionally, having a few drugs in market poses a limitation in cases when patients develop

tolerance and dependence the ones available. More studies therefore ought to be done to avail

ways of eliminating dependence and availing more drugs in the market for such cases.

THE END, THANK YOU