This video discusses optimizing cardiac output in the post-operative management of the pediatric cardiac patient.

Initial publication: January 29, 2014.
Last reviewed: May 23, 2019.
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Optimizing Cardiac Output After Surgery, by Dorothy Beke.

Hello. My name is Dorothy Beke. I'm a clinical nurse specialist in the Cardiac Intensive Care Unit at the Children's Hospital Boston. In this video on post-operative considerations after pediatric cardiac surgery, I will discuss issues related to optimizing cardiac output in the post-operative pediatric cardiac patient.

Maintaining Cardiac Output.

Preserve myocardial function and minimize oxygen consumption by decreasing stress to the heart. Too much inotropic support, such as with dopamine or epinephrine, causes the heart to work harder, produces cardiac arrhythmias, and increases both systemic and pulmonary vascular resistance. Low intracardiac or central venous pressures will cause tachycardia and decreased peripheral profusion. Fluid boluses of 5 to 10 milliliters per kilogram may be indicated to ensure adequate cardiac
preload.

Monitor for Increased Systemic and Pulmonary Vascular Resistance.

Increased pulmonary vascular resistance may be due to excessive pulmonary blood flow, inflammatory and ischemic responses related to cardiopulmonary bypass, edema, or prolonged mechanical ventilation. Increased systemic vascular resistance may be related to left ventricular failure, cardiopulmonary bypass, hypoxia, acidosis, or low body temperature, or pain. Measures to decrease pulmonary and systemic vascular resistance include adequate mechanical ventilation and oxygenation, analgesia and sedation as well as afterload reducing agents such as nitroprusside. Milrinone has both inotropic and afterload reducing effects. Maintain cardiac output for improving cardiac contractility with inotropic medications such as dopamine, and by maintaining normal acid-base balance and adequate tissue oxygenation. Normal sinus rhythm will optimize cardiac output.

Milrinone. The PRIMACORP trial was one of the few multi-centered, randomized, double blinded, placebo-controlled trials of a pediatric cardiovascular drug. Milrinone is a non-catecholamine inotropic agent with vasodilatory and lusitropic or cardiac relaxation effects. It has been shown to improve cardiac output while lowering filling pressures and systemic and pulmonary vascular resistance with minimal cardiac oxygen consumption. In the PRIMACORP trial, patients were randomized to high-dose Milrinone of 0.75 micrograms per kilogram per minute, 1/3 were randomized to low-dose Milrinone of 0.25 micrograms per kilogram per minute, and 1/3 were randomized to placebo. The prophylactic use of Milrinone in a 64% relative risk reduction in developing low cardiac output syndrome and the first 36 hours after cardiopulmonary bypass with high-dose Milrinone of 0.75 micrograms per kilogram per minute.