Noninvasive Administration of Inhaled Epoprostenol and Inhaled Milrinone in Extubated, Spontaneously Breathing Patients With Right Ventricular Failure and Portal Hypertension: A Report of 2 Cases

Abstract

We describe the cases of 2 patients free from mechanical ventilation after a cardiac surgery with systemic venous congestion from right ventricular (RV) failure. Management of these patients included RV preload reduction with diuretics and RV afterload reduction with inhaled pulmonary vasodilators. Noninvasive combination of inhaled epoprostenol and inhaled milrinone through the AirLife filtered nebulizer system (CareFusion) was used. Reduction of splanchnic venous congestion was assessed by Doppler portal flow pulsatility.

Doppler Interrogation of the Femoral Vein in the Critically Ill Patient: The Fastest Potential Acoustic Window to Diagnose Right Ventricular Dysfunction?

“…This is particularly useful when these findings are combined with other clinical, hemodynamic, and echocardiographic variables associated with RV dysfunction and venous congestion. Similarly to the changes observed in hepatic or portal venous Doppler following fluid resuscitation and vasoactive treatment ( 19 , 21 , 60 ), changes in CFV Doppler signals could be also be used for that purpose. The technique is currently used by the ICU nursing personnel and medical students on ICU rotation.…”

“…At this point, diuretics and inhaled vasodilators (prostacyclin and milrinone) were initiated to reduce organ congestion ( 19 , 21 , 36 ). By postoperative day 3, the patient’s cumulative fluid balance was 200 mL positive, he no longer required vasopressor support, and he could be discharged to the ward.…”

Advanced airway management and respiratory care in decompensated pulmonary hypertension

“…Caution should be used with inotropic agents such as milrinone or dobutamine due to their systemic vasodilatory effects, as patients with systemic level pulmonary artery pressures may decompensate or cardiac arrest on initiation if systemic vascular resistance decreases without support [45][46][47]. Inhaled milrinone, by itself or in combination with inhaled prostacyclin, has been shown to be a promising as they improve mean pulmonary artery pressures and cardiac index, while having minimal to no effect on the systemic circulation [48][49][50].…”

Femoral Vein Pulsatility: What Does It Mean?

“…Diuretic treatment was continued with intravenous furosemide, oral metolazone, and an inhaled noninvasive combination of epoprostenol and milrinone every 4 hours. 9 Norepinephrine was restarted at the end of the day at an infusion rate of 0.03 mg/kg/min in order to improve RV perfusion given the vasoplegic state. A cerebral computed tomography scan showed evidence of a left occipital stroke with multiple cerebellar lacunae and zones of left temporal and parietal ischemia.…”

“…In comparison, a normal average optic nerve sheath diameter is less than 5.5 mm. 8,9 HR, heart rate. On POD 2, vasoactive support was reduced, and the patient's net volume status was now 1.6 L greater compared with preoperative status.…”