Adult Critical Care Protocol: May be administered by IV infusion by a nurse in Adult Critical Care; Each loading dose and infusion rate must be ordered by physician; nurses are not approved to titrate milrinone; Must be administered via central venous access device; Continuous infusions must be administered by infusion device and the pump library must be enabled. One study compared the combination of intra-arterial milrinone infusion followed by intravenous administration versus a continuous intravenous milrinone infusion. A short summary of this paper. Loading dose 50 microgram/kg resulted in sub-therapeutic concentrations. Following the loading protocol, a saline infusion running at a rate similar to the milrinone infusion will be commenced for a maximum period of 35 h or until discontinuation of iNO if it occurs sooner. The pharmacokinetic parameters are not dose-dependent, but the area under the plasma concentration versus time curve after injections is dose-dependent. To add to the patient’s difficulties, home care agencies in the area are unable to provide home infusion of dobutamine. Milrinone infusion resulted in moderately increased heart rate, but systemic arterial pressure remained unchanged. Milrinone infusion protocol. The remaining 3 underwent mechanical angioplasty. Your kidney function and electrolytes may also need to be checked with blood tests. During 2 successive periods, milrinone was administered using either a combination of intra-arterial milrinone infusion followed by intravenous administration until day 14 after initial bleeding (IA+IV protocol), or a continuous intravenous milrinone infusion for at least 7 days (IV protocol). All patients underwent a 24- to 72-hour infusion of intravenous milrinone followed by upward titration of oral vasodilator therapy and diuretics to maintain improvement in hemodynamics. B. Initiate therapy with a 50 mcg/kg bolus given slowly over ten (10) minutes. To use the Flexible Container, tear the overwrap at the notch and remove the Pre-Mix solution container. MILRINONE (PRIMACOR®) INFUSION PROTOCOL PROTOCOL: A. I.V. No medical complications associated with this protocol were observed. Increase in mortality. Dobutamine is easier to titrate due to its short half-life, so it is often a preferred agent if the patient's response to inotropy isn't entirely predictable. Premixed infusions are already diluted and ready to use. Five patients (23%) had angiographically-proven vasospasm recurrence within 48 hours after the procedure. The loading dose should be administered using a milrinone 1mg/mL vial. The only alternative, says Cobb, is to refer patients to an inpatient facility where dobutamine can be administered. When administering PRIMACOR (milrinone lactate) by continuous infusion, it is advisable to use a calibrated electronic infusion device. Milrinone is a phosphodiesterase 3 inhibitor with both positive inotropic and vasodilator properties. Product and placebo preparation and infusion regimen. 36 A more recent study compared the effectiveness of continuous intravenous infusion of milrinone with that of dobutamine; there was no significant difference in mortality in the two groups. Administered as a continuous infusion, milrinone is indicated for the short-term treatment of patients with acute decompensated heart failure. A 2006 prospective, randomized study comparing milrinone vs. dobutamine support in patients awaiting cardiac transplantation found a significant difference in total treatment cost of $16227 ± $1334 USD (milrinone) vs. $380±$533 USD (dobutamine) (P < .00001). Fewer hospitalizations. Administered as a continuous infusion, milrinone is indicated for the short-term treatment of patients with acute decompensated heart failure. 5 (LOE IV GOR C) Term infants with pulmonary hypertension: Half-life (t. ½ ) averaged 4 hours. However, milrinone is renally eliminated, which can make it difficult to titrate in patients with renal failure. READ PAPER . Compatible with TPN. Note: PRIMACOR Flexible Containers (200 mcg/mL in 5% Dextrose Injection) are for intravenous infusion only and should not be used for a loading dose. Continuous Infusion: Diluent: Milrinone drawn from vials must be diluted. This manual has over 300 ready-to-implement policies and procedures that are current with The Joint Commission (TJC) and CHAP standards, as well as CMS regulations. You will initially receive this infusion in a clinic or hospital setting. Increases quality of life by decreasing signs and symptoms. Neurocritical Care, 2012. Download PDF. Since then he has remained clinically stable on oral medications for 18 months. The milrinone infusion was then slowly weaned until it was discontinued. BENEFITS. Despite limited data supporting long-term milrinone therapy in adults with congestive heart failure, Milrinone is given as a continuous infusion through a needle placed into a vein. The flexible containers provide two ready-to-use dilutions of Milrinone in volumes of 100 mL and 200 mL of 5% Dextrose Injection. Milrinone causes a bit more vasodilation, so it might be better for cardiogenic shock. MCN's Home Infusion … Infusion: Dilute in NS, 1/2NS, or D5W to 200 mcg/mL; use undiluted if giving 20 mg/100 mL in D5W. a continuous infusion of milrinone for doses of 0.5micrograms/kg/min or less. Milrinone is available as sterile aqueous solutions of the lactate salt of Milrinone for infusion intravenously. Milrinone can be recommenced on a patient who has received a milrinone infusion in the previous 48 hours. Infusion rates were initiated most commonly at 0.75 mcg/kg/min (range 0.15–1.0 mcg/kg/min) with ceiling doses ranging from 0.75 to 2.5 mcg/kg/min (commonly 1.25–1.5 mcg/kg/min). In addition to its use in acute decompensated heart failure, milrinone can also be employed as a home infusion therapy or a bridge to cardiac transplant. For now, both Hospice Atlanta and Hospice Caring Project remain undecided about the future of dobutamine and milrinone use in their own facilities. Infuse milrinone according to the following administration schedule: - 50 g/kg IV push slowly over 10 minutes, then - 0.375 g/kg/min x 1 hour; - 0.5 g/kg/min x 1 hour; - 0.375 g/kg/min x 1 hour; - discontinue infusion. I'm not sure what information you are looking for, Milrinone is a drug that relaxes the muscles in the veins to allow better blood flow. Milrinone loading infusion 0.75 microgram/kg/min for 3 hours followed by maintenance infusion 0.2 microgram/kg/min achieved target (180–300 nanogram/mL). On the day of study, patients were admitted to the coronary care unit for placement of a right heart catheter via the right or left internal jugular vein. IV Administration. Your heart rate and blood pressure will be monitored intermittently by the home care nurse while you are being treated with milrinone. Special considerations. MCN Healthcare's Home Infusion Therapy Services Policy and Procedure Manual has been developed and written to provide a comprehensive, operational framework for Home Infusion Nurses and Pharmacists. Since milrinone is renally cleared, patients with decreased renal function may have an exaggerated effect to the given dose. Injection: Administer slowly over 10 minutes; may use undiluted for initial direct IV injection. The medication was infused continuously 24 hours a day through an IV inserted in the chest or arm and stored in a small bag or fanny pack, allowing patients to be mobile. Family burden. Dosage recommendations using a 1mg/mL concentration of milrinone are included for informational purposes only. Any dose … Bolus is optional (Bolus is not recommended in most recent AHA Guidelines 2013) C. Standard Concentration 20 mg milrinone in100 ml premixed bag of D5W. Mauro Cardoso. High-dose milrinone significantly reduced the risk of de-velopment of low cardiac output syndrome compared with placebo, with a relative risk reduction of 55% (P= 0.023) in 238 treated patients and 64% (P=0.007) in 227 patients without major protocol violations. Boluses, when utilised, ranged from 50 to 200 mcg/kg. The saline infusion will be titrated up in increments similar to the milrinone infusion. Patients in the study received one of three types of inotropic medications: milrinone, dobutamine or dopamine. The reversion rate of cerebral vasospasm was 71% (59% - 83%) in the intra-arterial + intravenous protocol and 64% (58% - 71%) in the intravenous protocol. Milrinone Home Infusion RISKS Catheter related bloodstream infections. The nominal concentration of lactic acid is 0.282 mg/mL. Compatible with both NaCl and Dextrose containing solutions. Milrinone infusion at a low dose (i.e 0.25 mcg/kg/min) does not require weaning as changes in haemodynamics usually take 4-6 hours. Few head-to-head studies compared the cost of continuous inotrope infusions. This paper. Concerns abou … Milrinone Dosing and a Culture of Caution in Clinical Practice Cardiol Rev. Protocol for Intravenous Milrinone Lactate Treatment for Outpatients. Milrinone is an invaluable agent in the treatment of end-stage heart failure patients who are refractory to optimal medical therapy. Dosing of milrinone varied between studies, and an intravenous bolus prior to commencing infusion was not universal. Milrinone is administered by intravenous infusion. Hypotension. Enables patient to go home from the hospital. Milrinone is a PDE inhibitor with both inotropic and vasodilating properties. Infusion: Administer via calibrated electronic controlled-infusion device. Download Full PDF Package. In adult congestive heart failure patients, milrinone has a volume of distribution of 0.38 L/kg, a mean elimination half-life of 2.3 hours, and a clearance of 0.13 L/kg/hour. Perform telemetry. Arrhythmias. The timing and criteria for increasing … The Flexible Container has a concentration of milrinone equivalent to 200 mcg/mL in 5% Dextrose Injection. It is usually given to patients with advanced or life threatening heart failure. Milrinone and Homeostasis to Treat Cerebral Vasospasm Associated with Subarachnoid Hemorrhage: The Montreal Neurological Hospital Protocol. Maintenance = 0.25 mcg/kg/min infusion, titrating to effect (range: 0.25-0.75 mcg/kg/min) In our limited experience, a loading dose has usually not been required in neonates. The time for milrinone to reach steady state will vary and would normally be 4-5 half lives of milrinone. Primacor may be diluted with solutions containing dextrose or saline prior to injection. Dilute 10 mg (10 mL) of milrinone in 40 mL of diluent or 20 mg (20 mL) of milrinone in 80 mL of diluent. Milrinone in PPHN Anecdotal reports have shown that milrinone can be an Compatible diluents include 0.45% NaCl, 0.9% NaCl, and D5W. infusion or if the milrinone line is required run 0.5mL/hour of sodium chloride 0.9% if less than 10Kg or 1mL/hour of sodium chloride 0.9% if equal to or over 10Kg for 3 hours to clear the line. Each mL contains 285 mcg Milrinone lactate equivalent to 200 mcg Milrinone USP. 36 Full PDFs related to this paper. The patient required no further hospitalizations, and his functional capacity improved from NHYA Class IV to Class I. Intravenous Medication Pump. Milrinone cost per month ranges between $4500-$21,000 and dobutamine between $1140-$2790 (estimates are based on a 75 kg patient with infusions of 0.5 mcg/kg/min and 5mcg/kg/min for milrinone and dobutamine respectively) (20). Medicare will reimburse for these therapies and for associated equipment such as infusion pumps, however nursing visits are not included in these estimates. Storage Milrinone is only given by a doctor in a hospital. Dosage regimen: continuous infusion of high dose (>0.5 mcg/kg/min), low dose (<0.5 mcg/kg/min) Concomitant inotropes: milrinone used as the single agent in the treatment of cardiac dysfunction (i.e. Two of them were successfully reversed after another intraarterial infusion of milrinone. Milrinone may be commenced at ward level in the event of a rapidly deteriorating clinical situation if directed by a Consultant Cardiologist or Intensivist, once a PICU bed is booked and available. without the use of concomitant inotropes) This is a protocol. 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