Milrinone Versus Dobutamine in Critically Ill Patients

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

PHASE4

Total Enrollment

192 participants

Study Classification

INTERVENTIONAL

Study Start Date

2017-08-30

Study Completion Date

2020-06-12

Brief Summary

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The investigators are interested in determining if there is a meaningful difference between two of the most commonly used medications used to improve the pumping function of the heart among critically ill patients admitted to the Coronary Care Unit (CCU) at the University of Ottawa Heart Institute (UOHI). To do this, the investigators will randomly assign patients who are felt to require use of these medications by their treating physicians to one of the two most commonly used agents in Canada: Milrinone or Dobutamine. Each patient will be closely monitored by their healthcare team, and their medication will be adjusted based on each patient's clinical status. Information from blood work (e.g. kidney and liver function, complete blood counts, and other markers of how effectively blood is circulating in the body), assessment of end-organ function (e.g. urine output, mentation), abnormal heart rhythms noted on monitoring and results of imaging studies (e.g. angiogram, echocardiograms.) will be collected for analysis. All patients will be followed for the duration of their hospital stay at UOHI.

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Detailed Description

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The use of various inotropes in the care of critically ill cardiac patients has become increasingly widespread: while predominantly used in decompensated heart failure, they have also been used in cardiogenic shock complicating acute coronary syndrome (ACS) and septic shock. Purported mechanisms of efficacy include improved cardiac output, improved end-organ perfusion, and vasodilation of both pulmonary and systemic circulations. Two of the most commonly used agents are Milrinone, a phosphodiesterase 3 inhibitor, and Dobutamine, a synthetic catecholamine with affinity for both beta-1 and 2 receptors. Both the American College of Cardiology (ACC) and the European Society of Cardiology (ESC) support inotropes for acute and chronic heart failure management with low cardiac output states. Furthermore, the ACC recommends consideration of inotropic therapy within the STEMI guidelines when ACS is complicated by cardiogenic shock, heart failure or for hemodynamic support in isolated right ventricle infarctions. Beyond primarily cardiac etiologies, inotropes have been identified as first-line additive therapy for cardiac augmentation to Norepinephrine in patients with septic shock complicated by myocardial dysfunction. Despite the lack of convincing data supporting a morbidity or mortality benefit with the use of inotropes in severe, decompensated heart failure, cardiogenic or septic shock, or in ACS, inotropic therapy is still widely used across various critical care settings. Furthermore, to date, there has been no head to head comparison of the two more commonly used positive inotropes: Dobutamine and Milrinone. Selection of one inotrope over another is often guided by physician and center preference, and consideration of and purported avoidance of possible adverse effects. In this pilot study, the investigators aim to describe that characteristics of patients receiving inotropic support in the CCU setting and identify possible differences in morbidity and mortality between Dobutamine and Milrinone among a heterogeneous population of patients admitted to the CCU at UOHI, which may help to inform a larger clinical trial in the future.

The purpose of this pilot study is to: (a) describe the characteristics of patients receiving inotropic support in the coronary care unit (CCU) setting (hemodynamics prior to inotrope initiation, etiology of cardiogenic shock state, use of PA catheter and values if deemed necessary by medical team) and (b) identify possible differences in morbidity \[atrial and ventricular arrhythmias, hepatic and renal function, markers of end-organ perfusion (lactate, urine output, mentation status), use of vasopressors, sustained hypotension of systolic blood pressure less than or equal to 90 mmHg for greater than 30 minutes, need for mechanical support, cardiac transplant, total length of CCU stay, length of CCU stay greater than 14 days\] and mortality between patients in cardiogenic shock treated with Dobutamine versus Milrinone.

Conditions

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Low Cardiac Output Syndrome Cardiogenic Shock Acute Coronary Syndrome Pulmonary Edema

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Consecutive patients admitted to the Coronary Care Unit (CCU) at the Ottawa Heart Institute from start of study (tentatively set for August 2017 with anticipated end date of June 2020) and identified by the treating medical team as requiring initiation of inotrope therapy will be screened and randomized based on the healthcare team's clinical assessment of predominantly LV or RV systolic dysfunction (biventricular dysfunction will be assigned to predominantly LV dysfunction). All decisions to initiate inotrope therapy will be made by the primary care team with no involvement from the research team.

Primary Study Purpose

TREATMENT

Blinding Strategy

QUADRUPLE

Participants Caregivers Investigators Outcome Assessors

The study participants, treating medical team and research team will be blinded to randomization; the pharmacy staff, CCU nurses and allied healthcare team members will not be blinded to the randomization.

Study Groups

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Left ventricular [LV] +/- Biventricular dysfunction

Assessment of left ventricular \[LV\] or biventricular dysfunction will be based on clinical assessment, available imaging (echocardiogram, left ventriculogram, MUGA/RNA scan, cardiac MRI, etc.) and known past medical history (if available and contributory). Patients identified as having biventricular dysfunction will be randomized within the LV dysfunction arm of the trial. Patients in this arm will be randomized in a 1:1 fashion to Milrinone or Dobutamine.

Group Type ACTIVE_COMPARATOR

Milrinone

Intervention Type DRUG

Patients will be initiated on Milrinone at 0.125 mcg/kg/min \[stage 1\] and will be titrated according to a blinded protocol from stages 2 to 5 \[0.250, 0.375, 0.5 and \>0.5 ug/kg/min\]. All orders to initiate and titrate the dose of the allocated inotrope will be written in the chart as follows: 'Study inotrope dose to be \[increased/decreased/maintained\] at stage \[1-5\]' so as to ensure that treating physicians remain blinded to the allocated drug.

Dobutamine

Intervention Type DRUG

Patients will be initiated on Dobutamine at 2.5 mcg/kg/min \[stage 1\] and will be titrated according to a blinded protocol from stages 2 to 5 \[5.0, 7.5, 10 and \>10 ug/kg/min\]. All orders to initiate and titrate the dose of the allocated inotrope will be written in the chart as follows: 'Study inotrope dose to be \[increased/decreased/maintained\] at stage \[1-5\]' so as to ensure that treating physicians remain blinded to the allocated drug.

Right ventricular [RV] dysfunction

Assessment of right ventricular \[RV\] dysfunction will be based on clinical assessment, available imaging (echocardiogram, left ventriculogram, MUGA/RNA scan, cardiac MRI, etc.) and known past medical history (if available and contributory). Patients in this arm will be randomized in a 1:1 fashion to Milrinone or Dobutamine.

Group Type ACTIVE_COMPARATOR

Milrinone

Intervention Type DRUG

Patients will be initiated on Milrinone at 0.125 mcg/kg/min \[stage 1\] and will be titrated according to a blinded protocol from stages 2 to 5 \[0.250, 0.375, 0.5 and \>0.5 ug/kg/min\]. All orders to initiate and titrate the dose of the allocated inotrope will be written in the chart as follows: 'Study inotrope dose to be \[increased/decreased/maintained\] at stage \[1-5\]' so as to ensure that treating physicians remain blinded to the allocated drug.

Dobutamine

Intervention Type DRUG

Patients will be initiated on Dobutamine at 2.5 mcg/kg/min \[stage 1\] and will be titrated according to a blinded protocol from stages 2 to 5 \[5.0, 7.5, 10 and \>10 ug/kg/min\]. All orders to initiate and titrate the dose of the allocated inotrope will be written in the chart as follows: 'Study inotrope dose to be \[increased/decreased/maintained\] at stage \[1-5\]' so as to ensure that treating physicians remain blinded to the allocated drug.

Interventions

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Milrinone

Patients will be initiated on Milrinone at 0.125 mcg/kg/min \[stage 1\] and will be titrated according to a blinded protocol from stages 2 to 5 \[0.250, 0.375, 0.5 and \>0.5 ug/kg/min\]. All orders to initiate and titrate the dose of the allocated inotrope will be written in the chart as follows: 'Study inotrope dose to be \[increased/decreased/maintained\] at stage \[1-5\]' so as to ensure that treating physicians remain blinded to the allocated drug.

Intervention Type DRUG

Dobutamine

Patients will be initiated on Dobutamine at 2.5 mcg/kg/min \[stage 1\] and will be titrated according to a blinded protocol from stages 2 to 5 \[5.0, 7.5, 10 and \>10 ug/kg/min\]. All orders to initiate and titrate the dose of the allocated inotrope will be written in the chart as follows: 'Study inotrope dose to be \[increased/decreased/maintained\] at stage \[1-5\]' so as to ensure that treating physicians remain blinded to the allocated drug.

Intervention Type DRUG

Other Intervention Names

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Mil Phosphodiesterase-3 inhibitors [PDE3] Inhibitor Dob Beta 1/2 Agonist

Eligibility Criteria

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Inclusion Criteria

* Have one or more of the following:
* Low cardiac output state, evidenced by sustained hypotension (systolic blood pressure \<90 mmHg) and end organ dysfunction (altered level of consciousness, elevated lactate, renal or hepatic dysfunction)
* Clinical evidence of systemic and/or pulmonary congestion despite use of vasodilators and/or diuretics
* ACS complicated by cardiogenic shock (defined as persistent hypotension with systolic blood pressure \<90 mmHg with severe reduction in cardiac index \[\<1.8 L/min/m2 without support or \<2.2 L/min/m2 with support\], left ventricular end-diastolic pressure \>18 mmHg)
* Augmentation of cardiac output when patient already on maximal vasopressor therapy
* Or medical team's decision that patient needs inotropic therapy

Exclusion Criteria

* Unwillingness or inability to provide informed consent by the patient or substitute decision maker for healthcare decisions
* Female participants who are currently pregnant
* Patients presenting with an out-of-hospital cardiac arrest (OOHCA)
* Healthcare team preference for use of specific inotrope (Milrinone or Dobutamine)

Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No