Abstract
BackgroundThe detrimental effects of inotropes are well-known, and in many fields they are only used within a goal-directed therapy approach. Nevertheless, standard management in many centers includes administering inotropes to all patients undergoing cardiac surgery to prevent low cardiac output syndrome and its implications. Randomized evidence in favor of a patient-tailored, inotrope-sparing approach is still lacking. We designed a randomized controlled noninferiority trial in patients undergoing cardiac surgery with normal ejection fraction to assess whether an dobutamine-sparing strategy (in which the use of dobutamine was guided by hemodynamic evidence of low cardiac output associated with signs of inadequate tissue perfusion) was noninferior to an inotrope-to-all strategy (in which all patients received dobutamine).ResultsA total of 160 patients were randomized to the dobutamine-sparing strategy (80 patients) or to the dobutamine-to-all approach (80 patients). The primary composite endpoint of 30-day mortality or occurrence of major cardiovascular complications (arrhythmias, acute myocardial infarction, low cardiac output syndrome and stroke or transient ischemic attack) occurred in 25/80 (31%) patients of the dobutamine-sparing group (p = 0.74) and 27/80 (34%) of the dobutamine-to-all group. There were no significant differences between groups regarding the incidence of acute kidney injury, prolonged mechanical ventilation, intensive care unit or hospital length of stay.DiscussionAlthough it is common practice in many centers to administer inotropes to all patients undergoing cardiac surgery, a dobutamine-sparing strategy did not result in an increase of mortality or occurrence of major cardiovascular events when compared to a dobutamine-to-all strategy. Further research is needed to assess if reducing the administration of inotropes can improve outcomes in cardiac surgery.Trial registration ClinicalTrials.gov, NCT02361801. Registered Feb 2nd, 2015. https://clinicaltrials.gov/ct2/show/NCT02361801
Highlights
The detrimental effects of inotropes are well-known, and in many fields they are only used within a goal-directed therapy approach
While the detrimental effects of inotropic therapies are well-known, and a goal-directed therapy was effective in reducing complications after major noncardiac surgery [8, 9], randomized evidence supporting the use of goal-directed therapy in cardiac surgery is still lacking
Study population One-hundred sixty patients were enrolled in the study: 80 patients were allocated to the dobutamine-sparing strategy, while 80 patients received the dobutamine-to-all approach (Fig. 1)
Summary
The detrimental effects of inotropes are well-known, and in many fields they are only used within a goal-directed therapy approach. Standard management in many centers includes administering inotropes to all patients undergoing cardiac surgery to prevent low cardiac output syndrome and its implications. We designed a randomized controlled noninferiority trial in patients undergoing cardiac surgery with normal ejection fraction to assess whether an dobutamine-sparing strategy (in which the use of dobutamine was guided by hemodynamic evidence of low cardiac output associated with signs of inadequate tissue perfusion) was noninferior to an inotrope-to-all strategy (in which all patients received dobutamine). In an effort to avoid low cardiac output syndrome and its implications, standard management in many centers includes administering inotropes to all patients undergoing cardiac surgery [3,4,5]. Even if the evidence suggesting that inotropes in cardiac surgery may be harmful only comes from low-quality observational studies, experts suggest to restrict their use only to those patients who have precardiotomy heart failure or have difficult separation from cardiopulmonary bypass (CPB) or postcardiotomy cardiogenic shock [13, 14]
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