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Milrinone and the treatment of clinical vasospasm : The MNH Protocol

Milrinone and the treatment of clinical vasospasm : The MNH Protocol. April 2013 Mark Angle, M.D. Kuwait City. Vasospasm. Syndromic Hemolysate Induced Systemic and Local Inflammatory Response. Vasospasm. Universal Distal Vasodysregulation Episodic Proximal Arteritis.

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Milrinone and the treatment of clinical vasospasm : The MNH Protocol

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  1. Milrinone and the treatment of clinicalvasospasm :The MNH Protocol April 2013 Mark Angle, M.D. Kuwait City Milrinone and the treatment of clinical vasospasm

  2. Vasospasm • Syndromic • HemolysateInduced • Systemic and Local Inflammatory Response Milrinone and the treatment of clinical vasospasm

  3. Vasospasm • Universal Distal Vasodysregulation • Episodic Proximal Arteritis Milrinone and the treatment of clinical vasospasm

  4. CerebralVasospasm • Symptomatic in 30-40% of sub-arachnoidhemorrhage • 20-50% stroke (delayedneurologicaldeficits) despitecurrenttherapy : • HHH • Angioplasty • MagicBullets Milrinone and the treatment of clinical vasospasm

  5. Milrinone • Phosphodiesterase III inhibitor • Inotrope, peripheralvasodilator • Dosage (cardiac) : • 50 µc/kg bolus • 0.75 µc/kg/min infusion Milrinone and the treatment of clinical vasospasm

  6. MNH Protocol • Normovolemia (CVP ~ 6 mmHg) • Normonatremia ([Na] > 140 meq/L) • Normoglycemia • Normothermia • Permissive Hypertension • Milrinone : • 150 µc/kg bolus • 0.75 µc/kg/min infusion Milrinone and the treatment of clinical vasospasm

  7. MNH Protocol • Levophed to maintainmeanblood pressure atpre-milrinonelevel • Rebolus and increase by 0.25 µc/kg/min for persistent or recurrentsymptoms • Weaningprotocol : • 0.75 µc/kg/min X 72 hours • 0.50 µc/kg/min X 48 hours • 0.25 µc/kg/min X 48 hours Milrinone and the treatment of clinical vasospasm

  8. MNH Protocol • For refractorysymptoms • Induced Hypertension • Angiography/Angioplasty/Intra-arterial Infusion Milrinone and the treatment of clinical vasospasm

  9. MNH Protocol Milrinone and the treatment of clinical vasospasm

  10. MNH Protocol Milrinone and the treatment of clinical vasospasm

  11. MNH Protocol Milrinone and the treatment of clinical vasospasm

  12. MNH Protocol Daily mean alpha power in patient trendedagainst the modulation of the dose of milrinone. Milrinone and the treatment of clinical vasospasm

  13. MNH Protocol Daily mean alpha power in patient trendedagainst the modulation of the dose of milrinone. Milrinone and the treatment of clinical vasospasm

  14. Milrinone • Possible ContributoryEffects: • IncreasedCardiac Output • Altered Blood Rheology • Anti-inflammatoryEffects • Direct CerebralVascular Dilatation Milrinone and the treatment of clinical vasospasm

  15. Milrinone and the treatment of clinical vasospasm

  16. Milrinone and the treatment of clinical vasospasm

  17. Conclusions • Cerebralvasospasmremains an important determinant of outcomeafter SAH • Standard therapyisresource intensive, physiologicallychallenging and onlypartially effective • Milrinonetherapyis simple, well-tolerated and highly effective in a “real-world” trial Milrinone and the treatment of clinical vasospasm

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