Primacor drip

[Genista]

Had a new order for Primacor IV drip today (milrinone). This is the first time I have ever heard of the drug, or given it to a pt. Cardiologist wrote order for med, but no parameters for monitoring (pt already on tele floor w/ routine tele orders). Primary MD was on floor shortly thereafter, and we asked for parameters to monitor. I think he was going to write for Q2H vs. I am curious what is standard monitoring, if you have given this drug? This was not titrated, but just a maintenance infusion rate. I've read my drug books, so I know we are watching pt's electrolytes, creat clearance, vs and tele. Just wondering what your protocol is. Thanks for your input.

[joeyzstj, LPN]

The way milrinone/primacor behaves in the settings of recent post open heart, cardiogenic shocky pt, or even a milrinone-naive pt, should not be applied to that of a chronic pt set to go home on a maint gtt. I feel much of the 'bad stuff' is biased towards the acute stages in it's use.

I agree. The majority of the patients I deal with are not chronic and therefore the response to primacor is often unexpected.

[BBFRN, BSN, PhD]

From what I hear, patients can go home on Primacor only after they have been on it in the hospital, and only after it has been verified that the patient can tolerate it. Still scary, though.

[ghillbert, MSN, NP]

I agree. The majority of the patients I deal with are not chronic and therefore the response to primacor is often unexpected.

I don't understand your point at all, joeyzstj. The recent poster was asking about protocols for management of patients on maintenance milrinone at home.

First, you said milrinone should only be used in patients with an arterial line and vasopressors.... then I said it's perfectly safe to use at home and WilECoyote agreed that it behaves differently in chronic patients... then you agreed with that poster.

So are you saying milrinone should or should not be used in at-home CHF patients?

[Summitk2]

I think most nurses would agree that a drug such as milrinone should be started in a hospital setting with continuous ECG monitoring and ideally invasive hemodynamic monitoring (Swan cath w/ CO/CI; note that an art line tells you nothing about CO or SV). I'm surprised that no one has mentioned monitoring for THERAPEUTIC effects of the drug, but only ADVERSE effects.

I think the discussion of continuing milrinone use outside the hospital setting belongs in a home health forum, not the CCU forum.

Anyone want to discuss use of milrinone in the ICU? I've found anesthesia likes using it in our open hearts, but I haven't asked why. I tend to add dobutamine and wean milrinone when I get these pts. Does anyone like using milrinone (w/ more pressors) rather than dobutamine in low CO pts? I've heard PDEIs can benefit pts who've been over-beta1-stimulated, but I haven't used it in that context yet.

[Virgo_RN, BSN, RN]

How often is Primacor used for longer than 48 hours?

[jamonit]

All the time. A large majority of our 1B patients go home on this drug. I work in a research-education hospital and it seems like everyone here is on milrinone. To tell you the truth, we never titrate. The cardiologists pretty much have it at a set rate. This is on a Progressive Care/Tele unit. Not the CCU. We also have ultrafiltration, Swans, PA caths and fresh transplants here.

[nursecass]

In our CCU I've seen primacor used both ways-acutely for open heart surgeries and more chronically for patients that may be waiting to get on a transplant list and will probably go home on it. So based on that, I have to agree with a lot that was said above.

If you are using it short term (i.e. open heart surgeries), and are titrating it down, then absolutely it should be used in an ICU setting where frequent vitals are carefully monitored (preferably through SWAN/A-Line set up are in place), and cardiac rhythms are monitored continuously (preferably at the bedside for RN reassurance/comfort). As for the surgeon's preference, I think it comes down to what they were taught, because I've asked a few about why they choose Primacor over Dobutamine, and it is always a generic response of "Well, I think it works better" without any actual data to back it up.

However, on the more chronic side of things, we have also transferred patients out to our Tele floor on a primacor gtt. These are patients however that have been on the unit for a while, have established their dosage, and their gtt will not be titrated (and more than likely they will go home with it). In those cases the patients have been stable on the gtt and dosage for several days without adverse reactions or need for pressors. But that is just my experience with Primacor in our hospital.

I agree with the previous poster about this being a great opportunity for you to establish a protocol for Primacor on your unit-sounds like it's needed! GL!

[elvis pringles]

I had a patient on a primacore drip in cardiogenic shock on a IABP.

After 48 hours the IABP was removed. Cardiac index remained good how soon should the primacore be titrated off. Patient was a little hypotensive.

[ghillbert, MSN, NP]

What was the etiology of the cardiac shock? If it was an acute cause, it may be okay to start weaning early. If it's a chronic problem, you'll probably need to take some more time.

The milrinone should be titrated down according to the hemodynamics.

[elvis pringles]

The patient was an acute MI. Should titration occur sooner rather than later if slight hypotension is the only hemodyanmic instability.

[ghillbert, MSN, NP]

If it was an acute problem that has been resolved, and the only hemodynamic issue is hypotension, I'd probably vote to wean it... but. Depends what the PA pressures are, what the cause of hypotension is (if undervolumed, this needs to be corrected first; if there's RV compromise leading to reduced LV stroke volume, I'd leave the inotrope on for a while).

[Nightcrawler, BSN, RN]

We routinely start Milrinone on our stepdown unit, monitoring closely for lytes, creat, pressure and for ventricular arrhythmias. From my experience, the patient needs to be closely monitored for adverse effects for the first 24-48 hours. Much depends upon the patients individual response. People do go home on Milrinone all of the time, but only after they have been closely monitored and their dosage has been optimized. The one person that I know of that is on a home infusion also comes in for ultrafiltration three times a week, so we are able to closely monitor her lytes.

As for the Milrinone vs Dobutamine question, if the patient needs pressor support, then I would prefer the Dobutamine. For the patient with a stable pressure that just needs an extra squeeze to help with renal perfusion for decreased output, I think that Milrinone is actually the safer drug, which patients can often tolerate with fewer complications and fewer ups and downs with their pressure.