drug utilization review

A total of 202 potentially eligible patients were identified. Of these, 197 received milrinone in the CCU between January 5 and June 19, 2004; an additional 5 patients who had received milrinone in the operating room but not the CCU were excluded from the study (Figure 1). Of the patients included in the study, 12 were admitted twice and 2 were admitted 3 times, for a total of 213 admissions. Most of the admissions (202 [94.8%]) were for cardiac disease, 5 (2.3%) were for sepsis, and 6 (2.8%) were for other medicosurgical diseases or conditions (Table 1). Serum creatinine values were available for 189 (88.7%) of the admissions. For 27 of these admissions, the patient had high creatinine on the first day in the CCU and 66 had elevated creatinine during therapy.

Table 1. Patient Characteristics and Outcomes for a Study of Milrinone Use in Critically Ill Children

Characteristic

No. of Admissions*

Mean ± SD or No. (%)

Weight (kg)

213

11.3 ± 14.4

Median (range)

6.4 (2.0-84.2)

Age (months)

213

28.7 ± 49.4


Median (range)

6.1 (<1 to 221.0)


Length of stay (days)


213


8.2 ± 18.7


Median (range)


3.0 (0.4-184.0)

Sex

213

Male

101 (47.4)

Female

112 (52.6)

Premature birth

213

3 (1.4)


Admission diagnosist


Cardiac

213

202 (94.8)


Nonsurgical


202


11 (5.4)


Biventricular repair


202


151 (74.8)


Single ventricle repair


202


40 (19.8)



Medicosurgical


213


11 (5.2)


Sepsis


11


5 (45)


Other


11


6 (55)


Renal function


High creatinine for aget


189


66 (34.9)


High creatinine for age on day 1§


188


27 (14.4)


Outcomes

AVO2difference > 30%


213


162 (76.1)

Lactate difference > 2 mmol/L


190


29 (15.3)


Arrhythmia


213


82 (38.5)

Platelet count < 50 x 109/L


213


27 (12.7)


Deaths


197


12 (6.1)

Dosing Practices for Milrinone Loading Doses

Milrinone therapy was started with a median loading dose of 99.2 pg/kg (range 22.1-162.2 pg/kg). Subsequent loading doses, for those who received them, were lower (median 49 pg/kg for the second to fifth loading doses) (Table 2). A total of 251 loading doses of milrinone were administered in 196 (92.0%) of the 213 admissions; just one loading dose was administered in 151 (70.9%) of the admissions. For 171 (80.3%) of the admissions, the initial loading dose was administered in the operating room. The median initial loading dose was higher if given in the operating room than if given in the CCU (median 99.7 pg/kg versus 51.0 pg/kg; p < 0.001 by Mann-Whitney-Wilcoxon test). levitra professional

Figure 1. Flow chart for sample selection

Figure 1. Flow chart for sample selection. Charts for 218 admissions (202 patients) were reviewed. Five patients did not undergo infusion of milrinone in the Critical Care Unit and were excluded. Therefore, 213 admissions (197 patients) were included in the analysis.

Table 2. Milrinone Dosing Characteristics

Dosing Parameter

n/N*
or No.

Mean ± SD or No.

(%)

Median (Range)

of Admissions

Loading dose


Cumulative loading dose (pg/kg)


196/213


95.4
± 53.5


99.3 (0-313.4)


No. of admissions with loading dose


196/213


1.2 ± 0.8


1 (0-5)

Location of administration


Operating room


175/213


0.8 ± 0.4


1 (0-2)


CCU


88/213


0.4 ± 0.8


0 (0-4)

Size of loading dose (pg/kg)t


Dose 1


187/213


88.9± 20.3


99.2 (22.1-162.2)


Dose
2


44/213


53.8 ± 21.5


49.2 (23.5-101.0)


Dose 3


10/213


51.6 ± 24.0


49.5 (19.2-97.8)



Dose
4


7/213


56.0 ± 21.4


49.3 (42.4-104.2)



Dose
5


3/213


47.5
± 4.5


49.3 (42.4-50.9)

Infusion


Start time relative to CCU admission
(h)


213


23.9 ± 141.6


0.3 (-15.6Ф to 1799)


Duration during CCU stay (h)


213


86.7 ± 118.4


43.1 (0.5-928.6)


Average dose rate (pg/kg per minute)


213


0.62 ± 0.20


0.64 (0.13-2.08)


Cumulative dose (mg/kg)


213


3.52 ± 5.63


1.47 (0.0167-40.63)


Cumulative duration of interruptions


213


12.0 ± 96.2


0 (0-1244)


Admissions with at least
1 interruption


213


16 (7.5)


No. of interruptions > 15 h


16


9 (56)


No. of interruptions < 15 h


16


7 (44)

Tapering

213


No


83 (39.0)


Yes


70 (32.9)


Unknown


60 (28.2)

Maintenance Infusion and Dose Adjustments

The median duration of milrinone infusions was 43.1 h (range 0.5-928.6 h), with the median length of stay being 3 days (range 0.4-184 days). In 159 (74.6%) of the 213  admissions, the patient completed 3 or fewer days of milrinone therapy. The median dose rate was 0.64 Fg/kg per minute. For most of the admissions (197 [92.5%]), the patients did not experience an interruption in the milrinone infusion. Dose tapering at the end of milrinone therapy was performed for 70 (32.9%) of the 213 admissions. canadian pharmacy viagra

There was no relationship between the milrinone infusion rate and serum creatinine level for children in any age group (Figure 2).

Figure 2. Average dose rate for

Figure 2. Average dose rate for milrinone as a function of maximum creatinine value, according to age-defined creatinine reference groups. The shaded area in each graph represents the normal creatinine range for the particular age group. For all age groups, average dose rate was weakly correlated with creatinine level (r2 < 0.0335), which suggests that milrinone was not dosed differently for patients with renal impairment.