Abstract 8110: Dobutamine versus Mirlinone for Intensive Hyperdynamic Therapy to Relieve Focal Cerebral Ischemia Caused by Vasospasm after Subarachnoid Hemorrhage
Therapeutic hemodynamic augmentation by increasing cardiac output (CO) is a valuable method of elevating cerebral blood flow and oxygenation in the dysautoregulated vascular territories affected by vasospasm after subarachnoid hemorrhage (SAH). We prospectively assessed the effect of hyperdynamic therapy with dobutamine (DOB) or milrinone (MIL) on regional cerebral oxygenation (rSO2) for reversing vasospasm-induced cerebral ischemia, using an integrative monitoring incorporated with uncalibrated pulse contour CO analysis and multi-channel near-infrared spectroscopy. One-hundred ten SAH patients diagnosed to have clinical deterioration due to vasospasm were assigned to receive hemodynamic augmentation with DOB or MIL (n=55 per each group). For hyperdynamic therapy, each inotrope was initiated at low dose (DOB: 3 μg/kg/min; MIL 0.15 μg/kg/min) and then increased in each dose increment until resolution of the symptoms unless any adverse effects occur during the therapy, based on our predefined hemodynamic regimen to induce similar dose-related increase in CO. Real-time CO and rSO2 changes in conjunction with the assessment of neurological improvements were compared. A total of 418 dose increment challenges (DOB, n=192; MIL, n=226) were performed. In spasm-affected territories, decreased and/or fluctuating rSO2 was detected compared with recordings in other brain region. Patients who exhibited rapid elevation of CO by each challenge had subsequent uptake and stabilization of rSO2. The responses (total number and degree of neurological improvements) were more significant in patients treated with DOB than those treated with MIL (P <0.05), although tachycardia that may affect stroke volume depression during the DOB therapy was more evident (DOB 27% vs. MIL 9%). Area under the ROC curve to predict rSO2 elevation or neurological improvement for both drug groups were significant (P <0.0001) and the values were significantly greater in DOB than in MIL (P <0.05). In conclusion, DOB can provide more effective hemodynamic augmentation in relieving focal cerebral ischemia in patients suffering from vasospasm after SAH. MIL is also effective in the hyperdynamic therapy but may be used as a second line in a patient subgroup where DOB was contraindicated.
- © 2011 by American Heart Association, Inc.