Scenario

You work in a paediatric cardiac intensive care unit (ICU), the unit protocol is to start prophylactic milrinone intraoperatively to prevent low cardiac output syndrome (LCOS). You receive a patient for whom levosimendan was started intraoperatively instead of milrinone, and you wonder whether levosimendan is superior to milrinone.

Structured clinical question

In postoperative congenital heart disease children (population), is levosimendan (intervention) better than milrinone (comparison) in improving cardiac function and prevention of LCOS (outcome), shown by heart rate, cardiac output/stroke volume, lactate clearance, inotrope requirement, markers of cardiac damage (troponin) and myocardial oxygen consumption (pressure rate index)

Search strategy

A literature search was performed using The Cochrane Library, Pubmed and Medline using key words ‘levosimendan and milrinone’ ‘pediatric cardiac surgery’, which yielded 10 studies and further web search was done, which yielded 18 more relevant studies. After analysing the abstracts, there were nine studies comparing levosimendan and milrinone. The full articles were analysed and four studies were undertaken in paediatric population, which are reviewed (See table 1).

Commentary

LCOS is a common complication in open heart surgery postcardiopulmonary bypass. Cardiopulmonary bypass causes myocardial injury, which may lead to LCOS. This is recognised by a constellation of signs such as elevated lactate, decreased mixed venous saturation, decreased urine output, increased heart rate and low blood pressure. In neonates and infants, cardiac output cannot be measured directly by invasive techniques, so surrogate markers of cardiac output are assessed.

LCOS is managed with various combination of catecholamine, vasodilators and vasopressors. An ideal agent to manage LCOS should improve cardiac output …