CASE REPORT 485

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tolerance of propofol. Postgrad Med 1 1985; 60. metabolism - an overview. Postgrad Med 1 1985:
suppl. 3: 152-156. 61, suppl 3:45-50.
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biopotency and site of action of drugs affecting Douglas El. Disposition of propofol in patients
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Anesthesiology 1981: 54:73-75.

The Combined Use of Noradrenaline, Amrinone

and Nitroglycerin in the Management of Severe
Low Cardiac Output After Coronary Artery Surgery
M. NAKATSUKA* AND K. MOBLEY**
Department of Anesthesiology, Medical College of Virginia, Virginia Commonwealth
University, Richmond, Virginia, U.SA.

Key Words: SURGERY: cardiac, Coronary artery, Amrinone, low cardiac output

In spite of improvements in surgical prognosis. I The combined use of inotropic

technique and myocardial preservation, low agents and vasodilators has proved useful in
cardiac output occasionally presents a patients with severe left ventricular
problem following cardiopulmonary bypass dysfunction. Use of vasodilator therapy,
(CPB) for coronary artery surgery. Low however, may be limited by the occurrence of
cardiac output in combination with ischaemic hypotension and patients with ischaemic
heart disease is associated with a poor heart disease may be sensitive to the
*M.D .. Department of Anesthesiology, chronotropic and dysrhythmogenic effects of
**M.B.. B.S .. F.F.A.R.C.S. catecholamines. We report the successful
Address for Reprints: Mitsuru Nakalsuka. M.D.. Department of
Anesthesiology. MCV Station - Box 695. Richmond. Virginia 23298-0695.
management of such a case with the combined
U.S.A. use of noradrenaline, amrinone and
Accepted for publication July 18. 1988 nitroglycerin.

Anaesthesia and Intensive Care. Vol. 16. 1"/0. 4. N01'ember. 1988

486 M. NAKATSUKA AND K. MOBLEY
CASE REPORT Multiple attempts were made to wean from
An obese 56-year-old man, weighing 98 kg, CBP with the combination of dopamine,
with a five-year history of chest pain, was dobutamine and nitroglycerin without
admitted to the coronary intensive care unit success. A systolic blood pressure of 90-100
with crescendo angina. Past medical history mmHg was eventually maintained with a
included asthma, chronic obstructive airway noradrenaline infusion up to 0.04 Ilg/kg/min,
disease, hypertension, and smoking. The followed by a bolus dose of infusion of
patient's medications included diltiazem, amrinone (7 Ilg/kg/min), resulting in an
metoprolol, theophylline, isosorbide improvement of ventricular contractility. The
dinitrate, sublingual nitroglycerin and daily patient was weaned off CPB with
use of an albuterol inhaler. The ECG showed noradrenaline 0.02-0.04 Ilg/kg/min, amrinone
normal sinus rhythm with occasional 7 Ilg/kg/min and nitroglycerin 0.5 Ilg/kg/min.
ventricular ectopic beats and ST depression in Arterial pressure was in the range of 100-120/
leads Ill, AVF and V6. Coronary angiography 70-80 mmHg, cardiac output 4-5 lImin, and
demonstrated 70% occlusion of the left main heart rate 90-100 beats/min with normal sinus
coronary artery, 85% occlusion of the left rhythm. Systemic vascular resistance was in
anterior descending artery, 70% occlusion of the range of 1200 to 1550 dyn.sec.cm- 5 .
the marginal branch, and 100% occlusion of In the surgical intensive care unit, the
the right coronary artery. Left ventricular cardiac output had improved and arterial
ejection fraction was 63%. The patient was pressure and heart rate were essentially
scheduled for triple aortocoronary artery unchanged. On the first postoperative day, the
bypass surgery. patient was weaned from the noradrenaline
Anaesthesia was induced uneventfully with and the amrinone was reduced to 3 Ilg/kg/min.
sufentanil 5 Ilg/kg, vecuronium 0.2 mg/kg and On the third postoperative day, amrinone was
100% oxygen. Sufentanil infusion and discontinued. Equilibrium multiple-gated
intermittent isoflurane were used for blood pool scintigraphy showed a left
maintenance. Following administration of ventricular ejection fraction of 47% with a
heparin, CPB was instituted and cold, slightly enlarged left ventricle. BUN and
hyperkalaemic cardioplegia was used to arrest creatinine were checked daily until discharge
the heart. Perfusion pressure was maintained and stayed in the range of 5-6.1 mmolll and
between 50 and 70 mmHg and urine output 100-120 Ilmolll respectively. He was
during bypass was 50-100 mllhour. Total discharged on the 15th postoperative day.
aortic cross-clamp time was 76 minutes. The DISCUSSION
right coronary artery was not bypassed Although rare, low cardiac output
because of significant calcification in the syndrome continues to be a serious challenge
distal coronary artery. following coronary artery surgery. I Inotropic
During weaning from CPB, the heart was drugs such as dopamine and dobutamine
markedly hypoactive, even with alone or with vasodilators have been used
atrioventricular sequential pacing. successfully in this condition. 2 Dopamine has
Dobutamine (10 Ilg/kg/min) in conjunction its positive inotropic effect by cardiac beta-
with a low-dose nitroglycerin infusion up to 1 receptor stimulation. Although useful in
Ilg/kg/min was initiated without success. patients with ischaemic heart disease and
When adrenaline (3 Ilg/min) was substituted ventricular dysfunction, dopamine may cause
for the dobutamine, myocardial contractility excessive tachycardia, dysrhythmias and an
improved, but this was followed by a increase in myocardial oxygen demand. 3
supraventricular tachycardia (SVT) of 160 Dobutamine has a potent positive inotropic
beats/min and a systolic blood pressure of 50 action with little effect on vascular tone and
mmHg. The adrenaline was discontinued. An with less of a chronotropic effect than
esmolol infusion successfully converted the naturally occurring sympathomimetic
SVT to normal sinus rhythm (90-100 beats/ amines. Dobutamine is a racemic mixture ofL
min); however, the heart was noted to be and D isomers. The L-isomer is a potent
dilated and the esmolol was discontinued. alpha-adrenergic agonist and a relatively weak
Anaesthesia and Intensire Care. r'o!. 16. /\'0. 4, .No\'ember. 1988
 CASE REPORT 487

beta-adrenergic agonist,3 whereas the coronary perfusion without increasing heart

D-isomer is a potent beta-l and beta-2 rate. 4 The amrinone was used to increase
agonist. 3 Noradrenaline has significant beta-l ventricular function without increasing heart
receptor activity in the myocardium. 3Alpha-l rate, not to augment the inotropic effect of
adrenergic receptors are also abundant in the noradrenaline but to counteract the excessive
myocardium and cause increased contractility vasoconstrictive effect of noradrenaline. 7
when stimulated. 3 In contrast to beta-l Noradrenaline in combination with
stimulation, this alpha-l receptor stimulation nitroglycerin may further increase coronary
does not increase sinoatrial automaticity and blood flow, especially subendocardial
is characterised by a slow heart rate coronary blood flow. s In summary,
independent of beta-l receptor effect. 3 Also combined use of noradrenaline, amrinone and
alpha-l receptor mediated vasoconstriction nitroglycerin may significantly improve
can improve coronary perfusion by increasing severe low cardiac output states following
or maintaining diastolic blood pressure. There CBP by increasing coronary blood flow,
may be less tachycardia with the use of augmenting contractility, and improving left
noradrenaline than with other inotropic and right ventricular function when used
agents due to its alpha-adrenergic activity in judicially. We also demonstrate that normal
the heart and also reflex baroreceptor renal function can be maintained with a
stimulation. 3 Excessive alpha-receptor noradrenaline, amrinone and nitroglycerin
mediated vasoconstriction may, however, combination by optimising preload and
increase afterload significantly to worsen the providing adequate cardiac output.
failing heart. Tolerance to the effect of
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Anaesthesia and Intensil'e Care. Vol. 16. No. 4. NOI·ember. 1988