**Dobutamine**

Amine as the structure similar to dopamine is primarily a beta-adrenergic agonist relatively selective beta-1. Is much more effective and positive inotropic and positive chronotropic capacity less arrhythmogenic than dopamine, has no affinity to dopamine receptors and therefore lacks the renal effect. A standard dose (2-15μg/kg/min) positive inotropic responses observed with a slight increase in heart rate and decreased peripheral resistance. 107,108

In the perioperative setting is used primarily as inotropic, often combined with vasopressor either to maintain adequate cardiac output and blood pressure and to achieve a combined effect of cardiac output and perfusion. On the other hand as shown by Susana Lobo et. al; randomizing 50 patients over 65 high-risk cardiac surgery, receiving IV fluids liquid + vs Dobutamine, the largest number of perioperative complications observed was present in those who do not use vs those who had dobutamine infusion: 52 % vs 16%, and mortality at 60 days was 28% vs 8% in the dobutamine group. 109,110,111,112,113,114

The drug's half life is 3-5 min, one of several effects is the progressive decrease in blood pressure and pulmonary wedge has an advantage over the effect of dopamine beta for a smaller effect observed tachycardic and arrhythmogenic action and dilation in the pulmonary circulation has been confirmed in the peripheral circulation. As observed Romson et al; administered dobutamine in varying doses and patients undergoing cardiopulmonary bypass the heart rate changes depending on the dose and this is lower in individuals over 65 years, there were minimal changes in blood pressure, instead a decrease in pulmonary capillary wedge pressure and central venous pressure increased systemic vascular resistance remained in a mild and constant left ventricular performance also increase due to increased heart rate 115,116

### **Phosphodiesterase inhibitors**

They are a family of enzymes involved in cellular physiology by regulating the concentration of intracellular second messengers are known at present eight of these isoforms of phosphodiesterases, which interests us is the number III. Cyclic AMP, produced from the stimulation of beta-adrenergic receptors may have two destinations: the culminating with an increase in cardiac contractility, and the other consisting of the degradation of cAMP to 5-AMP, produced by phosphodiesterase III . Inhibition of this enzyme protects cAMP, promoting their destination to the increase in contractility. It now has a group of inotropic drugs whose mechanism of action is precisely in the inhibition of phosphodiesterase-III. Of this group stand amrinone and milrinone for the extensive clinical experience has accumulated with its use. These substances belong to the bipyridines, this is a positive inotropic effect supplemented by a peripheral vasodilator, which contributes to a better ability to emptying of the heart. The hemodynamic effects of milrinone, administered as a loading dose of 50 micrograms / kg followed by continuous infusion of 0.35 to 0.75 micrograms / kg / min is significant reductions in diastolic pressure in the aorta, the mean aortic pressure and systemic vascular resistance by about 11% ejection fraction of left ventricle is increased by about 14%, these effects are closely related to plasma concentrations. 117,118,119,120

In the postoperative period especially in patients receiving milrinone pump has several effects on pulmonary circulation and inotropism as evidenced Mitsunori et al, which randomized 30 patients undergoing cardiac surgery treated with milrinone was reported, reduced the mean pressure of right atrial pressure in the pulmonary artery wedge, mean pulmonary pressure and systemic vascular resistance without making a significant change in mean arterial pressure or heart rate.

On the other hand the use of Milrinone has been shown to be beneficial in patients undergoing CSRC bomb and right ventricular dysfunction prior. Jong H. et al analyzed the effect of infusion of milrinone in patients undergoing CSRC and right ventricular dysfunction (VD) found no increase in cardiac index, heart rate, and decreased systemic vascular resistance. Changes in right ventricular ejection fraction were not significant, whereas in cardiac output and RV afterload if they were, finally improves graft flow in the breast and in the middle cerebral artery during surgery of the CSRC.

### **Dopamine**

28 Special Topics in Cardiac Surgery

The use of off-pump surgery was associated with less inflammatory response, with lower incidence of postoperative SV. However, the picture is commonly seen and may present a favorable course. Vasoplegic syndrome is associated with a poor prognosis, when it is resistant norepinerina poorer prognosis with increased morbidity and mortality. The reported mortality after cardiac surgery is 24% in series reported by Levin and colleagues, and 25% in series reported by Gómez et al, in which case the syndrome persisted for up to

The support with vasopressor, vasodilator and inotropic therapeutic behavior is common in the first 24 hours secondary to hemodynamic effects induced hypothermia, myocardial stunning, extracorporeal circulation, hypovolemia, sedation, and so on. Despite the frequency of use of catecholamines are well known adverse effects such as increased

Amine as the structure similar to dopamine is primarily a beta-adrenergic agonist relatively selective beta-1. Is much more effective and positive inotropic and positive chronotropic capacity less arrhythmogenic than dopamine, has no affinity to dopamine receptors and therefore lacks the renal effect. A standard dose (2-15μg/kg/min) positive inotropic responses observed with a slight increase in heart rate and decreased peripheral resistance.

In the perioperative setting is used primarily as inotropic, often combined with vasopressor either to maintain adequate cardiac output and blood pressure and to achieve a combined effect of cardiac output and perfusion. On the other hand as shown by Susana Lobo et. al; randomizing 50 patients over 65 high-risk cardiac surgery, receiving IV fluids liquid + vs Dobutamine, the largest number of perioperative complications observed was present in those who do not use vs those who had dobutamine infusion: 52 % vs 16%, and mortality at

The drug's half life is 3-5 min, one of several effects is the progressive decrease in blood pressure and pulmonary wedge has an advantage over the effect of dopamine beta for a smaller effect observed tachycardic and arrhythmogenic action and dilation in the pulmonary circulation has been confirmed in the peripheral circulation. As observed Romson et al; administered dobutamine in varying doses and patients undergoing cardiopulmonary bypass the heart rate changes depending on the dose and this is lower in individuals over 65 years, there were minimal changes in blood pressure, instead a decrease in pulmonary capillary wedge pressure and central venous pressure increased systemic vascular resistance remained in a mild and constant left ventricular performance also

They are a family of enzymes involved in cellular physiology by regulating the concentration of intracellular second messengers are known at present eight of these isoforms of phosphodiesterases, which interests us is the number III. Cyclic AMP, produced from the stimulation of beta-adrenergic receptors may have two destinations: the culminating with an increase in cardiac contractility, and the other consisting of the degradation of cAMP to 5-AMP, produced by phosphodiesterase III . Inhibition of this

myocardial consumption, arrhythmogenic, favor delirium, and so on. 104,105,106

60 days was 28% vs 8% in the dobutamine group. 109,110,111,112,113,114

increase due to increased heart rate 115,116

**Phosphodiesterase inhibitors** 

48hr vasoplegic. 99,100,101,102,103

**7. Drug therapy** 

**Dobutamine** 

107,108

Dopamine (D) precursor of norepinephrine in the biological synthesis, there are specific receptors for this substance, especially in the renal circulation, where it produces a vasodilatory effect which favors renal tubular function (Hiberman et.al 1984). At the heart there are dopamine receptors, but its function on contractility is weak and little known, this effect is not accompanied by an increase in resistance as pronounced as with peripheral epinephrine and norepinephrine under in vessels predominantly to dopamine receptor stimulation.

The mechanism of action is dose dependent at relatively low doses (1-5μg/kg/min) stimulates dopamine receptors predominantly with subsequent renal and mesenteric vasodilation (Szerlip, et. Al 1991). A moderate dose of 5-10 mg / kg / min stimulates beta adrenergic receptors leading to positive inotropic effects and high-dose alpha-adrenergic stimulation 10-15μg/kg/min carries peripheral vasoconstriction.

By perioperative is used for its effects on the renal circulation as well as its positive inotropic effect can be used in improving the ICC states inotropism significantly, the clinical effect is seen immediately as the drug's half life is 3 -4 min. Among its side effects can cause or exacerbate tachyarrhythmias, because its effect is mediated by increased levels of norepinephrine. At present medical evidence did not show benefit of using low doses of dopamine effect of splanchnic vasodilatation and renal function, however, this drug increases oxygen consumption at promoting tubular tubular ischemia, in addition there is poor correlation between blood levels with dose infused.

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 31

Their metabolism is primarily via hepatic glutathione by organic nitrate reductase. Its effect is dissipated in 30-60 min intravenous Its effect is achieved after 90 seconds and is dose dependent. The usual dose of 0.5-3 mg is / kg / min infusion or 5-200 g / min and 0.5 mg




One of the most commonly used vasodilators in the perioperative period, penetrating the endothelium acts to form nitric oxide, this results in the production of guanine monophosphate to guanine triphosphate. Thus cyclic GMP is the second messenger that triggers calcium binding. Its effect occurs seconds after the start of infusion. The commonly

At low doses predominantly dilated arteries and arterioles, and how the dose increases also becomes a venodilators. As with nitroglycerin may occur reflexively tachycardia. And increased venous capacitance and thereby reducing cardiac output. On the other hand it is important to consider that as an important arteriodilatador can produce the phenomenon of coronary steal, mostly because it does not vasodilation in arteries affected by atherosclerosis,

Among other effects has the ability to produce dilation of the pulmonary vascular bed arriving to produce hypoxia. Another effect is less desirable thiocyanate intoxication, which

Its administration should be in glucose solution covering both the drug and the line connecting the infusion pump. The usual dose is 40 - 300 micrograms / min. Going to be

Vasopressin also known as antidiuretic hormone is a peptide product of the hypothalamus and stored in the posterior lobe of the pituitary. Feedback effects in several organs including the brain where it acts as a neurotransmitter regulating body temperature, nociception and adenocorticotropica hormone release. In the pulmonary vasculature, moderate dose of vasopressin causes vasodilatation while high doses produce vasoconstriction. Vasopressin also has other effects on thrombosis and hemostasis, including platelet aggregation and

Plasma levels of vasopressin in patients after undergoing bypass surgery ranges from 100 -200 pg / ml, while the hemorrhagic shock promotes the release of plasma concentrations of 1000 pg / ml. Several publications indicate that the usual dose of this drug is between 0.01 to 0.1 U / min, and is effective in patients with shock vasodilation without adverse

Hypotension refractory to high doses of alpha-adrenergic agonists after cardiac surgery, after the use of cardiopulmonary bypass, has been referred to as Sx vasoplegic. This

prevent tissue oxygen delivery by blocking the final stages of the respiratory chain.

bolus. In post-qx therapy use in peri-and post-qx:

a persistence in the inhalation anesthetics.

to prevent episodes of ischemia by vasospasm


caused by halogenated anesthetics.


**Sodium nitroprusside** 

used dose is 1-40 mcg / min.

reducing the flow in the latter.

**Vasopressin** 

effects.

titrated according to a patient's response.

release of factor VIII and von Willebrand.

### **Norepinephrine**

Its structure is similar to that of epinerfrina is the endogenous neurotransmitter for postganglionic sympathetic nervous system, its basic function is to stimulate alpha-1 receptors and less beta-1 receptors and beta-2. Intravenous administration of norepinephrine increases blood pressure by increasing peripheral vascular resistance due to this increase, heart rate tends to decrease due to a vagal reflex which overrides the stimulation of myocardial beta-1 receptors, their After stimulation of these receptors causes a recent positive inotropic effect especially at low doses.

Under normal conditions this amine decreases renal blood flow (with minimal changes in glomerular filtration rate) and mesenteric, splanchnic and liver. The administration of norepinephrine should be through a central line to avoid tissue necrosis. Is much more convenient administration via infusion and the usual dose is 0.01 to 0.1 mg / kg / min or 2- 15 mcg / min. So perioperative norepinephrine may be used at low doses for its chronotropic effect and vasoconstrictive properties (intermediate dose). Especially for its effect on the peripheral circulation is indicated in cases where failure is demonstrated in the ability of vasoregulation, because it increases blood flow by increasing systemic blood pressure especially in shock. It should be used so cautious in patients with MAO inhibitors. The tx hypovolemic shock with norepinephrine leads to severe multiorgan hypoperfusion.

The use of norepinephrine in patients undergoing cardiac surgery is controversial because of fear that has regard to the commitment in the function mediated renal vasoconstriction. Hiroshi Morimatsu, et. randomized 100 patients to post-operative heart to norepinephrine infusion in line and this study was carried out monitoring of renal function with infusion of norepinephrine in postsurgical hypotension TAM <70 mmHg. The results was an increase in central venous pressure, decreased systemic vascular resistance index with increased heart rate will eventually change in serum creatinine of treaties. Kwak Y, showed that one of the applications of norepinephrine after surgery is the treatment of hypotension in patients with chronic pulmonary hypertension as they are benefiting from the control of blood pressure without increasing the PSAP but rather decreases many of them.

#### **Nitroglycerin**

Its mechanism of action is through biotransformation in vascular smooth muscle by activating guanylyl cyclase thereby resulting in an increase of cyclic GMP and thus vasodilation. The effectiveness of nitroglycerin decreases after 18-24 hr by a phenomenon of tolerance due to decreased formation of nitric oxide in this way. The NTG has the ability to vasodilate both beds (arterial and venous) at low doses, dominated by its vasodilatory effect and increases venous capacitance and thus decreasing venous pressure and diastolic filling. However high doses of nitroglycerin significantly increases venous capacitance and systemic arteriolar resistance, thereby decreasing the systolic blood pressure and cardiac output. As a mechanism the body responds by reflex sympathetic tachycardia and peripheral arteriolar vasoconstriction, despite this effect on the coronary circulation is vasodilation of both healthy and affected artery atherosclerosis, and also increase collateral circulation areas although its main effect is on the arteries coronary larger caliber and low on resistance of lesser caliber. On myocardial oxygen requirements, mainly affects the ventricular wall tension by increasing venous capacitance, which in turn decreases venous return to the heart leading to a decrease in ventricular wall tension and myocardial oxygen consumption. Another beneficial effect is that the decrease in pre-produced increase in LV perfusion and favoring the subendocardium.

Their metabolism is primarily via hepatic glutathione by organic nitrate reductase. Its effect is dissipated in 30-60 min intravenous Its effect is achieved after 90 seconds and is dose dependent. The usual dose of 0.5-3 mg is / kg / min infusion or 5-200 g / min and 0.5 mg bolus. In post-qx therapy use in peri-and post-qx:


30 Special Topics in Cardiac Surgery

Its structure is similar to that of epinerfrina is the endogenous neurotransmitter for postganglionic sympathetic nervous system, its basic function is to stimulate alpha-1 receptors and less beta-1 receptors and beta-2. Intravenous administration of norepinephrine increases blood pressure by increasing peripheral vascular resistance due to this increase, heart rate tends to decrease due to a vagal reflex which overrides the stimulation of myocardial beta-1 receptors, their After stimulation of these receptors causes

Under normal conditions this amine decreases renal blood flow (with minimal changes in glomerular filtration rate) and mesenteric, splanchnic and liver. The administration of norepinephrine should be through a central line to avoid tissue necrosis. Is much more convenient administration via infusion and the usual dose is 0.01 to 0.1 mg / kg / min or 2- 15 mcg / min. So perioperative norepinephrine may be used at low doses for its chronotropic effect and vasoconstrictive properties (intermediate dose). Especially for its effect on the peripheral circulation is indicated in cases where failure is demonstrated in the ability of vasoregulation, because it increases blood flow by increasing systemic blood pressure especially in shock. It should be used so cautious in patients with MAO inhibitors. The tx hypovolemic shock with norepinephrine leads to severe multiorgan hypoperfusion. The use of norepinephrine in patients undergoing cardiac surgery is controversial because of fear that has regard to the commitment in the function mediated renal vasoconstriction. Hiroshi Morimatsu, et. randomized 100 patients to post-operative heart to norepinephrine infusion in line and this study was carried out monitoring of renal function with infusion of norepinephrine in postsurgical hypotension TAM <70 mmHg. The results was an increase in central venous pressure, decreased systemic vascular resistance index with increased heart rate will eventually change in serum creatinine of treaties. Kwak Y, showed that one of the applications of norepinephrine after surgery is the treatment of hypotension in patients with chronic pulmonary hypertension as they are benefiting from the control of blood pressure

Its mechanism of action is through biotransformation in vascular smooth muscle by activating guanylyl cyclase thereby resulting in an increase of cyclic GMP and thus vasodilation. The effectiveness of nitroglycerin decreases after 18-24 hr by a phenomenon of tolerance due to decreased formation of nitric oxide in this way. The NTG has the ability to vasodilate both beds (arterial and venous) at low doses, dominated by its vasodilatory effect and increases venous capacitance and thus decreasing venous pressure and diastolic filling. However high doses of nitroglycerin significantly increases venous capacitance and systemic arteriolar resistance, thereby decreasing the systolic blood pressure and cardiac output. As a mechanism the body responds by reflex sympathetic tachycardia and peripheral arteriolar vasoconstriction, despite this effect on the coronary circulation is vasodilation of both healthy and affected artery atherosclerosis, and also increase collateral circulation areas although its main effect is on the arteries coronary larger caliber and low on resistance of lesser caliber. On myocardial oxygen requirements, mainly affects the ventricular wall tension by increasing venous capacitance, which in turn decreases venous return to the heart leading to a decrease in ventricular wall tension and myocardial oxygen consumption. Another beneficial effect is that the decrease in pre-produced increase in LV

a recent positive inotropic effect especially at low doses.

without increasing the PSAP but rather decreases many of them.

perfusion and favoring the subendocardium.

**Norepinephrine** 

**Nitroglycerin** 


### **Sodium nitroprusside**

One of the most commonly used vasodilators in the perioperative period, penetrating the endothelium acts to form nitric oxide, this results in the production of guanine monophosphate to guanine triphosphate. Thus cyclic GMP is the second messenger that triggers calcium binding. Its effect occurs seconds after the start of infusion. The commonly used dose is 1-40 mcg / min.

At low doses predominantly dilated arteries and arterioles, and how the dose increases also becomes a venodilators. As with nitroglycerin may occur reflexively tachycardia. And increased venous capacitance and thereby reducing cardiac output. On the other hand it is important to consider that as an important arteriodilatador can produce the phenomenon of coronary steal, mostly because it does not vasodilation in arteries affected by atherosclerosis, reducing the flow in the latter.

Among other effects has the ability to produce dilation of the pulmonary vascular bed arriving to produce hypoxia. Another effect is less desirable thiocyanate intoxication, which prevent tissue oxygen delivery by blocking the final stages of the respiratory chain.

Its administration should be in glucose solution covering both the drug and the line connecting the infusion pump. The usual dose is 40 - 300 micrograms / min. Going to be titrated according to a patient's response.

### **Vasopressin**

Vasopressin also known as antidiuretic hormone is a peptide product of the hypothalamus and stored in the posterior lobe of the pituitary. Feedback effects in several organs including the brain where it acts as a neurotransmitter regulating body temperature, nociception and adenocorticotropica hormone release. In the pulmonary vasculature, moderate dose of vasopressin causes vasodilatation while high doses produce vasoconstriction. Vasopressin also has other effects on thrombosis and hemostasis, including platelet aggregation and release of factor VIII and von Willebrand.

Plasma levels of vasopressin in patients after undergoing bypass surgery ranges from 100 -200 pg / ml, while the hemorrhagic shock promotes the release of plasma concentrations of 1000 pg / ml. Several publications indicate that the usual dose of this drug is between 0.01 to 0.1 U / min, and is effective in patients with shock vasodilation without adverse effects.

Hypotension refractory to high doses of alpha-adrenergic agonists after cardiac surgery, after the use of cardiopulmonary bypass, has been referred to as Sx vasoplegic. This

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 33

compared with 44.1 + / - 23.5 hours of receiving milrinone (p = 0.57). The incidence of post-qx ICC also showed no significant results in both groups (p = 0.25). On the third day of follow up, no significant differences in SBP readmission between the two drugs and there was no impact on mortality, the authors concluded that nesiritide does not reduce hospital stay post-qx like not modify other parameters of disease compared with

In a prospective double-blind (NAPA) Mentzer et al; consider the role nesiritide might play in patients with left ventricular dysfunction with MVR with cardiopulmonary bypass. Patients with ejection fraction less than or equal to 40% who underwent MVR and DCP were randomized to receive nesiritide or placebo for 24-96 hr after induction of anesthesia. The post-qx renal function, hemodynamic parameters and drug use (primary endpoints) were evaluated in patients with MVR with DCP, mortality and safety (secondary endpoints) were evaluated in all patients who received the drug, 303 patients randomized, 279 received the drug and 272 underwent MVR with DCP. Compared with placebo, nesiritide was associated with a slight increase in serum creatinine (0.15 + / - 0.29 mg / dl versus. 0.34 + / - 0.48 mg / dl, p <0.001) and a fall in glomerular filtration rate (- 10.8 + / - 19.3 mL/min/1.73 m (2) versus -17.2 + / - 21.9 mL/min/1.73 m (2), P = 0.001) during hospital stay or stay on 14. On the other hand, patients treated with nesiritide had a shorter hospital stay (p = 0.043) and lower mortality at 180 days. (P = 0.046). The authors concluded that nesiritide in the context of RVM with CPB is associated with improved renal function post-qx and possibly

There are currently a total of 8 studies with more than 2500 patients using aspirin CSRC. The doses used 325-1200 mg daily. Two of these studies showed significant benefit of aspirin a day after heart surgery. In contrast to the other 6 that saw no difference vs placebo with regard to occlusion of the bridges managed belatedly. In conclusion, the evidence so far suggests that the use of aspirin to reduce occlusion of coronary artery bypass bridges to 12 months after CSRC when given the 1st day after surgery, on the other hand is a medicine economic which is associated with few adverse effects and is of great benefit for patients with coronary artery disease peripheral with that aspirin should be given the most quickly

There are three studies involving 1900 patients to evaluate the use of these agents on the occlusion of coronary artery bypass grafts and the risk of cardiovascular events): The Post-CABG trial, LOCATE (Lopid Coronary Angiography Trial) and Cholesterol Lowering Atherosclerotic Study ( CLAS). All three showed a significant reduction in the progression of atherosclerosis in coronary artery bypass bridges. Thus the long-term use of lipidlowering drugs prevent the progression of atherosclerosis in both native arteries and in coronary bridges and reduces cardiovascular events, it was shown that the use of these

Pan et al, found that after adjusting the demographic and clinical differences, the preoperative use of statins was associated with a 50% reduction in mortality, but showed no benefit in the occurrence of AF or IM. Dotan et al, found that statins were associated

nesiritide in MVR and stable ventricular function.

as possible after cardiac surgery and continued indefinitely.

agents reduces the progression of atherosclerosis after 2 years RVM.

increased survival.

**HIipolipemiantes** 

**Aspirin** 

**8. Medical treatment** 

vasopressin has been used for this treatment with encouraging results. Masseti and colleagues studied 16 patients with intravenous vasopressin (0.1-1 IU / min) for the treatment of hypotension refractory to maximum dose of norepinephrine (> 30 mg / kg / min). Preoperative ejection fraction was 40.5% and NYHA functional class 3.5. Getting an increase in blood pressure of 89 mmHg baseline to 116, increase in SVR from 688 to 1043, decreased cardiac index from 2.6 to 2.9 L/min/m2, urine volume increased from 36.8 to 72.8 ml / h.

Whereas high doses of vasopressin and effective in the treatment of Sx vasoplegic after cardiac surgery with cardiopulmonary bypass.

In a recent study, Argenziano et al found that about 10% of patients undergoing cardiac surgery experienced hypotension by vasodilation after bypass surgery, which not necessarily is associated with cardiogenic or septic shock. Interestingly, in situations in which hypotension persists after surgery RVM, smooth muscle cells become less sensitive to circulating catecholamines. This phenomenon is due to decreased function of adrenergic receptors, the study of 50 patients conducted at Columbia Presbyterian Medical Center undergoing cardiac surgery were treated with vasopressin in the operating room or intensive therapy in the first 24 hr surgery (6). All patients had less than 60 mmHg TAM and decreased systemic resistance, despite support with catecholamines. This administration of vasopressin infusion of 0.09 U / min increased the TAM from 58 to 75 mmHg, the SVR increased from 920 to 1200 dyne s cm and achieving a reduction in the administration of norepinephrine in 32%.

### **Nesiritide**

Brain natriuretic peptide also known as BNP is a neurohormone secreted by the left ventricle in response to increased stress (both pressure and volume in the varga) in the ventricular wall. Physiological actions of BNP include natriuresis, vasodilation and neurohormonal modulation. So the tx with BNP has emerged as a viable option in the tx of acute CHF. Moreover, its determination of serum is currently used to differentiate cardiac dyspnea pulmonary dela type. In general, levels of BNP 100pg/ml excludes minors 1 decompensated CHF, whereas values greater than 500pg/ml indicates decompensation.

Neseritide is the recombinant form of endogenous human BNP. Has been shown to decrease filling pressures, increase cardiac output and improve the clinical condition of patients with decompensated CHF. In August 2001 was approved by the FDA for tx of CHF in those with decompensated dyspnea at rest or with minimal effort. The recommended dose is 2μg/kg initial bolus followed by infusion of 0.01μg/kg/min extended to a maximum of 48 hr.

Several studies have examined the possible application of perioperative neseritide so, in patients with left ventricular dysfunction who will undergo heart surgery. In a study prospectivco, open, randomized controlled, Brackbill et al examined the use of perioperative infusion of neriritide and showed improvement compared with milrinone. We included 40 hemodynamically stable patients with LVEF 35% or less that were undergoing bypass surgery. And they were randomized to a bolus of nesiritide or milrinone intraoperatively followed by an infusion of any of them for 24 hr. The time spent in post-qx therapy was the primary outcome measure. The incidence of post-qx ICC, the rate of readmission within 30 days, mortality and other clinical parameters were compared. Patients receiving nesiritide had a hospital stay of 50.6 + / - 46.8 hours compared with 44.1 + / - 23.5 hours of receiving milrinone (p = 0.57). The incidence of post-qx ICC also showed no significant results in both groups (p = 0.25). On the third day of follow up, no significant differences in SBP readmission between the two drugs and there was no impact on mortality, the authors concluded that nesiritide does not reduce hospital stay post-qx like not modify other parameters of disease compared with nesiritide in MVR and stable ventricular function.

In a prospective double-blind (NAPA) Mentzer et al; consider the role nesiritide might play in patients with left ventricular dysfunction with MVR with cardiopulmonary bypass. Patients with ejection fraction less than or equal to 40% who underwent MVR and DCP were randomized to receive nesiritide or placebo for 24-96 hr after induction of anesthesia. The post-qx renal function, hemodynamic parameters and drug use (primary endpoints) were evaluated in patients with MVR with DCP, mortality and safety (secondary endpoints) were evaluated in all patients who received the drug, 303 patients randomized, 279 received the drug and 272 underwent MVR with DCP. Compared with placebo, nesiritide was associated with a slight increase in serum creatinine (0.15 + / - 0.29 mg / dl versus. 0.34 + / - 0.48 mg / dl, p <0.001) and a fall in glomerular filtration rate (- 10.8 + / - 19.3 mL/min/1.73 m (2) versus -17.2 + / - 21.9 mL/min/1.73 m (2), P = 0.001) during hospital stay or stay on 14. On the other hand, patients treated with nesiritide had a shorter hospital stay (p = 0.043) and lower mortality at 180 days. (P = 0.046). The authors concluded that nesiritide in the context of RVM with CPB is associated with improved renal function post-qx and possibly increased survival.
