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Post-Cardiotomy LCOS Inotrope Choice — FRCA Final MCQ

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HardCardiothoracic AnaesthesiaPost-Cardiotomy LCOS Inotrope ChoiceFRCA Final

A 72-year-old man (ASA IV) undergoes emergency aortic valve replacement. Post-operatively in ICU he has a CO of 2.5 L/min, CI 1.4 L/min/m², CVP 18, PCWP 22, MAP 60. He is already on noradrenaline 0.3 mcg/kg/min and an IABP. The next-line inotrope should be:

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Correct answer: B — All of the above are reasonable options with evidence supporting their use

In severe post-cardiotomy low cardiac output syndrome unresponsive to an IABP and vasopressors, inotropic support is needed. All listed agents are reasonable: dobutamine (beta-1 agonist, increases CO), milrinone (PDE3 inhibitor, inodilator, reduces PVR), levosimendan (calcium sensitiser, improves contractility without increasing O2 demand), and adrenaline (potent mixed alpha/beta). Choice depends on: SVR (milrinone if high SVR, adrenaline if low), pulmonary hypertension (milrinone/levosimendan preferred), and local experience. Combination therapy is common. If all measures fail, mechanical support (ECMO/Impella) should be considered.

Reference: RCOA – 2023 – Cardiothoracic ICU module; ESC – 2021 – Heart failure guidelines