Recommended Dosing for Milrinone Drip in Heart Failure
For heart failure patients, milrinone should be administered with a loading dose of 50 mcg/kg given slowly over 10 minutes, followed by a continuous infusion of 0.375-0.75 mcg/kg/min, with dose adjustments based on hemodynamic response and renal function. 1, 2
Standard Dosing Protocol
Loading Dose
- 50 mcg/kg administered slowly over 10 minutes 1, 2
- Can be given undiluted or diluted to a total volume of 10-20 mL for easier visualization of injection rate 1
Maintenance Infusion
- Minimum: 0.375 mcg/kg/min (0.59 mg/kg/day) 1
- Standard: 0.5 mcg/kg/min (0.77 mg/kg/day) 1, 2
- Maximum: 0.75 mcg/kg/min (1.13 mg/kg/day) 1, 2
Preparation
- Dilute milrinone prior to maintenance dose administration
- Acceptable diluents: 0.45% Sodium Chloride, 0.9% Sodium Chloride, or 5% Dextrose 1
- Target concentration: 200 mcg/mL (e.g., 10 mL milrinone + 40 mL diluent = 50 mL total) 1
Dose Adjustment for Renal Impairment
Renal function significantly impacts milrinone clearance. Adjust infusion rates according to creatinine clearance:
| Creatinine Clearance (mL/min/1.73m²) | Recommended Infusion Rate (mcg/kg/min) |
|---|---|
| 5 | 0.2 |
| 10 | 0.23 |
| 20 | 0.28 |
| 30 | 0.33 |
| 40 | 0.38 |
| 50 | 0.43 |
Hemodynamic Effects and Monitoring
- Onset of action: Within 15 minutes of administration 3
- Duration of effect: Typically persists for 1-2 hours after discontinuation 2
- Expected hemodynamic improvements:
Important Monitoring Considerations
- Continuous hemodynamic monitoring during infusion
- ECG monitoring due to potential arrhythmogenic effects
- Monitor for 1-2 hours after discontinuation
- Gradual tapering essential to prevent hemodynamic deterioration 2
- Titrate to maximum hemodynamic effect but do not exceed 1.13 mg/kg/day 1
Cautions and Adverse Effects
- Major adverse effects: hypotension, ventricular arrhythmias, thrombocytopenia 2
- Use with caution in patients with:
- Systolic blood pressure <90 mmHg
- History of ventricular arrhythmias
- Coronary artery disease (may increase risk of arrhythmias and mortality) 2
Clinical Pearls
- Milrinone maintains effectiveness during beta-blocker therapy, making it suitable for patients on beta-blockers who may have inadequate response to dobutamine 2
- Use a calibrated electronic infusion device for continuous administration 1
- Inspect solution visually; do not use if particulate matter or discoloration is present 1
By following this dosing protocol and monitoring guidelines, milrinone can effectively improve hemodynamics in heart failure patients while minimizing risks of adverse effects.