during the postoperative period after weaning from cardiopulmonary bypass ( cpb ) , patients are at increased risk for developing a low cardiac output syndrome ( lcos ) . despite the availability of a wide range of inotropic agents , no consensus exists regarding the treatment of lcos after cpb . in this issue of critical care , gillies and coworkers review the literature systematically in order to identify , present and classify the evidence regarding choice of inotropic drugs . they observe that insufficient data exist to allow selection of a specific inotropic agent in preference over another in adult cardiac surgery patients ; that inodilators such as dobutamine and phosphodiesterase inhibitors are efficacious in the management of lcos ; that , although all -agonists can increase cardiac output , the best studied -agonist and the one with the most favourable side effect profile appears to be dobutamine ; and that phosphodiesterase inhibitors increase the likelihood of successful weaning from cpb as compared with placebo . first , the pathophysiology of the underlying cardiac failure ( e.g. dilatation , obstruction , associated right heart failure ) may impede inotropic effects and therefore influence the choice regarding intropic therapy . second , although not covered by gillies and coworkers , combination treatments are often employed in clinical practice and can involve either inodilators or inoconstrictors ; a thorough assessment of the effects of such combinations remains to be conducted . finally , those conducting multicentre randomized controlled trials to clarify the rationale for use of inodilators , potentially combined with inoconstrictors , should carefully consider which monitoring technique is best . we recently obtained results from a french multicentre survey into the use of inotropes after cardiac surgery ( o bastien , unpublished data ) that may shed some light on these issues . the survey was conducted using a questionnaire , which was sent to participating medical centres . information on a prospective minimum cohort of 15 patients per centre ( age > 18 years and undergoing cardiac surgery ) was anticipated over a maximum period of 1 month . the main objectives were to determine the rate of use of inotropes in lcos following cardiac surgery , and to identify the diagnostic and monitoring tools used in the treatment of lcos . a total of 1368 patients were represented in the survey , 1059 of them were from 30 university or general hospital centres ( 77.6% ) and 309 ( 22.6% ) were from private institutions . inotropes were used in a total of 513 patients ( 38% ) , with this proportion being similar in the various institutions . a single inotrope was used in 64% of cases , two inotropes in 26% , and three in 6% . 1 ) . interestingly , norepinephrine was the second most commonly chosen inotrope ( 157 patients [ 31% ] ) , followed by epinephrine ( 24% ; fig . 1 ) . use of inotropes was determined on a patient - by - patient basis ; protocols were followed in only 7% of the patients ; and inotropes were used systematically in 2% . an important component of the survey was to determine the reasons for choices regarding inotropic therapy . in 81% of cases inotropes other reasons were the presence of low urine output ( 31% ) , cardiac output below 2.5 l / min per m(30% ) , and inadequate ejection fraction ( 16% ) . in 67% of patients efficacy was assessed by echocardiography in only 37% of patients undergoing coronary artery bypass graft surgery ; however , echocardiography was used in 82% following mitral valve surgery . monitoring of cardiac output was done in only 42% of patients treated with inotropes ( fig . 2 ) . when considering these results , which strictly apply only to france , one may question the importance of determining the optimal monitoring strategy before conducting any multicentre trial in lcos . monitoring strategy means to be able to define , step by step , the appropriate tool to be used , including sufficient specificity for each component of the haemodynamic profile . in our efforts to establish a rationale for use of inotropes in lcos following cardiac surgery frequency of inotrope prescription in a french cardiac surgery survey ( agir  agents inotropes en chirurgie cardiaque ) as first or second choice ( n = 513 patients ) . haemodynamic parameters measured in clinical practice , as identified in the agir ( agents inotropes en chirurgie cardiaque ) study . ci , cardiac index ; hr , heart rate ; map , mean arterial pressure ; pap , pulmonary arterial pressure ; rap , right atrial pressure ; sv , systolic ejection volume ; svr , systemic vascular resistance .
results from a french multicentre survey on the use of inotropes after cardiac surgery are presented . 
 consideration of these findings , which strictly apply only to france , highlights the importance of developing monitoring strategies to help in decision making regarding therapy with inotropes in this context .