Cardiovascular Critical Care I
| (2) | Mupirocin 2% (Bactroban) every 12 hours to each nostril to maintain moist nasal |
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passages
| (3) | Oxymetazoline 0.05% (Afrin) to each nostril every 12 hours as needed for epistaxis |
|---|---|
| (e) | Gastroenterology |
| (1) | Intravenous proton pump inhibitor until location of GI source identified or for up to |
72 hours. Intermittent intravenous dosing may also be considered.
| (2) | Enteroscopy with or without colonoscopy; may consider one or more of the following: |
|---|---|
| • | Angiography and cautery |
| • | Balloon-assisted enteroscopy |
| • | Video-capsule enteroscopy |
| • | Surgery |
iii.
Long-term management
| (a) | Consider decreasing anticoagulation/antiplatelet therapy intensity. |
|---|---|
| (b) | Refractory bleeding despite previously stated interventions |
| (1) | Consider role of oral antifibrinolytics (i.e., aminocaproic acid). |
| (2) | Consider role of desmopressin or von Willebrand factor replacement if confirmed |
acquired von Willebrand disease and if LVAD speed cannot be further decreased.
| (3) | If GI arteriovenous malformations are present that are not amenable to intervention, |
|---|
octreotide 50 mcg subcutaneously every 8 hours may be considered.
Intravenous proton pump inhibitor
Hemolysis may be the presenting symptom of an underlying process, including infection,
pump thrombosis, or other mechanical or physiologic dysfunction.
ii.
Common presentation includes:
| (a) | Nonhemorrhagic anemia |
|---|---|
| (b) | Urine color changes with appearance of hematuria; in severe cases, can be brown or black |
| (c) | Hyperkalemia |
| (d) | LVAD pump alarms |
iii.
Workup for contributing factors:
| (a) | Evaluate LVAD and cardiac function for contributing factors, including documentation |
|---|
and alarm history for suction events, power spikes, speed changes, volume status, RV
function, arrhythmias
| (1) | Evaluate cannula(e) position and evaluate for obstruction/thrombus by ECHO or |
|---|
computed tomography (CT).
| (2) | Evaluate RV function by ECHO. |
|---|---|
| (3) | Evaluate for intra-device thrombosis by ECHO ramp testing (Echocardiography |
2014;31:E5-9; J Am Coll Cardiol 2013;62:2149-50; J Am Coll Cardiol 2012;60:1764-75).
| (b) | Ensure adherence to anticoagulation regimen according to patient’s established goals. |
|---|---|
| (c) | Evaluate laboratory values to establish the presence and degree of hemolysis and to |
identify any other potential contributors.
| (1) | Lactate dehydrogenase (LDH); normal values are 300–600 IU/L for most forms of |
|---|
MCS.
| (2) | Haptoglobin |
|---|---|
| (3) | Plasma-free hemoglobin |
| (4) | Blood cultures (an association has been identified with bacteremia and hemolysis in |
patients with LVADs – in some cases, presenting as thrombosis).
| (5) | Urine assessment – Send baseline urinalysis, urine culture, and appearance of |
|---|
changes daily to assess for improvement. Likely hemolysis, as evidenced by the
presence of casts and color changes (darkened tea, red, or black are highly suggestive
of hemolysis).