Utilization of a Dextrose-Only Purge Solution for an LVAD in Patients With Suspected HIT: A Case Series

Abstract

The Impella devices are percutaneous intravascular ventricular assist devices indicated for use in patients with cardiogenic shock that occurs following acute myocardial infarction (MI) or open heart surgery. These devices must be used with a purge solution that contains heparin per manufacturer recommendation, which will prevent blood from reaching the motor causing pump thrombosis and mechanical failure. We describe the utilization of a dextrose-only purge solution plus systemic argatroban in 2 patients with suspected heparin-induced thrombocytopenia (HIT). Each case describes a patient with suspected HIT following Impella placement for cardiogenic shock post-MI that had an increased bleeding risk. In each case, pharmacy monitored and adjusted the patients’ argatroban, resulting in therapeutic anticoagulation without major bleeding or thrombotic events. These case reports demonstrate that use of a dextrose-only purge solution in the Impella device may be a safe and effective option when combined with systemic argatroban in patients with suspected or confirmed HIT who exhibit increased bleeding risk. Further research is needed to determine the optimal concentrations and duration of anticoagulation-free purge solution in these patients.

Heparin-Induced Fever in a Cardiac Transplant Candidate

“…For patients who cannot tolerate heparin, D5 only in the purge solution combined with systematic anticoagulation via direct thrombin inhibitors is often utilized. 8 For our patient, D5 only was initially used with systematic bivalirudin; however, due to pump thrombosis requiring tissue plasminogen activator, bivalirudin was mixed in dextrose for the purge solution without recurrence of pump thrombosis.…”

Standardizing Lower Heparin Concentrations for Use in Anticoagulation of Percutaneous Left Ventricular Assist Device (pVAD) D5W Purge Solutions

“…Further, some patients may require even further reduced concentrations or omission of heparin due to increased bleeding or heparin-induced thrombocytopenia (HIT). [4][5][6] While standardization of heparin concentrations is an established best practice for safe medication use, 7 these complex patients may require alternative concentrations. Here, we discuss standardizing alternative low-dose heparin concentrations for purge solutions, which we have prebuilt in our system as standardized choices to reduce risk medication errors.…”