Left Ventricular Assist Device Insertion Medication

Updated: Jul 06, 2016
  • Author: Craig H Selzman, MD, FACS; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Medication

Medication Summary

Standard cardiac surgery anesthesia is used with LVAD procedures. The goals of pharmacotherapy are to reduce morbidity and prevent complications.

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Anesthetic Agents

Class Summary

After standard monitoring equipment is attached and peripheral venous access achieved but before the arterial line is inserted, the midazolam dose is administered. Before placement of the arterial line, it should be ensured that a radial artery graft will not be used for CABG.

Propofol (Diprivan)

Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic properties when administered intravenously. Propofol IV produces rapid hypnosis, usually within 40 seconds. The effects are reversed within 30 minutes following the discontinuation of infusion. Propofol has also been shown to have anticonvulsant properties.

Etomidate (Amidate)

Amidate is a nonbarbiturate imidazole compound with sedative properties. It is short acting and has a rapid onset of action; the duration of action is dose dependent (15-30 minutes). Its most useful feature as an induction agent is that it produces deep sedation while causing minimal cardiovascular effects.

The major application of etomidate is induction for endotracheal intubation, particularly in patients with, or at risk for, hemodynamic compromise. Etomidate has been shown to depress adrenal cortical function; however, this effect is not significant clinically during short-term administration. Since the drug is mixed in propylene glycol, continuous infusion not recommended.

Thiopental

Thiopental is a short-acting barbiturate sedative-hypnotic with rapid onset and a duration of action of 5-20 minutes. Like methohexital, it is most commonly used as an induction agent for intubation. To use thiopental as a sedative, titrate in dosage increments of 25 mg (adjust to lower dose in children).

Isoflurane (Forane, Terrell)

Isoflurane is an inhalation anesthetic. It may have a myocardial protective effect and therefore is especially useful in off-pump surgery. Isoflurane potentiates the effects of muscle relaxants. Small doses of muscle relaxants can achieve complete paralysis when administered concomitantly with isoflurane.

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Antifibrinolytic Agents

Class Summary

Antifibrinolytics are used to enhance hemostasis when fibrinolysis contributes to bleeding. Because of the risk of thromboembolic events, screening for pulmonary AVMs should be performed before use.

Aminocaproic acid (Amicar)

Aminocaproic acid inhibits fibrinolysis via inhibition of plasminogen activator substances and, to a lesser degree, through antiplasmin activity.

Tranexamic acid (Cyklokapron, Lysteda)

Tranexamic acid is an alternative to aminocaproic acid. It inhibits fibrinolysis by displacing plasminogen from fibrin.

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Blood Components

Class Summary

Plasma is the fluid compartment of blood containing the soluble clotting factors.

Fresh frozen plasma

Fresh frozen plasma is for use in patients with blood-product deficiencies.

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Anticoagulants, Hematologic

Class Summary

Anticoagulants prevent recurrent or ongoing thromboembolic occlusion of the vertebrobasilar circulation. In patients with heparin-induced thrombocytopenia, LVAD implantation has been performed successfully, albeit with additional risk, by using alternative anticoagulants.

Heparin

Heparin may be used if thrombocytopenia is not present. Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. Heparin prevents the recurrence of a clot after spontaneous fibrinolysis.

Argatroban

Argatroban is a selective thrombin inhibitor that inhibits thrombin formation by binding to the active thrombin site of free and fibrin-bound thrombin. It inhibits thrombin-induced platelet aggregation.

Dabigatran etexilate (Pradaxa)

Dabigatran etexilate is a selective thrombin inhibitor that inhibits thrombin formation by binding to the active thrombin site of free and fibrin-bound thrombin. It inhibits thrombin-induced platelet aggregation.

Bivalirudin (Angiomax)

Bivalirudin inhibits coagulant effects by preventing thrombin-mediated cleavage of fibrinogen to fibrin.

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Pulmonary Vasodilators

Class Summary

After insertion of the LVAD, attention is focused on decreasing pulmonary vascular resistance and protecting RV function. Inhaled nitric oxide (NO) is a pulmonary vasodilator indicated to treat pulmonary hypertension. NO is also being studied for severe hypoxemia in acute respiratory distress syndrome (ARDS).

Nitric oxide, inhaled (INOmax)

NO is produced endogenously from the action of the enzyme NO synthetase on arginine. It relaxes vascular smooth muscle by binding to the heme moiety of cytosolic guanylate cyclase, activating guanylate cyclase, and increasing intracellular levels of cyclic guanosine monophosphate (cGMP), which then leads to vasodilation. When inhaled, NO decreases pulmonary vascular resistance and improves lung blood flow.

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Vasodilators

Class Summary

Nitrates reduce myocardial oxygen demand by lowering preload and afterload. In severely hypertensive patients, nitroprusside causes more arterial dilatation than nitroglycerin. Nevertheless, in view of the possibility of thiocyanate toxicity and the coronary steal phenomenon associated with nitroprusside, IV nitroglycerin may be the initial therapy of choice for afterload reduction.

Nitroglycerin sublingual (Nitro-Bid, NitroMist, Nitrostat, Nitrolingual)

Sublingual nitroglycerin tablets and spray are particularly useful in patients who present with acute pulmonary edema with a systolic blood pressure of at least 100 mm Hg. As with sublingual nitroglycerin tablets, the onset of action of nitroglycerin spray is 1-3 minutes, with a half-life of 5 minutes. Administration of the spray may be easier, and it can be stored for as long as 4 years.

Topical nitrate therapy is reasonable in a patient presenting with class I-II congestive heart failure (CHF).

Nitroprusside sodium (Nitropress)

Nitroprusside produces vasodilation of venous and arterial circulation. At higher dosages, it may exacerbate myocardial ischemia by increasing the heart rate. It is easily titratable.

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Inotropic Agents

Class Summary

Inotropic support for the RV is routinely provided (eg, with milrinone, epinephrine, and dobutamine).

Milrinone

Milrinone is a bi-pyridine–positive inotrope and vasodilator with little chronotropic activity.

Dopamine

Dopamine is a naturally occurring endogenous catecholamine that stimulates beta1-and alpha1-adrenergic and dopaminergic receptors in a dose-dependent fashion. It stimulates the release of norepinephrine.

In low doses (2-5 μg/kg/min), dopamine acts on dopaminergic receptors in renal and splanchnic vascular beds, causing vasodilatation in these beds. In midrange doses (5-15 μg/kg/min), it acts on beta-adrenergic receptors to increase heart rate and contractility. In high doses (15-20 μg/kg/min), it acts on alpha-adrenergic receptors to increase systemic vascular resistance and raise blood pressure.

Dobutamine

Dobutamine is a sympathomimetic amine with stronger beta than alpha effects. It produces systemic vasodilation and increases the inotropic state.

Epinephrine (Adrenalin)

Its alpha-agonist effects include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Its beta2-agonist effects include bronchodilation, chronotropic cardiac activity, and positive inotropic effects.

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