Incidence and Risk Factor Analysis for Gastrointestinal Bleeding and Pump Thrombosis in Left Ventricular Assist Device Recipients.

Left ventricular assist devices (LVADs) are associated with hemostatic complications. We describe the incidence and risk factors for gastrointestinal bleeding (GIB) and pump thrombosis (PT) to optimize patient selection/management. An IRB-approved retrospective review of first LVAD implants between October 1, 2011 and September 30, 2013 at a single center was conducted. Endpoints included epidemiological and risk factor analyses for GIB and PT. Descriptive statistics, chi-squared, and t-tests were used. Sixty-four patients received continuous-flow LVADs. The 12-month incidence of GIB and PT was 23.4% and 12.5%. Time to first GIB was 72.6 days (9-160). The 1-, 3-, and 6-month rate of PT was 1.6%, 6.25%, and 12.5%, respectively. All PT required pump exchange. Females (50% vs. 16%, P = 0.026) and patients without antiplatelet therapy (12.5% vs. 50%, P = 0.046) were at increased risk of PT. No pre-implant comorbidities were associated with PT. Infection was not identified as a risk factor in our cohort (25% vs. 51.8%, P = 0.156). Mean INR preceding event was not different from nonevent patients (2.1 vs. 2.24, P = 0.24). Regarding biomarkers preceding event, elevated plasma free hemoglobin (pfHg) did not reach significance (75% vs. 58%, P = 0.383) while lactate dehydrogenase was elevated significantly (744 vs. 298, P < 0.001). Receiver operating characteristic (ROC) analysis demonstrated that an LDH of >500 was highly sensitive and specific for PT. No pre-implant factors were associated with GIB. Post-implant risk factors for GIB included infection (80% vs. 38.8%, P = 0.005) and infrequent elevations in pfHg (13.3% vs. 63.3%, P < 0.001). Increased pump speed as a GIB risk factor was confirmed (HeartMate II 9560 rpm vs. 9490 rpm, P < 0.001; HeartWare 2949 rpm vs. 2710 rpm, P < 0.001). Anticoagulation/antiplatelet therapy did not affect GIB: mean INR preceding event was not different from nonevent patients (2.21 vs. 2.27, P = 0.67) and antiplatelet use was not different (46.7% vs. 46.9%, P = 0.985). LVADs are associated with early hemostatic-related morbidity. Few pre-implantation risk factors were elucidated; however, post-implantation factors including antiplatelet therapy, infection, and pump speed were identified.

Impact of parenteral nutrition guideline implementation on growth of very low-birth-weight infants in a neonatal intensive care unit.

BACKGROUND: In preterm neonates, parenteral nutrition (PN) is utilized to provide adequate energy and maintain the expected growth rate of a fetus. To optimize growth, our institution implemented comprehensive guidelines for prescribing PN. This study compared the effect of this change on growth outcomes of very low-birth-weight (VLBW) infants at 28 days' postnatal age (PNA). METHODS: Neonates <1250 g who received PN for >7 days were divided into preimplementation and postimplementation cohorts based on date of birth. The primary objective was to compare the average weight velocity (g/kg/day) of neonates at 28 days' PNA. Secondary objectives included identifying the average number of days to regain birth weight and comparing the percentage of infants above the 10th percentile for weight for age at 28 days with those at baseline. RESULTS: There were 204 neonates in cohort 1 (before implementation) and 176 neonates in cohort 2 (after). No difference in weight velocity was identified (12.9 ± 5.2 vs 12.1 ± 4.9 g/kg/day; P = .177). No difference was detected in days to regain birth weight (9.2 ± 4.6 vs 9.9 ± 4.7; P = .909) or in the percentage of patients above the 10th percentile for weight for age (birth: 85.3% vs 83.5% [P = .634]; 28 days: 73% vs 64.8% [P = .082]). CONCLUSION: No difference was observed in the weight velocity of VLBW neonates <1250 g at birth when using the implemented guideline for PN prescription writing at our institution.