Category: Clinical Sciences/Health Conditions
The patient is a 66-year-old man with chronic lymphocytic leukemia who underwent HeartMate III LVAD placement as destination therapy for chronic systolic heart failure.
The patient was admitted to inpatient rehabilitation on postoperative day 49 with decreased functional ambulation and limited activities of daily living (ADL), with a total functional independence measure (FIM) score of 70. He required a milrinone drip for ongoing symptoms of right heart failure after LVAD. Pharmacy staff trained nurses regarding management of this medication on admission. During his stay, the patient developed nausea, vomiting, and diarrhea, with low per os (PO) intake. Blood pressure (measured by Doppler sonogram) remained stable with no low flow alarms, kidney function remained stable, and electrolytes were repleted as needed. The patient’s ambulation improved from 20 feet (minimum assistance) to 210 feet with rolling walker (modified independent) on discharge. His total FIM score increased to 96. He was discharged home after 3 weeks and was doing well at home one week later.
Daily communication occurred with the cardiothoracic team and pharmacy, with contributions from the medicine hospitalist. The patient required frequent titration of diuretics with daily monitoring of cardiac parameters, clinical volume status, and activity tolerance in therapies. Due to the risk of pump thrombosis, stroke, and hemorrhage, the patient’s international normalized ratio (INR) was also trended daily, with frequent adjustments to accommodate changes in PO intake in the setting of illness and intermittent nausea. Close communication with multiple teams resulted in a relatively uncomplicated rehabilitation stay, despite medical complexity and acute illness. The patient successfully completed inpatient rehabilitation with safe discharge home.
With collaboration between medical teams and close monitoring of cardiac parameters, clinical volume status, and labs, acute inpatient rehabilitation can be a uniquely safe and beneficial option for patients with functional deficits and LVAD on continuous milrinone.
Lauren Woo– Resident Physician, Northwestern McGaw/ Shirley Ryan Ability Lab
Jessica Marone– Medical Student, Northwestern University Feinberg School of Medicine
Matthew Oswald– Attending Physiatrist, Assistant Professor, Physical Medicine & Rehabilitation, Shirley Ryan Ability Lab / Northwestern Feinberg School of Medicine