Summit 2014, Care of the patient with an LVAD
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Transcript Summit 2014, Care of the patient with an LVAD
Post Operative Care of the Left Ventricular
Assist Device Patient in the Acute Care Setting
Presented by
Jude Melendez, MS, RN, CCRN- CSC and
Loretta Nerney, BS, RN, CCRN
Key Concepts
The newly implanted LVAD patient is a post
op cardiac surgery patient first, LVAD
patient second.
Nurses need a good understanding of LVAD
pump physiology for hemodynamic
monitoring.
Goal of LVAD therapy:
Increase CO
Improve end-organ
function
Improve Quality of
Life
Improve morbidity and
mortality
Reprinted with the permission of Thoratec Corporation
Pump Physiology
Continuous-flow LVADs deliver flow throughout
the entire cardiac cycle
Flow is determined by
Pump speed: Flow increases with speed
increases
Preload dependent
Afterload sensitive
The aortic valve may not always open and
patients may not have a palpable pulse
Pulsatility Index (PI)
As the left ventricle contracts and relaxes, the flow
through the pump increases and decreases, adding a
degree of pulsatility
PI is the magnitude of this flow pulse
The pulsatility index (PI) will normally decrease as
pump speed is increased
PI will change with patient conditions that normally
affect stroke volume (physiologic demand, volume
status, RV function)
Suction Events
If pump speed is set too high or conditions exist to affect preload,
the pump may decompress the LV to the point of collapsing the walls
together.
Evaluate the cause – they are the
same complications that can arise
for any cardiac surgery patient
Hypovolemia/vasodilation (affecting
preload)
Post-operative bleeding
Tamponade
Arrhythmia
RV failure
Reprinted with the permission of Thoratec Corporation
Nursing Assessments
Systems Survey
Device Parameters and Hemodynamics
Monitoring for complications
Patient and Caregiver needs
Hemodynamic Assessments
Arterial line
Swan-Ganz catheter
Physical S/S of good perfusion
TEE when in doubt
Device Parameters
Monitor for
variations
from patient
baseline
Arterial waveform for LVAD patients
http://pics3.this-pic.com/key/dampened%20arterial%20line%20waveform
Systems Survey: Cardiac
Therapy Goals & Interventions
MAP 70-85 mmHg
Normothermia
Pressors (dopamine, vasopressin, levophed)
Fluid resuscitation
Cardiac Index > 2.2, LVAD flow > 3.5 liters/minute
Adequate preload
Balance RV failure vs. adequate LVAD filling
Increase RV contractility (epi, primacor)
Decrease RV afterload: iNO
Treat arrhythmias promptly – protect heart function
Monitor labs: abg, mvg, lactic acid
Systems Survey
Neuro status
Pain management and sedation
Evaluate for CVA
Pulmonary status
If on iNO, ventilator dependent until weaned off
SaO2 may not be obtainable; correlate to abg
Underlying pulmonary dysfunction
Hematologic status
Assess for bleeding: chest tubes, incisions, drive line site
Monitor H/H, TEG, Coags
Hemolysis? Monitor LDH
Systems Survey
Renal function: assess for adequate perfusion & functioning
Monitor/replace electrolytes
Monitor urine output
Monitor BUN/creatinine
Hepatic function: assess for dysfunction from pre-op history
of heart failure
Assess for coagulopathies
Blood glucose control
Systems Survey
Infection control
Antibiotic prophylaxis
Address all risk factors: nutrition, mobility & skin integrity,
glucose control, sterile dressing changes, drive line protection
GI function & Nutrition
Promote gastrointestinal motility post op
Assess pre-albumin levels
RED HEART ALARM
Rule out power
failure or
equipment
malfunction.
Otherwise, there
is a low pump
flow state.
Assess the
patient for
post-op
complications.
Reprinted with the permission of Thoratec Corporation
Complications: LOW FLOW
Low Flow and Low CVP
Replace volume
Give vasoconstrictors if right heart is weak
Check H/H; rule out bleeding
Rule out mechanical versus coagulopathy
Monitor H/H, platelet, PT, PTT, Fibrinogen, TEG : replace
products, administer protamine
Monitor chest tube drainage
Complications: LOW FLOW
High CVP & suction events
RV Failure
Possible Causes : Any increase in RV afterload;
pulmonary HTN, volume overload, acidosis,
hypoxia, ischemia, pulmonary embolus
Cardiac Tamponade
S/S: Hypotension, elevated filling pressures,
reduced SvO2, reduced urine output, slowed chest
tube output
CXR/CT scan
Complications: LOW FLOW
Other Low Flow Considerations
Pump thrombus
may see power spikes, grating or rough pump noise, falsely high
pump flows, clinical signs of heart failure, increased native
pulsatility, hemolysis
Treatment: anticoagulant or thrombolytic therapy, possible pump
exchange
Arrhythmia
NO CHEST COMPRESSIONS/ OK TO DEFIBRILLATE
Inflow cannula obstruction (septal occlusion)
may see reduced pump speed and hear device chatter
High afterload
Rx with vasodilators
Safety Pearls
No chest compressions
ACLS drugs and cardiac defibrillation OK to give
No MRI
Avoid getting system components wet
Maintain patient equipment and keep a spare system
controller and a spare power source with the patient at all
times
Transitioning care
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Psychosocial needs
Educational needs
Elements for discharge to home
VAD support group
References
O’Shea, G. (2012). Ventricular Assist Devices: What Intensive
Care Unit Nurses Need to Know About Postoperative
Management. AACN Advanced Critical Care. 23(1) 69-83.
Slaughter, M., Pagani, F., Rogers, J., Miller, L., Sun, B.,
Russell, S. …Farrar, D.(2010). Clinical Management of
Continuous-flow Left Ventricular Assist Devices in Advanced
Heart Failure. The Journal of Heart and Lung Transplantation. 29
(4S) S1-S39.
Thoratec Corporation. (2012). HeartMate II LeftVentricular Assist
System LVAS: Instructions for Use. Pleasanton, CA: Thoratec
Corporation.