Transcript Case Study: L.V.A.D Patient - Kristen Highland`s Professional

L.V.A.D
Hope for the
broken
heart
Kristen Highland
Dietetic Intern
June 6, 2011
OUTLINE
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Background on heart function and failure
What is an LVAD?
Introduction to TW
Timeline of hospital stay
Assessment
Diagnosis
Intervention
Monitoring & Evaluation
Where is TW now?
Summary/Discussion
Normal Heart Function
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Circulates blood
throughout the body to
tissues and organs
Ejection Fraction
(EF): measure of the %
of blood ejected from
the heart with each
heartbeat
Normal EF = 50-70%
HEART FAILURE
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Progressive condition in which damage
to the heart causes weakening of the
cardiovascular system
2 main causes: CAD and MI
Affects 5 million Americans
Causes an average of 250,000 deaths in
the US per year
Dx: EF <40%
STAGES OF HEART FAILURE
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Class I (Mild): no limitation of physical activity
Class II (Mild): Slight limitation of physical
activity. May cause fatigue, palpitation, or
dyspnea.
Class III (Moderate): Significant limitation of
physical activity. Less than normal activity causes
fatigue, palpitation, or dyspnea.
Class IV (Severe): Any physical activity causes
discomfort. Symptoms of cardiac insufficiency at
rest
WHAT IS AN L.V.A.D???
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Left Ventricular Assist
Device
Mechanical circulatory
device used to partially
or completely replace
the function of a failing
heart
4 main parts: pump,
power supply cord,
controller, and power
pack
REASONS FOR USE
1.
2.
3.
Bridge to Recovery (temporary)- after heart
attack, heart surgery, or other debilitating
shock to the heart
Bridge to Transplant (long-term)- to keep
patient alive until donor heart becomes
available
Destination Therapy (long-term)- for
patients who don’t qualify for a heart
transplant d/t cancer, CKD, or another lifeshortening condition
NUTRITIONAL
COMPLICATIONS
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Anorexia
Delayed Gastric
Emptying
Nausea
Early satiety
Hyperglycemia
Cardiac Cachexia
Cardiac Cachexia
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Cachexia: Complex metabolic syndrome
associated with underlying illness and
characterized by loss of muscle with or
without loss of fat mass
Cardiac Cachexia: Caused by an anaboliccatabolic imbalance with a shift toward
catabolism
-increased cortisol and epinepherine
-activation of the renin-angiotensinaldosterone axis
Meet TW
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Male, 48 years old
Med hx: HTN, dyslipidemia,
infected groin abscess (requiring
surgical excision x2), ongoing
tobacco use
Social hx: Married truck driver, hx.
of drinking 6 beers/day (quit 1
month ago), currently smokes at
least 1PPD of cigarettes, no
current illicit drug use
Dx: SOB, diastolic dysfunction (EF
15-20%)
Anthropometrics
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Height: 5’ 7”
Admit weight (4/8):
78.1 kg
BMI: 27
IBW: 67.3 kg
%IBW: 116
Food/Nutrition Related History
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Wife reports good
appetite at home
Food choices not
necessarily the
healthiest
No known food
allergies
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Home Medications
-Lipitor
-Aspirin
-Lasix
-Oxycodone
-Augmentin
-Nicotine patch
-Vitamin C
Physical Findings
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Slightly overweight,
middle-aged male
Some peripheral
edema
No signs of muscle
wasting in temples
or extremities
unhealed groin
abscesses
Day 1-2 (4/8-4/9)
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Cardiac work-up
Plan for diuresis with lasix drip
Potassium and Magnesium repleted as needed
TW states he is feeling better
Medications
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Clorazepate
Hydrocodone
Naloxone
Aspirin
Colace
Insulin (Humalog)
Vancomycin
Acetaminophen
Oxycodone
Morphine
Lasix
Labs 4/8
Lab Name
Results
Ref. Range
Sodium
132 mmol/L (L)
135-144 mmol/L
Potassium
3.8 mmol/L
3.7-5.5 mmol/L
Chloride
93 mmol/L (L)
99-110 mmol/L
Glucose
124 (H)
60-99 mg/dL
BUN
7 mg/dL
6-23 mg/dL
Creatinine
0.67 mg/dL
0.60-1.30 mg/dL
Calcium
9.2 mg/dL
8.3-10.4 mg/dL
Hematocrit
38.6% (L)
40.0-53.0%
Hemoglobin
13.4 g/dL (L)
13.5-17.7 g/dL
Day 5 (4/12)
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Wt: 76.3kg (1.8kg loss)
Heart Catheterization and Coronary
Angiogram
Total occlusion of left main coronary
artery
NYHA Class IV systolic and diastolic
heart failure
Day 6 (4/13)
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Wt: 73.2 kg
Surgery: Coronary Artery Bypass Graft
x2
Unable to be weaned from bypass 
Placement of 1st LVAD: Temporary
Tandem Heart
Intubated and sedated with Propofol
Coronary Artery Bypass Graft
Day 7 (4/14)
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First Assessment
Screened TW d/t Albumin 2.8
Albumin likely secondary to surgery
No nutrition diagnosis or intervention
performed at this time
Day 9 (4/16)
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Wt: 80.4kg
Still intubated and sedated
NPO x 4 days
Dobutrex, Epi, vasopressin off
Weekend RD determined TW was at risk for
Malnutrition
TPN started:
-Unhealed groin wounds
-wanted to decrease stool output
TPN Order
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Penn State (VE=10.5,
temp=36.9)
Req: 1730 kcals, 75-88g
PRO
275 g Dextrose
100g Amino Acids
No lipids added
-Propofol providing 462
kcals from fat
Labs 4/17
Lab Name
Results
Ref. Range
Sodium
138 mmol/L
135-144 mmol/L
Potassium
4.0 mmol/L
3.7-5.5 mmol/L
Chloride
111 mmol/L (H)
99-110 mmol/L
Glucose
101 mg/dL (H)
60-99 mg/dL
Phosphorus
4.1 mg/dL
2.3-4.7 mg/dL
Magnesium
1.9 mg/dL
1.7-2.5 mg/dL
Albumin
2.4 g/dL (L)
3.2-4.9 g/dL
Prealbumin
6.0 mg/dL (L)
18.0-32.0 mg/dL
Day 11 (4/18)…
THE BIG DAY!!!
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Determined that TW would need long
term left ventricular mechanical
assistance
4/17: Family meeting to discuss Heart
Mate II LVAD
4/18: Surgery to remove Tandem Heart
and implant Heart Mate II
-Prealbumin = 7
Day 14 (4/21)
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Evening 4/20:
-TW extubated
-Propofol is discontinued
4/21: Received consult to begin TF
Albumin = 2.8
Nutrition Diagnosis
Inadequate ProteinEnergy intake R/T post
surgery status, AEB
extended NPO x 9 days
Intervention
What would
YOU
do???
TW’s Needs
A.S.P.E.N. Guidelines
 Calories
1.) Mifflin x 1.1 A.F = 1716 kcals
2.) 25kcals x 73.2kg = 1830 kcals
* Estimated needs = 1800 kcals/d
 Protein
- 1.2-1.4g/kg for wound healing
*Estimated needs = 88-102g/d
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TF Regimen (started 4/21)
Formula: Perative (High Kcal/High PRO)
 Goal Rate: 60 mL/hr x 24 hrs
-Start @ 15 mL/hr, increase Q8 hours to goal
 1872 kcals, 96g PRO, 1138 mL water
 Flushes: 360 mL (60 mL Q4 hours)
 Total water: 1498 mL
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MONITORING & EVALUATION
Calorie Count (4/23)
Diet Order: Mechanical Soft, Ensure TID
 Intake:
-1016 kcals
-54g PRO
-56% kcal requirements
-66% PRO requirements
*Still on TF
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Calorie Count (4/24)
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Diet Order: Diabetic, 2g Na, 300 mL
trays
Intake (only breakfast & lunch):
-822 kcals
-37g PRO
-39% kcal requirements
-39% PRO requirements
Calorie Count (4/25)
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Needs increased to 2100-2200 kcals/d and 1.3-1.4g
PRO/day
Calorie count
-1055 kcals
-60g PRO
-50% kcal requirements
-63% PRO requirements
TF discontinued
-tolerating diet advancement
-appetite slowly increasing
- willing to drink Ensure to meet PRO needs
Coumadin and diet education provided to TW and spouse
Day 20 (4/27)
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Prealbumin = 17 mg/dL
Calorie Count d/c
Eating 100% of meals
Drinking Ensure
TW reports “feeling so full”, but compliant with eating
to meet PRO needs
Wounds beginning to heal
Moved from CRU to main cardiac floor
“Nutrition problem resolved”
Family advised to consult RD with any further
questions
The last few days
5/1
-intake = 1322 kcals
-wt: 69.6 kg
 5/2
-wt: 68.6 kg
 5/4
-per nursing, eating 80-100% of meals
-TW reports eating much better the past 2 days
 5/5
-wt: 69 kg
-wt. loss during stay likely related to diuresis
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Medications 5/2
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Coumadin
Aspirin
Metoprolol
Simvistatin
Spironolactone
Amoxicillin
Colace
Amiodarone
Lisinopril
Labs 5/5
Lab Name
Sodium
Potassium
Chloride
Glucose
Calcium
BUN
Creatinine
GFR
Results
137 mmol/L
4.5 mmol/L
103 mmol/L
107 mg/dL (H)
9.3 mg/dL
11 mg/dL
0.54 mg/dL (L)
>60
Ref. Range
135-144 mmom/L
3.7-5.5 mmol/L
99-110 mmol/L
60-99 mg/dL
8.3-10.4 mg/dL
6-23 mg/dL
0.60-1.3 mg/dL
>=60
Plan for discharge
Day 26 (5/3)
-VAD Board meeting to discuss case
-Pros/Cons of TW’s entire process
 Day 28 (5/5)
-DISCHARGED!
-Moved to Providence House
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BAD NEWS….
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Readmitted to the
hospital on 5/23
- recurrent unhealed
groin abscess
-surgery on 5/25 for
drainage of abscess
-d/c on 5/27
Summary
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48 year old male
Admitted with Class IV heart failure and
unhealed groin abscesses
Received long term Heart Mate II LVAD
In need of TPN and TF post surgery
Discharged once tolerating oral diet
Readmitted on 5/23 for drainage of recurrent
groin abscesses
d/c again on 5/27
Hope for the best! 
References
Hsich E, Wilkoff B. “Diseases & Conditions” Cleveland Clinic C.C., Aug. 2010, Web. 29 May 2011.
http://my.clevelandclinic.org/heart/disorders/heartfailure/ejectionfraction.aspx
McClave S, et al. “Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of
Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)” Journal of Parenteral and
Enteral Nutrition 33 (2009): 277-316.
Romeo, et al. “Heart Failure” Heart Failure Online 2010, Web. 29 May 2011.
http://www.heartfailure.org/eng_site/hf.asp
Scurlock C, et al. “Impact of New Technologies on Metabolic Care in the Intensive Care Unit” Current Opinion in Clinical Nutrition and
Metabolic Care 12 (2009): 196-200.
Slaughter M, et al. “Clinical Management of Continuous-flow Left Ventricular Assist Devices in Advanced Heart Failure” The Journal of
Heart and Lung Transplantation (2010): 1-39.
Stahovich M, et al. “The Next Treatment Option- Using Ventricular Assist Devices for Heart Failure” Crit Care Nurs Q 30 (2007): 337-
346.