Transcript Management of Young Children Requiring Ventricular Assist Devices

Management of Young Children Requiring
Ventricular Assist Devices – It’s Not All That VAD!
Ashleigh Butgereit Harlow, BSN, RN, CCRN
Clinical Instructor, Cardiac Intensive Care Unit
Children’s National Health System
Washington, D.C.
I do not have any relevant financial relationships
with any commercial interests to disclose.
Our Center
• Children’s National Health System in Washington,
D.C.
• Academic free-standing pediatric facility
– 303 beds
– 124 critical care beds
Objectives
• To share our center’s experiences in caring for young
children requiring ventricular assist devices (VADs)
• Discuss indications and contraindications for VAD
use
• To describe strategies for encouraging
developmentally appropriate, safe activities during
hospitalization
• To describe utilization of specialized dressing and
slings for device securement and enhanced wound
healing
Children’s National Heart Institute
• CICU and Heart and Kidney Unit
– eCPR
– Cardiac Transplant
– Mechanical Circulatory Support
Does your center implant/manage pediatric VADs?
A) yes
B) no
Indications For Use of VADs In Young Children
Infants & Children ( >3kg) who are candidates for
cardiac transplant and also have:
• Severe biventricular dysfunction
• Severe isolated left ventricular dysfunction
• Need mechanical circulatory support as a bridge to
cardiac transplant or as bridge to recovery
Indications For Use of VADs In Young Children
The Berlin Excor pump is the only device approved for
use in pediatric patients (Humanitarian Use Device)
• Frequent neurological complications (~30% of patients)
• Inability to treat as outpatient
Contraindications
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Not a candidate for cardiac transplant
Inability to tolerate systemic anticoagulation
Anticipated need for MRI
Presence of mechanical aortic valve
Special population challenges:
– Single ventricle physiology (40-60 % mortality)
Post-Operative Goals
Immediate
• Stabilization in the
CICU
• 2:1 ratio
Long-Term
• CICU
• Mobility
• Growth and
development
• Family-Centered Care
• VAD Safety
If your center cares for pediatric VAD patients, where are
hemodynamically stable patients cared for following
extubation?
A) ICU only
B) ICU and Step Down Unit
C) Step Down and Acute Care
D) Acute Care
E) My unit is an admission-to-discharge unit
Getting Dressed
Dressing Changes at Children’s National
Basic Berlin Dressing Change
Supplies
Complex Berlin Dressing
Change Supplies
Adhesive Remover
Puracol
Sterile Towels
Arglaes Silver Powder
Cover Sponges (4x4)
Quik Clot
Gauze Sponges (4x4)
Drawtex
Chloraprep Swab Sticks
Silver Mepilex Dressings
Suture Removal Kit
Duoderm Xtra Thin
3M Skin Prep Pads
Roll of Twill Tie
Mepilex Standard (4x4)
Tubifast
Acticoat Flextend
Hypertonic (3%) Saline
Dressing Changes at Children’s National
Remove old dressing carefully using adhesive remover
Sterile Procedure
• Don clean gown, sterile gloves, hat, and mask
• Create sterile field with sterile towels
• Scrub pump and cannulas (to the Dacron) with CHG (begin at most distal
aspects)
• Apply sterile towel under pump
• Clean cannula insertion sites, periwound skin, and Dacron with CHG; air
dry
• Irrigate sites with 3% saline; air dry
• Apply puracol to open areas (if needed)
• Apply strips of hemostatic dressing to any oozing sites as needed
• Wrap 1-inch strips of Acticoat flex around cannula sites
• Apply pre-cut Mepilex to each cannula sites
• Wrap 4x4 around each cannula site
• Apply 4x4 rolled gauze under each cannula site and between cannulas
• Apply several flat 4x4s to cover cannula sites and then cover sponges
over entire area
• Apply duoderm to both sides of trunk; apply Hypafix tape across large
dressing to duoderm
• Apply small transparent dressing(s) to inferior aspects of dressing to
water proof area
• Cut Tubifast to make a cummerbund (to fit around chest); insert tie twill
tape to pre-cut openings
• Apply mechanical heart sling made by PT to keep device secure
Skin Protection
Skin-Friendly Dressings
Photos Courtesy of June Amling, MSN, RN, CNS, CWON, CCRN
The Perils of Poorly Healing Skin
Photos Courtesy of June Amling, MSN, RN, CNS, CWON, CCRN
…there is often light at the end of the “wound healing”
tunnel!
Photos Courtesy of June Amling, MSN, RN, CNS, CWON, CCRN
Vigilance and Anticipatory Management
Photos Courtesy of June Amling, MSN, RN, CNS, CWON, CCRN
Anticoagulation
Anticoagulation and the Patient Experience
• Anticoagulation is required for patients receiving
mechanical circulatory support
• Subcutaneous injections may be painful and distressing
• Pain adjuncts (Buzzy©, topical analgesia)
• IV Lovenox
• Risks of Anticoagulation
Safety Considerations
Device Securement
Photos Courtesy of Mandana Fisher, PT, DPT
Device Securement
Environment of Care
When caring for active toddlers with a VAD, what
bed/crib strategy do you employ?
A) Open Crib or Bed
B) Crib or bed with enclosure mechanism
C) Open Crib or Bed with Safety Attendant (sitter)
D) Other
Safe Ambulation
Procedure for Intra-hospital Transport with Berlin
Heart Patient
• Pt must not be carried
• Bedside RN must inform attending and charge nurse
when leaving the unit
• A power source must be identified at destination
• Pt must be accompanied by 2 members of the VAD
Team
• Pt must travel with the following:
o Monitor
o Oxygen tank
o Self-inflating bag
o Mask
o 2 clamps (to use if cannulas become
disconnected)
o ¼ x ¼ connector (to repair a broken drive line)
o Sterile scissors
o Emergency medications
In case of emergency, the transporting team will
activate the code team and call the CICU attending.
Image courtesy of Jeremy Rusnock Photography, LLC.
Used with permission.
Growth and Development
Normalizing the Hospital Experience
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Child life specialists
Music Therapy
Art Therapy
Movement Therapy
Think Outside of the Patient’s Room!
Socialization
Photos used with permission.
Socialization
Copyright St. Louis Children’s Hospital
• Peer interaction
• Infection control
Photosused with permission.
In Conclusion…
• Encourage normal growth and development
• Emphasizing safe ambulation and device securement
I’d love to hear from you!
[email protected]
References
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American Academy of, P. (Ed.). (2013). Children, Adolescents, and the Media. Pediatrics, 132(5), 958-961.
Berlin Buddies - Berlin Heart Patients Bond While Awaiting Heart Transplant. (n.d.). Retrieved September 1, 2015.
Byrnes, J., Bhutta, A., Rettiganti, M., Gomez, A., Garcia, X., Dyamenahalli, U., . . . Prodhan, P. (2015). Steroid Therapy
Attenuates Acute Phase Reactant Response Among Children on Ventricular Assist Device Support. The Annals of Thoracic
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Cies, J., Santos, L., & Chopra, A. (2014). IV Enoxaparin in Pediatric and Cardiac ICU Patients. Pediatric Critical Care Medicine,
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Eghtesady, P., Almond, C., Tjossem, C., Epstein, D., Imamura, M., Turrentine, M., . . . Canter, C. (2013). Post-transplant
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Lisa, K. (2010, August 1). Yoga as a Complementary Therapy for Children and Adolescents A Guide for Clinicians. Retrieved
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Patregnani, J. (2015). Monitoring the Harm Associated with Use of Anticoagulants in Pediatric Populations Through TriggerBased Automated Adverse-Event Detection. The Joint Commission Journal on Quality and Patient Safety, 41(3), 108-115.
Singh, T. (2013). Letter by Singh Regarding Article, "Berlin Heart EXCOR Pediatric Ventricular Assist Device for Bridge to
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Sinha, P., Deutsch, N., Ratnayaka, K., Lederman, R., He, D., Nuszkowski, M., . . . Jonas, R. (2014). Effect of mechanical
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