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
•
•
•
•
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.