care of the left ventricular assist device patient · ppt file · web...
TRANSCRIPT
Care of the Left Ventricular Assist Device Patient
Presented by
Jude Melendez, MS, RN, CCRN- CSC and
Loretta Nerney, BS, RN, CCRN
Post Operative Care of the Left Ventricular Assist Device Patient in the Acute Care Setting
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.
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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
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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
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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)
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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
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Nursing Assessments
Systems Survey
Device Parameters and Hemodynamics
Monitoring for complications
Patient and Caregiver needs
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Hemodynamic Assessments
Arterial line
Swan-Ganz catheter
Physical S/S of good perfusion
TEE when in doubt
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Device Parameters
Monitor for variations from patient baseline
Put in complications section
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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
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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
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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
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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
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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
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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
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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
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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
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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
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References
OShea, 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 Left Ventricular Assist System LVAS: Instructions for Use. Pleasanton, CA: Thoratec Corporation.