Download - LVADs in the Emergency Department
![Page 1: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/1.jpg)
Z A K C E R M I N A R A P H A R M DU W M E D I C I N E R E S I D E N T
S E P T E M B E R 4 , 2 0 1 4
LVADS IN THE EMERGENCY DEPARTMENT
![Page 2: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/2.jpg)
CONTENT
• Background• Pharmacotherapy• Infections• GI Bleeds• Arrhythmias/Codes• Miscellaneous
![Page 3: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/3.jpg)
PATIENT PRESENTATION
• MJM 64 y/o male• ICM s/p LVAD 6/2014• Hx of 2 recent admits for GI bleeds• Presented to the ED on 8/21 with solid, black
stools since 1200 that day with mild fatigue
![Page 4: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/4.jpg)
PMH
• Coronary artery disease• Hx of complete heart block• HeartMate II LVAD in place• Chronic anticoagulation• Hx of acute renal failure• Acute blood loss anemia• Protein calorie malnutrition• Situational depression• Insomnia
![Page 5: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/5.jpg)
HISTORIES
• Allergies:• NKDA
• Family History:• Father: CVA• Brothers: DM
• Social History:• EtOH: Occasional• Tobacco: Smoked for 40-45y, quit• IVDU: Denies
![Page 6: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/6.jpg)
HOME MEDICATION LIST
Indication Medication
Heart History ASA 81 mg PO Daily
Metoprolol Succinate 25 mg PO BID
Pravastatin 20 mg PO daily
Warfarin 1.5 mg PO QmondayWarfarin 2 mg PO QTuWThFSaSu
GERD/GI Bleed Hx Pantoprazole 40 mg PO daily
Pain APAP 650 mg PO Q6H PRN
Oxycodone 5 mg PO Q6H PRN
Constipation Docusate 200 mg PO daily PRN
Supplements Multivitamin PO daily
Vitamin D 1000 IU PO daily
Magnesium Oxide 400 mg PO BID
![Page 7: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/7.jpg)
VITALS
• Admission to ED• Weight: 86.5 kg• Height: 6’ 1”• BMI: 25.2• BP=MAP: 61• Temp: 36.7• RR: 20
![Page 8: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/8.jpg)
LABS: CBC
WBC RBC Hgb Hct MCV Plt
8/21 5.82 2.39 7.2 22 94 279
Na K Cl CO2 Anion Gap
SCr BUN Ca Corrected Ca
8/21 140
4.2 111
24 5 1.12 24 8.2 9.32
LABS: BMP
![Page 9: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/9.jpg)
LABS: LFTS
PT INR aPTT
8/21 27.4 2.6 37
AST ALT Alk Phos
Bili Albumin
8/21 25 25 56 0.7 2.6
LABS: COAGULATION
![Page 10: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/10.jpg)
BACKGROUND
• Heart failure (HF) is increasing in prevalence• 5.7 million currently have diagnosis• 670,000 are newly diagnosed yearly• 1 year mortality rate is 20%• Less than 15% survive 8-12 years• Pharmacotherapy can be used to manage HF in
the earlier stages• Transplant is the preferred therapy for end-stage
HF• Left ventricular assist devices (LVADs) have
become increasingly more popular
Circulation. 2012 Jan 3;125(1):e2-e220.
![Page 11: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/11.jpg)
BACKGROUND CONT.
• LVADs decrease symptoms by decreasing the work of the heart• LVADs:• Reverse HF• Bridge to transplant• Destination therapy
Circulation. 2012 Jan 3;125(1):e2-e220. Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 12: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/12.jpg)
PHARMACOTHERAPY
• Angiotensin-converting enzyme inhibitors (ACEIs)• Angiotensin II receptor blockers (ARBs)• Aldosterone Antagonists• Digoxin• Beta blockers• Diuretics• Hydralazine (+/- nitrates)• Warfarin
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 13: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/13.jpg)
INFECTIONS
![Page 14: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/14.jpg)
INFECTIONS
• Infection rates have been shown to be 25-80%• VAD-related infections should be treated
aggressively• Common VAD-related infections• Driveline• Pocket• Mediastinitis• Pump endocarditis
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 15: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/15.jpg)
J Heart Lung Transplant. 2011 Apr;30(4):375-84.
![Page 16: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/16.jpg)
INFECTIONS CONT.
• Goal of therapy is to keep infection confined to prevent progression• Device related infections do not prevent
transplant• Non-VAD related infections require aggressive
treatment
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 17: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/17.jpg)
INFECTIONS CONT.
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
• Retrospective study by Nienaber et al. • They identified 101 episodes of LVAD infections in 78
of 247 patients (32%)• Most common infection: Drive line infections (47%)• Followed by VAD and non-VAD related BSIs (24% and
22%)• Pathogens:• Gram-positive cocci, staphylococci (45%) • Gram-negative bacilli, nosocomial (27%)
• Chronic suppressive antimicrobial therapy: 42% • Intraoperative debridement: 14%• VAD removal: 3 patients
![Page 18: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/18.jpg)
BLEEDING
![Page 19: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/19.jpg)
BLEEDING
• Bleeding is the most common adverse event associated with VAD therapy• Common bleeding issues:• Epistaxis• Gastrointestinal bleeding• Vaginal bleeding• Cuts or other trauma• Complications after outpatient procedures
• Bleeding may be related to:• Systemic anticoagulation• Operation• Acquired von Willebrand disease
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 20: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/20.jpg)
POSTOPERATIVE BLEEDING
• Immediate postoperative bleeding may be related to:• Adhesions• Cannulation sites• Coagulopathy
• In many causes can be controlled using:• Blood products• Hemostatic agents (aminocaproic acid) • Desmopressin acetate• Protamine sulfate
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 21: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/21.jpg)
VON WILLEBRAND SYNDROME
• In a study of 26 patients with LVADs• All subjects developed von Willebrand syndrome • It was reversible on explant
• A different prospective study examined the characteristics of von Willebrand syndrome related to LVADs• All patients developed von Willebrand syndrome
• The cause is unknown• It may be due to the stress of the continuous flow VAD
leading to proteolysis of the multimers
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 22: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/22.jpg)
HEMOLYTIC ANEMIA
• Hemolysis occurs when RBCs lyse as they pass through the VAD • Related to platelet activation
• Patients may develop symptoms:• Fatigue• Dark tea-colored urine• Icterus
• Management includes:• Close monitoring • Possible addition of dipyridamole
• May occur at a rate of 1.2% to 3%
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 23: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/23.jpg)
ARRHYTHMIAS/CODING
![Page 24: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/24.jpg)
ARRHYTHMIAS
• Arrhythmias occur in approximately 27% to 38% of VAD patients• Treatment options include: • Fluid boluses• Antiarrhythmic agents (amiodarone, beta-blockers +/-
mexilitene)• Normalization of serum electrolyte• Weaning pressors• Direct current cardioversion/Defibrillation
• Always continue preoperative antiarrhythmics after LVAD implantation
Int J Cardiol. 2013 Oct 15;168(6):5143-8.Crit Care Med. 2014 Jan;42(1):158-68.
![Page 25: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/25.jpg)
CODING
• When terminal rhythms occur with power outputs indicating flow through the device use only:• Electrical cardioversion/defibrillation• Epinephrine• Atropine
• When power output is low, compressions may be necessary
• The major risk with chest compressions is dislodgement of:• The device • The outflow cannula
• This is mainly of concern with the larger devices• Alternative is abdominal compressions, given 1–2 inches
left of midline
Int J Cardiol. 2013 Oct 15;168(6):5143-8.Resuscitation. 2014;85(5):702-4. doi: 10.1016.
![Page 26: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/26.jpg)
ABDOMINAL COMPRESSIONS
• One case study of performed abdominal resuscitation in an LVAD patient successfully• Abdominal compressions can maintain a coronary
perfusion pressure of 15 mm Hg• At ROSC, care should be taken to support the
ischemic RV
J Cardiothorac Surg 2011; 6:91.
![Page 27: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/27.jpg)
MISCELLANEOUS
![Page 28: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/28.jpg)
MISCELLANEOUS
• Neurologic• Turbulent flow leads to thrombus formation and stroke• Newer pumps decrease this risk
• RV Failure• An imbalance can develop between the ventricles• Incidence ranges from 11.8% to 14.8%• Can lead to pulmonary hypertension
• Multiple Organ Failure• Device Malfunction
Int J Cardiol. 2013 Oct 15;168(6):5143-8.
![Page 29: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/29.jpg)
BACK TO MJM
• Medications given in the ED:• Pantoprazole 80 mg bolus• Pantoprazole 8 mg/hr drip
• Medications in the ICU:• Pantoprazole 8 mg/hr drip for total 24 hrs• Pantoprazole 40 mg PO BID through 8/27• All home medications• Warfarin was held
![Page 30: LVADs in the Emergency Department](https://reader036.vdocuments.mx/reader036/viewer/2022062720/56813488550346895d9b6c20/html5/thumbnails/30.jpg)
REFERENCES
1. Roger VL, Go AS, Lloyd-Jones DM et al. Heart disease and stroke statistics 2012 update: a report from the American Heart Association. Circulation. 2012 Jan 3;125(1):e2-e220.
2. Pistono M, Corrà U, Gnemmi M et al. How to face emergencies in heart failure patients with ventricular assist device. Int J Cardiol. 2013 Oct 15;168(6):5143-8.
3. Nienaber JJ, Kusne S, Riaz T et al. Clinical manifestations and management of left ventricular assist device-associated infections. Mayo Cardiovascular Infections Study Group. Clin Infect Dis. 2013;57(10):1438-48. Hannan MM, Husain S, Mattner F et al. Working formulation for the standardization of definitions of infections in patients using ventricular assist devices. International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2011;30(4):375-84.
4. Pratt AK, Shah NS, and Boyce SW. Left Ventricular Assist Device Management in the ICU. Crit Care Med. 2014 Jan;42(1):158-68.
5. Rottenberg EM, Heard J, Hamlin R et al. Abdominal only CPR during cardiac arrest for a patient with an LVAD during resternotomy: A case report. J Cardiothorac Surg 2011; 6:91.
6. Shinara Z, Bellezzoa J, Stahovich M et al. Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation. 2014;85(5):702-4. doi: 10.1016.