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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. T he newly implanted LVAD patient is a post op cardiac surgery patient first, LVAD patient second.

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post operative care of the left ventricular assist device patient in the acute care setting

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
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.
slide3

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
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
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
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
Nursing Assessments

Systems Survey

Device Parameters and Hemodynamics

Monitoring for complications

Patient and Caregiver needs

hemodynamic assessments
Hemodynamic Assessments
  • Arterial line
  • Swan-Ganz catheter
  • Physical S/S of good perfusion
  • TEE when in doubt
device parameters
Device Parameters

Monitor for variations from patient baseline

arterial waveform for lvad patients
Arterial waveform for LVAD patients

http://pics3.this-pic.com/key/dampened%20arterial%20line%20waveform

systems survey cardiac
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
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 survey1
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 survey2
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
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
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 flow1
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 flow2
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
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
Transitioning care

Psychosocial needs

Educational needs

Elements for discharge to home

VAD support group

references
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 Left Ventricular Assist System LVAS: Instructions for Use. Pleasanton, CA: Thoratec Corporation.