2020 prodigy refresher vad
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Presentation on VADs for the Prodigy #refresh21 free online refresher.
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2020 prodigy refresher vad
- 1. Stop Draggin’ My Heart Around…. Life Sustaining Interventions in EMS and Critical Care: An Overview
- 2. Who am I • Steve Cole • 30+ years in EMS • Work in SW Idaho • EMS Training Captain • Adjunct faculty at local university • No financial disclosures
- 3. Questions and Objectives • How to Ventricular Assist Devices Work? • Describe the function of ventricular assist devices (VAD) • How do I assess a patient with a Ventricular Assist Device? • Describe key assessments of a patient with a VAD • How to I care for a patient with a VAD if they are in distress? • Discuss treatment strategies for patients with a VAD Suffering an emergency • What do I have to be cognizant of when transporting a patient with a VAD? • Discuss prehospital and intra-facility implications of patients with a VAD
- 4. Definitions • VAD: Ventricular Assist Device • L-VAD: Left Ventricular Assist Device • TAH: Total Artificial Heart • Pulsatile Flow • Continuous Flow This Photo by Unknown Author is licensed under CC BY-NC-ND
- 6. Ventricular Assist Devices • A VAD is a Mechanical Circulatory Support (MCS) device designed to restore blood flow and improve survival, functional status, and quality of life for those suffering from advanced heart failure • The device is implanted in parallel with the heart, taking over a majority of its circulatory function • Multiple devices and brands in use • Refer to the ICCAC Field Guide • www.mylvad.com • No age limit
- 7. Ventricular Assist Devices • The device takes blood from a lower chamber of the heart and helps pump it to the body and vital organs, just as a healthy heart would. • It “assists” the left ventricular function of the heart.
- 8. Why is this important?
- 9. There are about 3,000 new devices implanted each year. Nate Southerland, eastidahonews.com in 2016
- 10. Why a VAD? • Temporary, bridge-to-transplant (BTT) • About 25% • Permanent, destination therapy (DT) • About 50% • Other Temporary indications • bridge-to-candidacy/bridge-to-decision • bridge-to-recovery • Survival • 80% survive > 2 years • 30% survive > 5 years
- 11. Types of VADs • L-Vad – Left Ventricular Assist Devices • R-VAD – Right Ventricular Assist Devices • BiVAD- Bi-Ventriculat Assist Devices. • Total Artificial Hearts (discussed later)
- 12. Types of VADs • A BiVad is not a separate class of VAD, but the combination of Left and Right VADs in the same patient.
- 13. The “Drive Line” • The device is “powered” externally, with the “drive line” entering the body to run the “pump” • The actual “power” is external in the “controller”.
- 14. Example of L-VAD system: HeartWare System Implanted Pump Driveline Battery Battery Controller
- 15. Example of L-VAD system: HeartMate II System Implanted Pump Battery Battery Controller Driveline
- 16. External VAD Components Patients have options for carrying their external equipment to best suit their comfort and lifestyle Ensure that the equipment is protected at all times with no stress on the driveline Patients will have an additional supply bag for their extra batteries and backup Controller close at hand. This bag should always accompany the patient on transport
- 18. Power Management • Patients are responsible for managing their power • They have 6-8 batteries in rotation and a home charger • Batteries generally last 8 – 14 hours per pair • Exchanged one at a time, so one • power source is always connected • to the Controller • Patients only need to be on A/C power when sleeping
- 19. Critical VAD Connections Never disconnect both power sources! Never disconnect driveline! HeartWare HVAD HeartMate II Power Driveline Power Power Power Driveline
- 20. The Controller For HeartMate 2 and 3 press MENU button to access parameters ALARM SILENCE Alarms have symbol and message on screen Yellow (beeps) Pump is ON Red (steady tone) Pump may be OFF
- 21. Assessment
- 22. VAD Patient Assessment • Attempt to auscultate over the apex of the heart for a “whirling” or “smooth, humming” sound indicating that the VAD is working • A cable exits the abdominal wall that connects the device to power and the control unit • SOME VAD patients also have an implanted cardiac defibrillator and/or a pacemaker
- 24. Assessments: LOOK AT THE CONTROLLER What is the flow rate??? What are the RPMs? Alarms have symbol and message on screen Yellow (beeps) Pump is ON Red (steady tone) Pump may be OFF
- 25. Caution with clothing removal • Use caution when cutting and removing clothes, to avoid damaging the device • VAD patients should always have a sterile dressing covering the driveline exit site in the lower abdomen. • The dressing should not get wet.
- 26. Assessments • MOST L-VADS are a continuous flow device. This means: • Whirling sound in chest. • No Pulse: A palpable pulse is variable and clinically insignificant in VAD patients • Pulse Oximetry: Pleth will be unreliable. SPO2 may still be useful though. • Look for physical s/s of ↓ oxygenation • No systolic or diastolic blood pressure • NIBP may be able to get a MAP • Doppler B/P = MAP • Rely on other prefusion signs • EKG is typically unaffected (may be AF, , Stable VT, or even VF!!! or other underlying condition) • Rely on total assessment. • Assess for bleeding issues. Patients are at high risk for bleeding complications due to blood thinner use • Trauma • Falls • GI bleed
- 27. VAD complications: Bleeding • Most common complication • GI bleeding common (15- 30%) • Site bleeding
- 28. VAD complications: Stroke • 13-30% incidence depending on VAD type. • About ½ will be fatal • Ischemic/Embolic more common than hemorrhagic
- 29. VAD complications: infection • Independent predictor of mortality • Originally 41%, down to approx. 20% of patients • Many hospital admissions in VAD patients are secondary to infection, not cardiac problems. • Early detection and treatment is essential to reduce mortality • Assess for signs of infection (especially at the insertion point) or sepsis
- 30. Assessing Pump Flow • Flow (L/min) • Average adult Cardiac Output at rest is ~ 5 L/min • Body size / blood volume effects pump flow potential • The Flow parameter is an estimate • Flow will mainly fluctuate with changes in activity, body position, and blood volume • Hyper / hypovolemia • Other physiologic conditions can also effect flow: • Right Heart Function • Rhythm disturbances • Hypo / hypertension • Valvular function • Pulmonary hypertension • Thrombosis
- 31. Treatment • ***CALL THE VAD HOTLINE *** • Verify the pump is “on” • Treat as important as a “pulse check”. • Involve Caregivers. They have had extended training in the patient’s particular VAD. • V.O.M.I.T. as indicated • Hypovolemia is a common complication • Fluid Resuscitation is a common intervention. • Vasopressors for patients refractory to fluid challenges.
- 32. LVAD Patient Management PRELOAD Volume Blood Pressure CVP / PVR Right Heart Function Valvular Function Rhythm AFTERLOAD SVR MAP 65-85 ANTICOAGULATION Coumadin ASA INR 2-3 PUMP SPEED Set RPM to BLOOD IN = BLOOD OUT
- 33. Treatment – ACLS? • ***CALL THE VAD HOTLINE *** • Airway management and respiratory support considerations unchanged • OK to defibrillate or SCV per ACLS, but consult VAD Hotline first if the patient is stable • Avoid placing the pads directly over the device (consider anterior-posterior pad placement) • Do Not Administer vasodilatory meds without consulting the VAD hotline. • i.e. Nitroglycerine • Persistent arrhythmias are treated after contacting the VAD coordinator • Antiarrhythmics doses unchanged by LVAD, but may be changed by other underlying conditions. • CPR is usually last resort. • LISTEN for “whirling sound” first. If present, no CPR unless ordered by VAD-Control Center
- 34. Transportation and Destination Decisions • ***CALL THE VAD HOTLINE *** • Always transport “go-Bag” with the patient. • If possible, take an experienced care giver too. • These patients have multiple co-morbidities and high risk clinical concerns • Heart Failure • Stroke • LVAD related issues • High risk of infection • Coagulopathic issues • These patients should be transported to either the VAD center, the highest level of care available in your system. Consult VAD hotline. Q: What does that mean in your local area?
- 35. Total Artificial Hearts (TAH) Liotta-Cooley Artificial Heart https://well.blogs.nytimes.com/2011/02/14/a- plastic-heart-that-beat-for-three-days/?_r=0
- 36. VAD versus TAH Ventricular Assist Device • Usually Pulseless • Whirling assessed by auscultation • EKG has underlying rhythm • No NTG (*preload dependent) • Cardioversion/Defibrillation OK • CPR OK • Mean Arterial Pressure only. • MAP 70-85 mm Hg • Often have an ICD/Pacemaker Total Artificial Heart • Pulsatile • Externally perceptible • EKG asytolic or minimally active • NTG for SBP > 140 mm Hg • No cardioversion/defibrillation • No CPR • Normal BP • No ICD/Pacemaker
- 37. Total Artificial Heart • Surgically implanted, externally powered • Technically a “BiVAD”. • The lower ventricles are surgically removed • Takes up less space in the chest than a VAD.
- 39. TAH • The device is implanted in place of the lower portions of the heart, taking over a majority of its circulatory function
- 40. Bridge Therapy • Bridge Therapy offers a 62% chance of 2 year survival • Medical Therapy Less than 26% survival for 1 year • 10% 2 year survival https://healthblog.uofmhealth.org/heart-health/living-for- years-without-a-heart-now-possible
- 41. Wrapping up…
Editor's Notes
- The International Consortium of Circulatory Assist Clinicians.
- The basic parts of a VAD include: a small tube that carries blood out of your heart into a pump; another tube that carries blood from the pump to your blood vessels, which deliver the blood to your body; and a power source.
- https://www.eastidahonews.com/2016/09/my-heart-failed-and-today-i-become-part-machine/ There are over 1700 new devices inplanted each year.
- Implanted in heart failure patients Augments the function of the ventricles in circulating blood Sometimes implanted as a temporary treatment (“bridge therapy” , and sometimes used as a permanent solution “destination therapy” to very low cardiac output There are 3 common indications for implanting an LVAD: Bridge to Transplant The patient must meet criteria to be listed for a heart transplant The VAD is taken out at time of transplant Destination Therapy The patient does not qualify for a heart transplant but meets criteria for Destination Therapy The patient lives the rest of their life with an VAD Bridge to Recovery VAD for a few days or weeks, provides temporary support Ex. Patient with post partum cardiomyopathy
- The two basic types of VADs are a left ventricular assist device (LVAD) and a right ventricular assist device (RVAD). If both types are used at the same time, they may be called a biventricular assist device (BIVAD). However, a BIVAD isn't a separate type of VAD. The LVAD is the most common type of VAD. It helps the left ventricle pump blood to the aorta. The aorta is the main artery that carries oxygen-rich blood from your heart to your body. RVADs usually are used only for short-term support of the right ventricle after LVAD surgery or other heart surgery. An RVAD helps the right ventricle pump blood to the pulmonary (PULL-mun-ary) artery. This is the artery that carries blood to the lungs to pick up oxygen. Both an LVAD and RVAD (sometimes called a BIVAD) are used if both ventricles don't work well enough to meet the needs of the body. Another treatment option for this condition is a total artificial heart.
- What is the power source? The power source is either batteries or AC power. The power source is connected to a control unit that monitors the VAD’s functions. The batteries are carried in a case usually located in a holster in a vest wrapped around the patients shoulders. What does the control unit or controller do? The control unit gives warnings, or alarms, if the power is low or if it senses that the device isn’t working right. It is a computer.
- Auscultate below the apex the device sits below the diaphragm.
- By auscultating over the apex, providers will be listening over the device itself.
- 67 yo patient went into cardiac arrest after he accidentally cut his LVAD wires. ED physician reconnected with hemostats and restored flow.
- Because they have a blood pump, VAD patients may be stable in V-Tach or V-Fib VAD flows may be affected Persistent arrhythmias are treated after contacting the VAD coordinator Many VAD patients have an ICD / Pacemaker If patient’s ICD delivers a shock, notify VAD Coordinator Okay to defibrillate & cardiovert VAD patients per ACLS protocol Okay to administer anti-arrhythmic medications per ACLS protocol All VAD patients are on anticoagulation medications They are at high risk for embolic or hemorrhagic stroke. Level of consciousness may deteriorate rapidly Because patients are already anti-coagulated, they do not follow routine stroke protocol
- Bleeding is the most common complication and cause of readmission after VAD implantation.23 Of these, gastrointestinal bleeding (GIB) is the most common, occurring in 15% to 30% of patients across all device-types, especially among older patients with previous history.24,39,40 Various mechanisms, such as low-pulsatility, shear-stress leading to acquired von Willebrand deficiency, angiodysplasia (arteriovenous malformation) and anticoagulation have been proposed, with endoscopic or laboratory correlations.
- As the mechanism of infection is direct, excellent hygiene is imperative in addition to preoperative antibiotic therapy and avoidance of hematomas, which can be a nidus for infection. Early recognition and aggressive treatment are essential in preventing rapid dissemination of pathogen, which may ultimately require device exchange.
- https://well.blogs.nytimes.com/2011/02/14/a-plastic-heart-that-beat-for-three-days/?_r=0 “Nearly 42 years ago, the world’s first artificial heart was implanted in a history-making operation at St. Luke’s Hospital in Houston. The patient, 47-year-old Haskell Karp, was dying of heart failure and awaiting a heart transplant. The artificial device, implanted April 4, 1969, kept him alive for three days until a human heart was available for transplant. Sadly, he lived less than two days after the human heart was implanted. The procedure also led to one of the longest-running feuds in medical history. “ https://www.nytimes.com/2007/11/27/health/27docs.html?scp=1&sq=denton%20cooley&st=cse
- Total Artificial Heart is the only device that provides immediate, safe blood flow of up to 9.5 L/min through both ventricles to help vital organs recover faster. Once stable, Total Artificial Heart patients in the hospital are listed UNOS Status 1A and moved to the top of the transplant list. Compared to all heart devices, the SynCardia TAH has the highest rate of successful bridge-to-transplant.
- The two basic types of VADs are a left ventricular assist device (LVAD) and a right ventricular assist device (RVAD). If both types are used at the same time, they may be called a biventricular assist device (BIVAD). However, a BIVAD isn't a separate type of VAD. The LVAD is the most common type of VAD. It helps the left ventricle pump blood to the aorta. The aorta is the main artery that carries oxygen-rich blood from your heart to your body. RVADs usually are used only for short-term support of the right ventricle after LVAD surgery or other heart surgery. An RVAD helps the right ventricle pump blood to the pulmonary (PULL-mun-ary) artery. This is the artery that carries blood to the lungs to pick up oxygen. Both an LVAD and RVAD (sometimes called a BIVAD) are used if both ventricles don't work well enough to meet the needs of the body. Another treatment option for this condition is a total artificial heart.
- https://healthblog.uofmhealth.org/heart-health/living-for-years-without-a-heart-now-possible Stan Larkin, pictured above, a 25-year-old with a rare form of cardiomyopathy who lived for 555 days — outside of the hospital — using a Total Artificial Heart before receiving a heart transplant at UMHS in May. “He’s absolutely thriving now.”