ALL THE BELLS AND WHISTLES OF TROUBLING SHOOTING A VAD! · 2019-03-26 · ALL THE BELLS AND...
Transcript of ALL THE BELLS AND WHISTLES OF TROUBLING SHOOTING A VAD! · 2019-03-26 · ALL THE BELLS AND...
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ALL THE BELLS AND WHISTLES OF TROUBLING SHOOTING A
VAD!PATRICK C. CULLINAN, DO, FCCM, FACOEP, FACOI
Associate Clinical Professor, UIWSOM
Adjunct Assistant Professor, University of Texas Health Science Center,
Department of Emergency Medicine
San Antonio, Texas Methodist, Santa Rosa and Baptist Health Systems
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NO DISCLOSURES!
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OBJECTIVES:
•Review Types of Ventricular Assist Devices
•Discuss the physiology of VADs
•Review a systematic approach to evaluating a sick ED
patient with a VAD
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FACTS AND NOTHING BUT THE FACTS
•5.7 million people treated for heart failure
•50% with the diagnosis of CHF will die in the next 5 years
•> 30 Billion/year to treat heart failure
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VADS
•1st implanted left ventricular assist device was … 1966
•1st long term implant was … 1988
•1st FDA approval came in … 1994
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VADS
•Bridge to transplantation
•Bridge to decision
•Bridge to recovery
•Destination therapy
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VADS•Pulsatile
•HeartMate I
•Continuous
•HeartMate II
•Jarvik 2000
•HeartWare
•HeartMate III
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HEARTMATE I
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HEARTMATE II
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JARVIK 2000
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HEARTWARE
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VADS
•Axial
•Centrifugal
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AXIAL
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CENTRIFUGAL
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PRE-ARRIVAL
•Type of device
•Implantation hospital/VAD coordinator
•DNR status
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PHONE A FRIEND
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INITIAL ASSESSMENT•C, A, Bs …circulation/connections
•Mental status
•EKG
•US, Doppler … BP assessment
•Skin, capillary refill, signs of sepsis
•Caution with pulse ox
THINK LIKE ATLS
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SECONDARY ASSESSMENT•DEVICE
•Power
•Auscultate LUQ of abdomen – “HUM”
•Connections – Just like a ventilator
•Adjusting settings?
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VAD PARAMETERS•RPMs – Set
•Power – measured
•Directly proportional to flow across the pump
• Low – Low flow, high systemic BP
•High – High flow, pump thrombosis
•Flow – calculated, surrogate for cardiac output
•Pulse Index – reflects variation in ventricular
pressure
• Indirectly reflects LV contractility
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COMPLICATIONS•Cardiac arrest – CPR?
•AMS
•CVA
•Hemorrhage
•Sepsis
•Dysrhythmias
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COMPLICATIONS
•Cardiac arrest – CPR?
•Drugs - yes
•Compressions – maybe
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AMS
•Etiology
•Standard evaluation
•Treat the underlying problem
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CVA
•Ischemic
•Carotids
•Pump thrombus
•Hemorrhagic
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HEMORRHAGE
•Antiplatelet drugs
•Anticoagulants - Coumadin
•AVMs with GI bleeding (20-40%)
•Acquired Von Willebrand deficiency
•FFP
•Cryoprecipitate
•DDAVP and/or vasopressin
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SEPSIS
•Typical sites
•Drive line infection
•Early antibiotics
•Cover MDR and MRSA
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DYSRHYTHMIA
•Stable – medication
•Unstable - cardioversion
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COMPLICATIONS
•Hypovolemia…vasodilated, sepsis, diarrhea
•Bleeding…GI, trauma
•Hemolysis…Dark urine, jaundice
•Preload issue
•Clinical status, Power
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PRELOAD•Right heart failure
•Pulmonary hypertension
•Arrhythmia…afib, SVT, Vtach, Vfib
•Cardiac tamponade
•Thromboembolism…PE, pump clot
- PUMP POWER?
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AFTERLOAD
•Malignant hypertension
•Goal MAP 60-80
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RIGHT VENTRICULAR FAILURE•Increased pulmonary resistance
•Hypoxia, hypercarbia, acidosis
•Increased CVP
•Arrhythmia – afib, vfib, vtach
•LV pump malposition – suction events
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RIGHT VENTRICULAR FAILURE
•Management ?
•Cardioversion
•Inotropes
•Vasopressors
•Slowing RPMs
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SUMMARY•Phone a friend – VAD coordinator
•Rapid assessment of A, B, C, Device
• EKG, ECHO, US/Doppler BP
•Trouble shoot Device
•Ancillary tests
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SUMMARY•Treatment
• Cardioversion?
• Airway/Breathing
• Volume vs no volume
• Pressors vs inotropes vs antihypertensives
• RV and MAP
• Blood products?
• Antibiotics
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