# LVAD's



## fma08 (Aug 13, 2008)

At our last company meeting, we were informed that there were now 2 people in our community that have "heart pumps" implanted. We were told that in case of an emergency, we were to be aware that they may be calling just us just so they have a power source for their device. 

Here is a link to some general info on them:

http://www.chfpatients.com/implants/lvads.htm

Anyway, my question is has anyone had to deal with a patient that has had one before? Or deal with complications of one? Just curious as to some possible precautions or things to think about when caring for these patients.


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## Flight-LP (Aug 13, 2008)

I've worked a few LVAD pts., I have never had an issue. All LVAD pts. will have a battery backup and a hand pump should something else other than the power supply fail. Just remember that if you have to hand pump it, you in essence are their left ventricle. I've heard of it done, but have never had to myself. It's very similar to an IABP failing during transport. In depth CE is an absolute must, preferrably from one of the CV surgeons who implants them.............................


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## Epi-do (Aug 13, 2008)

I learned something new today!  I hadn't even heard of these before.  I skimmed over the article, but will definately go back and read it more in depth once I get home from the fire house.


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## VentMedic (Aug 13, 2008)

It is amazing what technology is available to patients that allows them to go home for awhile and continue their lives.

This issue of *Cardiology Clinics *is devoted to cardiac assist devices.
http://cardiology.theclinics.com/issues/contents?issue_key=S0733-8651(00)X0004-5


*Outpatient management of long-term assist devices*
http://download.journals.elsevierhealth.com/pdfs/journals/0733-8651/PIIS0733865102001388.pdf

*Long-term implantable left ventricular assist devices: out-of-hospital program*
http://download.journals.elsevierhealth.com/pdfs/journals/0733-8651/PIIS0733865102001406.pdf

other links
*The Cardiologist’s New Frontier: Mechanical Support for Heart Failure*

http://www.texasheartinstitute.org/Education/CME/explore/events/eventdetail_5213.cfm

Good sites for those that like a little advanced reading.
http://www.texasheartinstitute.org/Education/CME/explore/searchEvent_XSL.cfm

*Excellent overview article of various assist devices. *
*Circulatory Assist Devices*  (includes IABP) (pages 15 and 16 show why there are specialities in the medical profession)
http://www.med.umich.edu/AnesCriticalCare/Documents/Rosenberg_Circulatory_Assist_Devices.pdf

*Advanced Issues in the Post-Operative Care of The Heartmate LVAD*
http://www.med.umich.edu/AnesCriticalCare/Documents/Rosenberg-Heartmate_LVAD.pdf

http://www.med.umich.edu/AnesCriticalCare/templates/education_resident_online_lecture_series.html

Also good articles on:
"Basics of Mechanical Ventilation" (Haas)
"Lung Protective Ventilation Strategies for ALI/ARDS Management" (Haas)
"ARDS & ALI: Continuing Challenges & Innovative Strategies" (Napolitano)
"Prone Positioning" (McMillan)
"Acute Respiratory Distress Syndrome" (Hyzy)
"Blood Substitutes"(Milligan)

I had referred to Prone Positioning and ARDS in another thread but didn't follow up with any links...until now.


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## Ridryder911 (Aug 13, 2008)

Although our area just now started placing them into patients we had several that went to Utah (where they were invented) for trial studies, etc. We actually started to have LVAD's patients about 12 years ago and have had several patients (about 25+) in a small community. Mainly they are patients that are young and can not await upon a donor heart. Some are as well terminal CHF patients; otherwise would be in good shape. 

One of our longest LVAD's patient is now on his third machine and has been on the device for at least 6 years. Yes, we have some patients that were technically in V-fib while the patient was pumping the manual pump (batteries went down). Now, talk about weird to see a patient in V-fib talking to you! As well, some have coded and we have had to intercept the device. We carry cheat cards as well as have biannual formal in-services with the team from the metro area, and used to also have a representative from Utah, and a patient with LVAD's. 

There are multiple types now that are being installed. So we have to be used to the different models. Each has its benefits and disadvantages. The new "jet" does not make as much noise or clicks/pumps but when it breaks down.. there is not much too do. The older models is loud, noisy, but can be worked upon and possibly re-established. 

In fact, the same local hospital that now perform these admit they very rarely or even plan on doing transplants anymore in lieu of placing the LVAD. Cost, rejection, and the main emphasis of finding a + donor appears to be the problem. 

Keep abreast of the new devices.. if you are not aware of them, you will be up a creek without a paddle. 

R/r 911


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## Jon (Aug 13, 2008)

I've seen some places that have worked with the county to get special dispatch instructions for the patient's residence to call for an aeromedical service to be placed on standby when EMS is activated for that patient.

The idea being that if the VAD fails, the patient needs to be transferred to the hospital that implanted it, because they are able to perhaps resolve the issue.


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## daedalus (Aug 13, 2008)

These devices..the implications for emergency cardiac care? What do we do should a patient have one implanted? Do all of them have pumps? It is amazing what can be done now in days.


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## Epi-do (Aug 13, 2008)

I haven't had a chance to look at any of the articles Vent posted, but I do plan on doing that.  

I was wondering though, what sort of changes do these devices cause on an ECG/EKG?  I know pacers have an affect on the tracing, and am guessing these devices most likely do as well.  Would they cause the QRS complex to be unusually wide?  Would you potentially see some sort of spike like you see with a paced rhythm?  Would the amplitude of the QRS be increased?

These questions very well may be answered in the above articles, but like I already said, I just haven't had a chance to look at them yet.  If they aren't, anyone that has had a patient with one implanted able to answer my questions anecdotally?


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## Ridryder911 (Aug 14, 2008)

It is not an electrical device as such as in a pacemaker. I have had patients in aystole and talking to me. It is an internal pump that actually circulates the blood. It uses a centrifuge type configuration and causes the blood to circulate throughout the body. Patients will see an immediate decrease in edema, increased cardiac output; however the noise, movement can be very irritating. Also the tubing are actually coming out of the body and one has to be of course on blood thinners.

Hopefully, this pic will be self explanatory. The straps hold the battery packs and the tubing's (etc) actually come out of the body and has to be cleansed often and most are on prophylactic antibiotics to prevent infection (which is common). 

As described there are different types and sizes. 


















R/r 911


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## VentMedic (Aug 14, 2008)

The basic assessment of the patient will be the same except you will be relying on color and consciousness for perfusion assessment as the quality of the pulses may vary with the make and model.  The EKG and assessment for electrical activity as well as the treatment will be pretty much the same although the power source may be an interference.  CPR becomes a serious question as dislodgement or damage to the equipment can cause death (but not always) and not doing CPR can cause death.   Hopefully your medical director and medical control will address these issues before you do see a patient requiring aggressive intervention.

These devices will also be found in the pedi population. 

Here's a JEMS article for an overview of prehospital care:
http://www.jems.com/news_and_articl...l;jsessionid=75943E9010AA48DFBD8E8471EFDFA0FC

Here is a good flight team case but will not be anything like what you will see in the home care situation:

http://www.universitymedevac.com/downloads/LVAD.pdf

Another case: 
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1336720

These two cases give you an idea of what is needed to prepare for if you want to do Flight and CCT with progressive teams.


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## Jeremy89 (Aug 14, 2008)

Ok, this is a random question, but WTF do they do with the blood while they implant this?  Same thing with open heart surgery.  How do the surgeons keep the body perfused and the brain supplied with O2?  Just curious if anyone knows...


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## VentMedic (Aug 14, 2008)

Jeremy89 said:


> Ok, this is a random question, but WTF do they do with the blood while they implant this?  Same thing with open heart surgery.  How do the surgeons keep the body perfused and the brain supplied with O2?  Just curious if anyone knows...




Extracorporeal Life Support (ECLS) or Cardiopulmonary Bypass 

http://www.med.umich.edu/AnesCriticalCare/Documents/Rosenberg_Circulatory_Assist_Devices.pdf

pages 14 - 18

Perfusionists
http://www.perfusion.com/cgi-bin/absolutenm/templates/articledisplay.asp?articleid=1549


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## Jeremy89 (Aug 14, 2008)

VentMedic said:


> Extracorporeal Life Support (ECLS) or Cardiopulmonary Bypass
> 
> http://www.med.umich.edu/AnesCriticalCare/Documents/Rosenberg_Circulatory_Assist_Devices.pdf
> 
> ...



Ah, i see.  Cool, thanks!


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## VentMedic (Aug 14, 2008)

A little clarification for CPR; hopefully the patient's family will be well versed and direct you to use the pump available before actual compressions.   Manual CPR compressions would be the last resort in most models.  As I stated before, damage and dislodgement to the device would probably not have a good outcome.  But, different devices may have different rules.  

Hopefully there will be some information on the patients in your area to assist your medical director in getting information to you for more training/education.   The hospitals that manage these devices will usually have classes in their education, CEU and inservice departments.  If contacted, their educators will probably send you information and updates on these devices. 

http://www.nursingcenter.com/prodev/ce_article.asp?tid=703667


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## Ridryder911 (Aug 14, 2008)

As well, most EMS should be abreast if there is a patient within their service area that has one. Hopefully, most hospitals will or have taught courses on how to deal with these patients when a patient receives one. What I have found though, is Physicians is the one's that are ignorant of the devices. Albeit they may know a little or "heard" of them; many do not know what to do if there is problems. 

We have a couple of "hot lines" to call for more advice. As well, the family has usually gone through extensive training and will usually have emergency information cards. 

There is debate upon the CPR issue as only when the patient appears symptomatic of poor cardiac output (dead). As one can see the device is located proximal to the myocardium and may cause damage but yet again if there is no perfusion it does not matter. We only had one patient that actually coded with the device. I remember the physician discussing on the phone with a nurse in Utah on what to do. Personally we did the usual cardiac arrest procedure, be extra cautious in defibrillation and making sure the LVAD was still functioning.. of course alarms where blaring and family obviously grieving. It was not successful. Please remember, these patients are in end stage as well they have worked very hard to stay alive (with the family).

Vent, I enjoyed reading the first case report. I have to admit, this type of patient always increases the "pucker" power by four fold and personally hate train wrecks. One is always amazed just how close to death a patient can be yet to be technically alive. 

R/r 911


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## VentMedic (Aug 14, 2008)

Thanks MMiz!

This is a test.   

Rid,
Thanks for posting more CPR clarification.   We are instructed to do compressions only in very are circumstances but have not done it.   Of course in the hospital we have other alternatives and I have been very lucky on transporting this type of patient.   

Either way, as you stated, the patients are end-stage and they (and families) knew what their alternatives were when they accepted the device.  Rarely will this be an option if the family and patient are not 110% on board.


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## daedalus (Aug 14, 2008)

It will be interesting in the future, should the FDA approve another Jarvik artificial heart. You cannot preform CPR with an artificial heart, so unless the patient carries some sort of device made for EMS should the heart fail, CPR, defibrillation, and cardiac drugs will be completely useless.


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## Ridryder911 (Aug 14, 2008)

While I worked in a CCU, it was not unusual to have "piggy back" hearts. Where the patient actually had two hearts.. one transplanted and the other the original. Talk about "funky" rhythms...


R/r 911


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## VentMedic (Aug 14, 2008)

daedalus said:


> It will be interesting in the future, should the FDA approve another Jarvik artificial heart. You cannot preform CPR with an artificial heart, so unless the patient carries some sort of device made for EMS should the heart fail, CPR, defibrillation, and cardiac drugs will be completely useless.



That has been done.  It is also mentioned in one of my previous circulatory assist links. 

TAH Total Artificial Heart
http://www.syncardia.com/index.php

I've got one of the coolest EKGs done during a piggy-back surgery at Loma Linda.  Loma Linda is known for its pedi and infant heart transplants.

Here's a "heart" warming story.

http://www.pe.com/localnews/inland/stories/PE_News_Local_D_heart16.40b741d.html


And here's at article from yesterday's news:
*Infant Heart Transplant Controversy Continues *

http://news.yahoo.com/s/hsn/20080814/hl_hsn/infanthearttransplantcontroversycontinues


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## daedalus (Aug 14, 2008)

I think this rates as one of the most interesting discussions we have had. Thanks to ventmedic and rid/ryder for all the expert input. I know I learned a good deal. I still do not understand the difference in the need for a IABP over a LVAD. Why would one be used over another?


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## Epi-do (Aug 14, 2008)

Thanks for all of the info, Rid and vent!  It just amazes me at all the new technology that keeps coming out and the things that modern medicine is capable of doing.


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## VentMedic (Aug 14, 2008)

daedalus said:


> I think this rates as one of the most interesting discussions we have had. Thanks to ventmedic and rid/ryder for all the expert input. I know I learned a good deal. I still do not understand the difference in the need for a IABP over a LVAD. Why would one be used over another?



The link I posted earlier on circulatory assist devices describes both.


The IABP is meant for short term to get a failing heart through something acute to buy time for healing, drug therapy, cath lab or surgery to be the definitive treatment.   The patient may only be on the IABP for 1 to 7 days usually.  Many times they may come out of the cath lab or OR on one and will be weaned off as the patient stabilized.   Something definitive was done to alleviate the acute failure. 

VADs are last resorts.  The heart has failed and there may be little chance for the heart to recover or be functional again.


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## Ridryder911 (Aug 14, 2008)

LVAD is portable as well as both have the same intent but NOT act the same. LVAD uses the vertex theory of pushing or propelling blood through the body either by jet or spinning device. 

IABP is a sheath tube with a balloon that is inflated on the wave form of the R-T period during systole. It is (usually) inserted in the femoral artery and placed into the lower descending aorta, where the inflation occurs synchronized with the ECG. When inflation occurs it actually increases the blood pressure by somewhat "shunting" or preventing the blood going to the distal perimeters. (Of course this description is watered down and from the top of the head) ...


R/r 911


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## Ridryder911 (Aug 14, 2008)

Epi-do said:


> Thanks for all of the info, Rid and vent!  It just amazes me at all the new technology that keeps coming out and the things that modern medicine is capable of doing.



Now, you can see where Vent and myself chuckle at those that describe or hint that one "can learn it all" mentality. Both of us have over 65+ years experience and have to continuously read, study and work  in clinical settings to maintain, be proficient and keep on top. 

Something I stress to all my students (no matter what level). If you decide to become an EMT or any member of the health care team, then you realize that for the remaining of your career, you will be required to read, study and keep abreast of things. If you don't; you will be dangerous to your career, your patient and to your profession. 

R/r 911


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## Airwaygoddess (Aug 14, 2008)

*Words to learn and live by........ Well said*

[

Something I stress to all my students (no matter what level). If you decide to become an EMT or any member of the health care team, then you realize that for the remaining of your career, you will be required to read, study and keep abreast of things. If you don't; you will be dangerous to your career, your patient and to your profession. 

R/r 911[/QUOTE]


This is something that is worth saying, to keep striving to learn, is one of the greatest gifts to patient care and to be part of a team.......-_-


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## Airwaygoddess (Aug 14, 2008)

*Airwaygoddess has some reading to do!*

Hmmmm...... this is going to be a triple Venti latte type of a reading night! ^_^^_^


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## VentMedic (Aug 14, 2008)

Ridryder911 said:


> Both of us have over 65+ years experience
> R/r 911



Clarification:  That is 65+ total for our years of experience added together and not EACH.  



IABPs and the VADs are shown at this site.  

http://www.texasheartinstitute.org/Research/Devices/iabp.cfm

This is one company that we use for IABP.
http://www.datascope.com/ca/cs100.html

http://www.datascope.com/ca/pdf/uts_ss.pdf

Datascope has an elearning section.
http://www.datascope.com/ca/elearning_programs.html


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## Ridryder911 (Aug 14, 2008)

VentMedic said:


> Clarification:  That is 65+ total for our years of experience added together and not EACH.



Dang .. the old age is creeping in. ...LOL Sorry, Vent did not attempt to make us any older than we are already!.....


R/r 911


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## VentMedic (Aug 21, 2008)

Here's an interesting update on a VAD.  The cost for research, developing, insertion and maintaining patients with these devices requires big investments with risks for the investors.

*Heart device pumping new life in patients, firm's bottomline*
http://www.insidebayarea.com/business/ci_10256926

The cost to the hospital and staff to train, educate and maintain competency with new technology as well as all the regular required education, updates and skill proficiencies is expensive.  The employees may also absorb some of this cost for their regular education.  To stay current the average RN and RRT working in Critical Care may easily spend over $1500 a year out of their pocket in addition to what the hospital provides.


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## Ridryder911 (Aug 21, 2008)

VentMedic said:


> The employees may also absorb some of this cost for their regular education.  To stay current the average RN and RRT working in Critical Care may easily spend over $1500 a year out of their pocket in addition to what the hospital provides.




Figure that + per speciality. (i.e. critical care, EMS, ED, Flight) I know I personally spent almost an 1/4 of my income either on courses or re-certification/professional fees. Enough to assist in my tax deduction. Unfortunate many hospitals and definitely EMS do not pay for all the required education to be the top of your field. 

I figure that this is just part of the sacrifice of being a professional and doing my job well. 

R/r 911


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