LVAD's

[fma08]

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.

 

[Flight-LP]

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.............................

 

[Epi-do]

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.

 

[VentMedic]

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.

 

[Ridryder911]

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

 

[Jon]

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.

 

[daedalus]

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.

 

[Epi-do]

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?

 

[Ridryder911]

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

 

[VentMedic]

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.

 

[Jeremy89]

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...

 

[VentMedic]

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

 

[Jeremy89]

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

Ah, i see. Cool, thanks!

 

[VentMedic]

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

 

[Ridryder911]

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

 

[VentMedic]

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.

 

[daedalus]

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.

 

[Ridryder911]

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

 

[VentMedic]

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

 

[daedalus]

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?