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Ventricular Assist Device Complications

Ventricular Assist Device Complications. Suzanne Wallace MSN, ACNP-C Northwestern Memorial Hospital Bluhm Cardiovascular Institute September 19, 2009. Early Complications (In hospital). Bleeding Tamponade Arrhythmias Suction Events ARF. Late Complications. Infection RV Failure

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Ventricular Assist Device Complications

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  1. Ventricular Assist Device Complications Suzanne Wallace MSN, ACNP-C Northwestern Memorial Hospital Bluhm Cardiovascular Institute September 19, 2009

  2. Early Complications (In hospital) • Bleeding • Tamponade • Arrhythmias • Suction Events • ARF

  3. Late Complications • Infection • RV Failure • Pump malfunction • Thromboembolism • Hemolysis • HTN • CVA – hemorrhagic vs. embolic • GI bleeding/AVMs

  4. Bleeding/Tamponade • Monitor CT output, no anticoag until hemostasis achieved (approx 24hours), monitor Hct – • Other potential sources late: GI, epistaxis, gums etc • Tamponade – typical in hospital first 24-48hrs – may be delayed (ie – w/supratherapeutic INR) • S/S: Hypotension/low MAPs, High CVP, Low Flows, arrhythmias, abrupt cessation of mediastinal CT outtput • Tx: emergent OR, exploration, volume resuscitation

  5. Arrhythmias • VT or VF • S/S: • dizzy, low flows, low PI, low SV, fatigue, palpitations • Etiology: • consider suction event, hemodynamic, lytes • Tx: • Volume resuscitation, anti-arrhythmics (Amio), electrolyte repletion (K > 4, Mg > 2), cardioversion/defib

  6. Suction Events • S/S: • dizziness, low flows, low CVP (may be high with RV dysfunction), arrhythmias(VT), dampened waveforms • Etiology: • hypovolemia, rpm increases, cannula position, RV dysfunction • Tx: • Volume resuscitation, decrease rpms temporarily, treat arrhythmias

  7. Infection • S/S and exam: • Leukocytosis, fever, erythema, drainage, tenderness around driveline site, positve cultures, hyperdynamic flows, hypotension • Etiology: (multifactorial) • Poor dressing technique, improper immobilization of driveline, immunosuppression (ANC < 1000), diabetes, low albumin/poor nutritional status • Tx: • Antibiotics (po/IV depending on severity), Possible OR for exploration, fluid resuscitation, dressing changes/Vacs etc.

  8. RV Failure • S/S: • High CVP, hypotensive, low flows • Dx: • exam, confirm with echo • Etiology: • HTN, volume overload, multiple transfusions • Tx: • Inotropes (Milrinone, Dobut) Diuresis, Adequate ventilation, NO/Vasodilators (Nitrates), RVAD support if severe

  9. Pump Malfunction • Mechanical malfunction – continuous/loud or red alarms on all VADs are BAD!! • Assess pt – 911 if indicated – Call Vad Pager • Etiology: mechanical , thromboembolic events (high pump power) • Change system controller if indicated • Note: if pump stopped > 5minutes(continuous flow) do not attempt to restart – support pt hemodynamically – will get TPA/thrombolytics – prior to restarting pump/going to OR (Directed by VAD implanting Center)

  10. Thromboembolism • Monitor for increasing pump power, look for thrombus (IVAD) • Maintain adequate speeds to maximize pump flow • Proper Anticoagulation – Goal INR 1.7-2.5 for most devices • Notify Vad coordinator – analyze waveforms • Severe – pumps can stop – need urgent OR

  11. Hemolysis • More common on pulsatile VADs • S/S: • Elevated LDH, Plasma Free Hgb, low H/H • Dark urine • Etiology: • Inflow/outflow occlusions, Pulsatile VADs – valves, Liver dysfunction, Multiple transfusions • Tx: • Pulsatile vads: decreasing rate, vaccuum • Continuous Flow VADs: temporarily reduce pump speed, • Transfuse

  12. Hypertension • S/S: • MAPs > 80, SBP > 120-140; Low Flows, High PIs, Possible Headache • Etiology: • Chronic HTN, Volume overload, Pain/Anxiety • Tx: • Antihypertensives: BBlocker ( if No RV- dysfunction), Ace-I (if Crt stable), Hydralazaine, Norvasc • Treat Pain/Anxiety • Diuresis

  13. Stroke • S/S: • HA, slurred speech, visual changes, unilateral weakness, numbness or paresthesias • Etiology: • hemorrhagic vs. thromboembolic – check INR, MAP/BP • Tx: • Medical Emergency: 911 – then Vad coordinator • Tx underlying cause – antihypertensives, give thrombolytics if indicated – (Head CT/Neuro consult) etc..

  14. GI bleeding/AVMs • S/S: • Abdominal pain, low H/H, blood in stool or emesis • Dx: • Colonoscopy, IR, guiac stool • Etiology: • Continuous flow/high pump speed?, supratherapeutic INR, antiplatelet, HIT pts • Tx: • Decrease coumadin dosing, antiplatelet agents, transfuse if indicated, Tx

  15. Summary • Multiple complications possible • Astute assessment skills • Early intervention • Notify Vad coordinator ASAP when complications Arise

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