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LVADs in the Emergency Department

LVADs in the Emergency Department. Zak Cerminara PharmD UW Medicine Resident September 4, 2014. Content. Background Pharmacotherapy Infections GI Bleeds Arrhythmias/Codes Miscellaneous. Patient Presentation. MJM 64 y/o male ICM s/p LVAD 6/2014 Hx of 2 recent admits for GI bleeds

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LVADs in the Emergency Department

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  1. LVADs in the Emergency Department Zak CerminaraPharmD UW Medicine Resident September 4, 2014

  2. Content • Background • Pharmacotherapy • Infections • GI Bleeds • Arrhythmias/Codes • Miscellaneous

  3. Patient Presentation • MJM 64 y/o male • ICM s/p LVAD 6/2014 • Hx of 2 recent admits for GI bleeds • Presented to the ED on 8/21 with solid, black stools since 1200 that day with mild fatigue

  4. PMH • Coronary artery disease • Hxof complete heart block • HeartMateII LVAD in place • Chronic anticoagulation • Hx of acute renal failure • Acute blood loss anemia • Protein calorie malnutrition • Situational depression • Insomnia

  5. Histories • Allergies: • NKDA • Family History: • Father: CVA • Brothers: DM • Social History: • EtOH: Occasional • Tobacco: Smoked for 40-45y, quit • IVDU: Denies

  6. Home Medication List

  7. Vitals • Admission to ED • Weight: 86.5 kg • Height: 6’ 1” • BMI: 25.2 • BP=MAP:61 • Temp: 36.7 • RR: 20

  8. Labs: CBC Labs: BMP

  9. Labs: LFTs Labs: Coagulation

  10. Background • Heart failure (HF) is increasing in prevalence • 5.7 million currently have diagnosis • 670,000 are newly diagnosed yearly • 1 year mortality rate is 20% • Less than 15% survive 8-12 years • Pharmacotherapy can be used to manage HF in the earlier stages • Transplant is the preferred therapy for end-stage HF • Left ventricular assist devices (LVADs) have become increasingly more popular Circulation. 2012 Jan 3;125(1):e2-e220.

  11. Background cont. • LVADs decrease symptoms by decreasing the work of the heart • LVADs: • Reverse HF • Bridge to transplant • Destination therapy Circulation. 2012 Jan 3;125(1):e2-e220. IntJ Cardiol. 2013 Oct 15;168(6):5143-8.

  12. Pharmacotherapy • Angiotensin-converting enzyme inhibitors (ACEIs) • Angiotensin II receptor blockers (ARBs) • Aldosterone Antagonists • Digoxin • Beta blockers • Diuretics • Hydralazine (+/- nitrates) • Warfarin Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  13. Infections

  14. Infections • Infection rates have been shown to be 25-80% • VAD-related infections should be treated aggressively • Common VAD-related infections • Driveline • Pocket • Mediastinitis • Pump endocarditis Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  15. J Heart Lung Transplant. 2011 Apr;30(4):375-84.

  16. Infections cont. • Goal of therapy is to keep infection confined to prevent progression • Device related infections do not prevent transplant • Non-VAD related infections require aggressive treatment Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  17. Infections cont. • Retrospective study by Nienaber et al. • They identified 101 episodes of LVAD infections in 78 of 247 patients (32%) • Most common infection: Drive line infections (47%) • Followed by VAD and non-VAD related BSIs (24% and 22%) • Pathogens: • Gram-positive cocci, staphylococci (45%) • Gram-negative bacilli, nosocomial (27%) • Chronic suppressive antimicrobial therapy: 42% • Intraoperative debridement: 14% • VAD removal: 3 patients Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  18. Bleeding

  19. Bleeding • Bleeding is the most common adverse event associated with VAD therapy • Common bleeding issues: • Epistaxis • Gastrointestinal bleeding • Vaginal bleeding • Cuts or other trauma • Complications after outpatient procedures • Bleeding may be related to: • Systemic anticoagulation • Operation • Acquired von Willebranddisease Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  20. Postoperative Bleeding • Immediate postoperative bleeding may be related to: • Adhesions • Cannulation sites • Coagulopathy • In many causes can be controlled using: • Blood products • Hemostatic agents(aminocaproic acid) • Desmopressin acetate • Protamine sulfate Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  21. Von Willebrand Syndrome • In a study of 26 patients with LVADs • All subjects developed von Willebrand syndrome • It was reversible on explant • A different prospective study examined the characteristics of von Willebrand syndrome related to LVADs • All patients developed von Willebrand syndrome • The cause is unknown • It may be due to the stress of the continuous flow VAD leading to proteolysis of the multimers Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  22. Hemolytic Anemia • Hemolysis occurs when RBCs lyse as they pass through the VAD • Related to platelet activation • Patients may develop symptoms: • Fatigue • Dark tea-colored urine • Icterus • Management includes: • Close monitoring • Possible addition of dipyridamole • May occur at a rate of 1.2% to 3% Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  23. Arrhythmias/Coding

  24. Arrhythmias • Arrhythmiasoccur in approximately 27% to 38% of VAD patients • Treatment options include: • Fluid boluses • Antiarrhythmic agents (amiodarone, beta-blockers +/- mexilitene) • Normalization of serum electrolyte • Weaning pressors • Direct current cardioversion/Defibrillation • Always continue preoperative antiarrhythmics after LVAD implantation Int J Cardiol. 2013 Oct 15;168(6):5143-8. CritCare Med. 2014 Jan;42(1):158-68.

  25. Coding • When terminal rhythms occur with power outputs indicating flow through the device use only: • Electrical cardioversion/defibrillation • Epinephrine • Atropine • When power output is low, compressions may be necessary • The major risk with chest compressions is dislodgement of: • The device • The outflow cannula • This is mainly of concern with the larger devices • Alternative is abdominal compressions, given 1–2 inches left of midline Int J Cardiol. 2013 Oct 15;168(6):5143-8. Resuscitation. 2014;85(5):702-4. doi: 10.1016.

  26. Abdominal Compressions • One case study of performed abdominal resuscitation in an LVAD patient successfully • Abdominal compressions can maintain a coronary perfusion pressure of 15 mm Hg • At ROSC, care should be taken to support the ischemic RV J CardiothoracSurg 2011; 6:91.

  27. Miscellaneous

  28. Miscellaneous • Neurologic • Turbulent flow leads to thrombus formation and stroke • Newer pumps decrease this risk • RV Failure • An imbalance can develop between the ventricles • Incidence ranges from 11.8% to 14.8% • Can lead to pulmonary hypertension • Multiple Organ Failure • Device Malfunction Int J Cardiol. 2013 Oct 15;168(6):5143-8.

  29. Back to MJM • Medications given in the ED: • Pantoprazole 80 mg bolus • Pantoprazole 8 mg/hr drip • Medications in the ICU: • Pantoprazole 8 mg/hr drip for total 24 hrs • Pantoprazole 40 mg PO BID through 8/27 • All home medications • Warfarin was held

  30. References • Roger VL, Go AS, Lloyd-Jones DM et al. Heart disease and stroke statistics 2012 update: a report from the American Heart Association. Circulation. 2012 Jan 3;125(1):e2-e220. • Pistono M, Corrà U, Gnemmi M et al. How to face emergencies in heart failure patients with ventricular assist device. Int J Cardiol. 2013 Oct 15;168(6):5143-8. • NienaberJJ, Kusne S, RiazT et al. Clinical manifestations and management of left ventricular assist device-associated infections. Mayo Cardiovascular Infections Study Group. Clin Infect Dis. 2013;57(10):1438-48. HannanMM, Husain S, MattnerF et al. Working formulation for the standardization of definitions of infections in patients using ventricular assist devices. International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2011;30(4):375-84. • Pratt AK, Shah NS, and Boyce SW. Left Ventricular Assist Device Management in the ICU. Crit Care Med. 2014 Jan;42(1):158-68. • RottenbergEM, Heard J, Hamlin R et al. Abdominal only CPR during cardiac arrest for a patient with an LVAD during resternotomy: A case report. J CardiothoracSurg 2011; 6:91. • Shinara Z, Bellezzoa J, Stahovich M et al. Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation. 2014;85(5):702-4. doi: 10.1016.

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