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Cardio Pulm Eval > final - VAD > Flashcards

final - VAD Flashcards

1
Q

clinical criteria for LVAD

A
  • NYHA Class III to IV or refractory heart failure
  • Left ventricular ejection fraction <25%
  • Peak VO2 <14
  • Severe HF despite optimal medical therapy
  • Inability to tolerate medical therapy
  • Requiring inotropic support
  • Does not respond to Biventricular pacing
  • 1 or more HF related admission in past 6 months
  • Recurrent symptomatic ventricular arrhythmias requiring defibrillation.
  • Progressive cardio-renal syndrome and hyponatremia
  • Ineligible for cardiac transplantation
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2
Q

inappropriate VAD candidates

A
  • Irreversible major end-organ failure
  • Uncertain neurologic status
  • Severe hemodynamic instability
  • Complex Comorbid Condition (i.e.
    cancer)
  • Physical or visual impairment
  • Cognitive or mental impairment
  • Unable to Tolerate
  • Anticoagulation/Bleeding Disorder
  • Sepsis/active infection
  • Severe right heart failure
  • Unresolved psychosocial issues (noncompliance, poor support)
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3
Q

also cant get a VAD if you got

A

severe:
▫ Peripheral Vascular Disease
▫ Chronic Obstructive Pulmonary Disease
▫ Renal Failure
▫ Diabetes
▫ Malnutrition
▫ Obesity

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4
Q

what really is a VAD anyway

A

A ventricular assist device (VAD) is an
implantable device designed to partially replace
the function of the failing heart, providing
mechanical circulatory support to restore the
circulation of blood flow to the body

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5
Q

what does a VAD do

A

▫ Decreases preload
▫ Decreases cardiac workload
▫ Increases systemic circulation & tissue perfusion
▫ Decreases neurohormonal response

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6
Q

all VADs have these 4 parts:

A

▫ An inflow cannula which takes blood from the ventricle to the pump
▫ A pump
▫ An outflow cannula that takes the pumped blood to the ascending aorta
▫ A power source for the pump

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7
Q

what should MAP be for patients with VAD

A

65-85 mmHg

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8
Q

what is ECMO

A

ECMO is a life support machine used in patients with a severe and life-threatening illness that stopped their heart and/or lungs from working properly (ex. cardiogenic shock, infection)

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9
Q

what are the goals of ECMO

A

▫ Improve tissue oxygenation
▫ CO2 clearance
▫ Cardiac Output
▫ ECMO may also be used to support patients with heart or lung disease while waiting for a transplant

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10
Q

ECMO indications

A
  • Cardiac Index <2.2L/min/m2 or Sv02<60%, on two inotropes
  • Rising lactate, worsening metabolic acidosis
  • Hypotension with escalating doses of pressors/inotropes
  • Acute hypoxic or hypercarbic respiratory failure on mechanical ventilation
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11
Q

ECMO Contraindications

A
  • Acute intracranial hemorrhage
  • CPR duration- witnessed vs. not witnessed
  • Contraindication to anticoagulation
  • Advanced cancer
  • End- stage liver disease
  • End- stage kidney disease
  • Age
  • Psychosocial
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12
Q

Ambulation in ECMO patients

A
  • Requires mobility order from CV surgery at ACMC
  • Pt must be off sedation, alert, and follows commands
  • Hemodynamic stability
  • No bleeding at cannulation site
  • Perfusionist present for mobilization of patient
  • Team effort for successful mobilization
  • Please refer to hospital specific mobility protocols
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13
Q

total artificial heart eliminates

A

▫ Failing ventricles
▫ Malfunctioning heart valves
▫ Arrhythmias and other electrical complications
▫ Donor heart rejection

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14
Q

i did not include any of the VAD types in here bc i dont care and am not sure that it matters

A
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15
Q

goal of PT post LVAD

A
  • To provide the highest quality of life to patients with end stage heart failure through exercise and rehabilitation.
  • To provide readiness for discharge from the hospital.
  • To minimize duration of VAD support in bridge to transplant patients while optimizing their surgical outcomes.
  • To improve muscle mass and tone, maximize strength, flexibility, and exercise capacity, improve myocardial oxygen consumption and improve cardiovascular aerobic conditioning
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16
Q

post op VAD complications

A
  • Hypovolemia
  • Right Heart failure and
    Pulmonary hypertension
  • Cardiac tamponade
  • Bleeding
  • Arrhythmia
  • Infection
  • Stroke
  • Hemolysis
  • Thromboembolism
  • Neurologic dysfunction
  • Psycho-social issues
17
Q

inpatient issues post-VAD

A

▫ Surgical wound healing and care
▫ Maintenance of skin integrity
▫ Pulmonary hygiene and lung function
▫ Range of motion
▫ Cardiovascular endurance
▫ Muscle force production
▫ Education of patient and family

18
Q

patient monitoring during therapy

A
  • Heart rate – continuous via telemetry
  • Blood pressure – pre, mid and post-exercise
  • Sp02 – pre, mid and post exercise
  • LVAD rate and flow pre/post if on power
    module
  • Signs and symptoms – continuous
  • Rate of perceived exertion (Borg scale) – with
    each mode of exercise
19
Q

normal parameters post VAD

A

⚫ LVAD flows 4.0L/min – 8.0 L/min
⚫ Pulse Index (PI) 4.0-7.0 – Heartmate II only
⚫ Exception: low PI in Heartmate 3 is typical, contact VAD coordinator with concerns
⚫ MAP 65- 85 mmHg
⚫ SpO2 90%-100%
⚫ RR 12-20 bpm
⚫ HR 60-120 bpm
⚫ Resting Borg Scale RPE of 6
⚫ Resting Dyspnea Index of 0

20
Q

what does LVAD cause an increase of?

A

diastolic pressure and flow

21
Q

what happens when the pump speed of a heartmate II is increased

A
  • diastolic pressure increases
  • systolic pressure is equal
  • pulse pressure (systolic-diastolic) decreases
22
Q

6MWT

A

▫ Initiate during pre-VAD work-up as pt conditions allows
▫ Rest for 5 minutes prior to walk. Check resting BP, SpO2, HR, RPE, and Dyspnea.
▫ Begin walking on a level surface. Check vitals 3 minutes and 6 minutes. During recovery phase check vitals 5 minutes post test.
▫ Repeat when medically appropriate after VAD implantation and every month thereafter to measure gains

23
Q

precautions/contraindications for exercise

A
  • Chest pain, fatigue, dizziness
  • Subjective intolerance using Borg Scale of perceived exertion (>13 on scale of 6-20)
  • MAP> 120 mmHg or <60 mmHg
  • Pump flows and/or PI of <3.0 LPM - defer therapy
    ▫ If pump flow and/or PI = 2.5-3.0 LPM and not symptomatic use clinical judgment
  • Heart rate >150 bpm
  • Oxygen Saturation < 85%
  • Hazard or Advisory Alarms
24
Q

ideal treatment progression - POD #1

A

▫ Start BUE/BLE PROM
▫ Address pressure relief and repositioning issues

25
Q

Ideal Treatment Progression - POD #2-3

A

▫ Sitting edge of bed, begin AAROM/AROM to BUE/BLE
▫ Chair to bed with assist
▫ Begin education of VAD if patient is cognitively appropriate

26
Q

Ideal Treatment Progression - POD #4-6

A

▫ Patient should be able to independently perform sitting exercises 3x/day
▫ Patient should be able to transfer to batteries appropriately
▫ Progress to standing exercises and begin ambulation
–> If patient is hemodynamically stable and BLE strength >3/5

27
Q

Ideal Treatment Progression #7-14

A

▫ Standing AROM to BUE/BLE
▫ Increase ambulation length and intensity
▫ Progress to least restrictive device
▫ Begin stair negotiation
▫ Patient will be independent with VAD prior to discharge home

28
Q

Ideal Treatment Progression #15-20+

A

▫ Patient will progressively increased length of walking in 5 min increments each week
▫ 3-4 short walks should be taken each day
▫ OK to start resistive UE/LE strengthening exercises

29
Q

activity contraindications

A
  • Patient is not allowed to take a bath or go swimming –> Special shower care kit to prevent short circuiting- only for use in shower
  • MD will decide if patient can resume driving –> Pt should sit in the back seat or a seat without airbags
  • No excessive jumping or contact sports
  • No exposure to MRI
  • Avoid strong static discharge ( i.e. TV, computer screens, vacuuming carpets)
  • No pregnancy
  • No excessive hip flexion/extension
    ▫ No NuStep or PedEx – dependent on surgeon
    ▫ Treadmill may be contraindicated at certain sites
30
Q

advisory alarms

A

▫ Occur during battery exchange
▫ Low battery life
▫ Yellow Wrench in Heartmate II/3
 a fault related to the controller
back-up battery, controller, driveline, or controller hardware.
 Low speed advisory warning

31
Q

hazard or critical alarms

A

▫ Called Red Heart Alarm in Heartmate II/3
▫ Pump flow <2.5 lpm
▫ Pump has stopped (no power)
▫ Percutaneous lead is disconnected
▫ Pump is not working properly

32
Q

what should you do if a hazard alarm goes off

A

Fucking. Panic.
* Return the patient to supine as soon as possible
* Check all connections and power sources
* Immediately seek additional help
–> Page VAD team and on-call perfusionist

33
Q

does red alarm = unresponsiveness?

A

no
▫ Remember most VAD patients will still have heart function, but it will be significantly reduced just like prior to their VAD placement
▫ Power must be restored IMMEDIATELY
▫ When non-circulating blood is in the pump for more than a few minutes, the risk of stroke or thromboembolism increases should the device be restarted

34
Q

should you do chest compressions if the pump is running?

A

no

35
Q

what should you do in the even of cardiac arrest if the pump is not running?

A
  1. perform device check, check power source and all connections, change controller if instructed
  2. start chest compressions only if unable to restart the VAD pump or there are no signs of perfusion
36
Q

if external defibrillation is necessary:

A

▫ Leave the pump running
▫ Do NOT disconnect the system controller from the percutaneous lead before delivering the shock

37
Q

suction event

A
  • Occurs when pump speed drops to low speed limit setting from the higher fixed speed
  • Suction events can cause ectopic beats (ex. PVCs)
38
Q

what can cause suction event

A

▫ pump speed is too high
▫ decreased preload such as hypovolemia/dehydration, tamponade,
R heart failure or pulm HTN, bleeding, or vasodilation
▫ Poor inflow cannula positioning; obstructed by LV wall or septum

Cardio Pulm Eval (10 decks)

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