Perioperative Management of the Mechanical Circulatory Support Patient. American Association of Thoracic Surgeons Allied Health Symposium May 4, 2013

Transcription

1 Perioperative Management of the Mechanical Circulatory Support Patient American Association of Thoracic Surgeons Allied Health Symposium May 4, 2013

2 Disclosures None 2012 MFMER slide-2

3 Objectives Review the perioperative process of MCS therapy. Articulate assessment findings specific to the MCS patient. Identify common postoperative complications of the MCS patient. Outline treatment strategies for these postoperative and outpatient issues. Analyze current research and data pertaining to MCS MFMER slide-3

4 Perioperative Management Preoperative Evaluation Intraoperative Considerations Postoperative Management Transition to Outpatient Care 2012 MFMER slide-4

5 Preoperative Evaluation: Guidelines for Implantation Anticipated survival benefit NYHA Class IV heart failure symptoms CMS patient selection and coverage criteria: Failure to respond to optimal medical management (45 of 60 days) or IABP dependent (7 days) or IV inotrope dependent (14 days) Left ventricular ejection fraction of less than 25% Peak oxygen consumption of <14 ml/kg/min 2012 MFMER slide-5

6 Preoperative Evaluation: Evaluation for Candidacy Review of comorbidities Past medical and surgical history Pre-existing conditions Extensive evaluation Laboratory assessment Imaging Multidisciplinary approach Palliative Medicine and Chaplain services Social Services Physical Medicine and Rehabilitation 2012 MFMER slide-6

7 Optimization Assists with decreasing adverse events Hospitalization Optimization of: Right heart function Volume status Organ function Nutrition 2012 MFMER slide-7

8 Operative Considerations Medications Antiplatelet agents Beta blocker PPI Antibiotics Mupirocin Broad spectrum 2012 MFMER slide-8

9 Postoperative Management: Patient Assessment Non-pulsatile, continuous flow Device has an oscillating sound Typically: No palpable pulse Blood pressure monitoring Heart tones are distant, but can be heard Hands and feet should be warm Hemodynamic Monitoring: Heart rate manipulation through pacing CI greater than 2.2 MAP mmhg CVP mmhg 2012 MFMER slide-9

10 Postoperative Management: Pharmacologic Concerns Antibiotic regimen Initiated preoperatively and continued for 48 hours Endocarditis Prophylaxis Gastric Prophylaxis Diuresis Anemia management Heart Failure Regimen 2012 MFMER slide-10

11 Postoperative Management: Anticoagulation Heparin May use until INR is therapeutic Initiate when chest tube output decreases Aspirin Warfarin Initial INR goal 2-3 Adjustment based on clinical picture 2012 MFMER slide-11

12 Postoperative Management: Nonpharmacologic Therapy Nutrition Tight glucose control Early initiation of feeding Rehabilitation Site care Stabilization of the driveline Daily (for at least the first three months) Showering 2012 MFMER slide-12

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14 Case #1 67 yo M, ischemic cardiomyopathy HMII VAD as DT Medication regimen: diuretic therapy MAPs over last 24 hours mmhg VAD: low flow, high PI 2012 MFMER slide-14

15 Postoperative Complication: Hypertension Monitor blood pressure using manual cuff with Doppler Automatic cuff pressures are not as accurate due to continuous flow Mean goal mmhg Treatment: Hydralazine ACE If creatinine and potassium stable Beta-blocker Watch if RV function is marginal 2012 MFMER slide-15

16 Case #2 56 yo F dilated cardiomyopathy HW VAD as BTT Symptoms: edema, JVD, MAPs 60s, poor kidney function VAD: low flow 2012 MFMER slide-16

17 Postoperative Complication: Right Ventricular Failure Optimize before surgery Findings: CVP >20 mmhg Adequate speed, low flow Treatment Maintain adequate oxygenation Inotropic support Nitric oxide Phosphodiesterase-5 inhibitors RV support 2012 MFMER slide-17

18 Case #3 35 yo F, postpartum cardiomyopathy HMII VAD as DT Speed set at 9200 rpms, frequently drops to 8400 rpms 2012 MFMER slide-18

19 Postoperative Complication: Suction Event Device will sense a drop in flow or PI Likely due to dehydration, speed increase, RV dysfunction Speed decreases to prevent suction Can cause VT Treatment: Low CVP: volume repletion High CVP: consider RV dysfunction ECHO to rule out need for speed change 2012 MFMER slide-19

20 Case #4 62 yo M, ischemic cardiomyopathy HMII VAD as BTT Inpatient rehabilitation Symptoms: fatigue, weakness, unable to participate in therapy, nausea 2012 MFMER slide-20

21 Postoperative Complication: Arrhythmias Symptoms: fatigue, weakness, flu-like symptoms AICD therapies are turned back on when stable Assessment: Pump parameter changes: decrease in PI, low flow EKG ECHO Standard labs (CBC, K, Mg) Consider suction event Treatment: Optimization of electrolytes Amiodarone Defibrillation/Cardioversion: equipment connected Beta-Blocker Therapy 2012 MFMER slide-21

22 CPR CPR can occur, however, pump dislodgement may result, especially if less than 6 months post-implant. If no flow and unable to hear sound of pump, start CPR per ACLS guidelines. If able to hear pump, do not do chest compressions MFMER slide-22

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24 Postoperative Management: Hospital Stay Average length of stay is 23 days All patients are referred to Rehab 60% of patients will transfer to the Rehabilitation Unit prior to discharge Patient and family receives in depth education on the device care, maintenance, alarms, drive line care, and follow-up requirements prior to discharge Complete two independent excursions Community preparation 2012 MFMER slide-24

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26 Outpatient Management: Follow-up Encouraged to have a follow-up visit with primary care in one week of return home Coumadin management is transitioned to a local Coumadin Clinic or the primary care provider Cardiac Rehabilitation Follow-up within one month of return home per outpatient visit protocol Visits include: Labs, Chest x-ray, EKG, ECHO, ICD interrogation, VAD interrogation, right heart catheterization, six minute walk or oxygen consumption treadmill test Visit with Cardiology and VAD Coordinator 2012 MFMER slide-26

27 Activity and Lifestyle Restrictions Lifting restrictions: No lifting over 10 pounds the first 8 weeks No more than 20 pounds weeks pound limit for LIFE Cardiac Rehab is recommended, referral completed prior to Rehab Admission Driving: No driving for 6-8 weeks after surgery No laying on abdomen No contact sports or jumping No swimming or submersion No MRI or magnetic scanners at airport Sternal precautions 2012 MFMER slide-27

28 References Boilson, B., Raichlin, E., Park, S., & Kushwaha, S. (2010). Device therapy and cardiac transplantation for end-stage heart failure. Current Problems in Cardiology, 35, Boyle, A. J., Russell, S. D., Teuteberg, J. J., Slaughter, M. S., Moazzami, N., Pagani, F. D., & Frazier, H. (2009). Low thromboembolism and pump thrombosis with the HeartMate II left ventricular assist device: analysis of outpatient anti-coagulation. The Journal of Heart and Lung Transplantation, 28, Christensen, D. M. (2012). Physiology of continuous-flow pumps. AACN Advanced Critical Care, 22 (1), Cowger, J., Romano, M. A., Stulak, J., Pagani, F. D., & Aaronson, K. D. (2011). Left ventricular assist device management in patients chronically supported for advanced heart failure. Current Opinion in Cardiology, 26, Feldman, D., Pamboukian, S.V., Teuteberg, J.J. (2013). The 2013 International Society for Heart and Lung Transplantation guidelines for mechanical circulatory support: Executive summary. The Journal of Heart and Lung Transplantation, 32 (2), O Shea, G. (2012). Ventriculart assist devices: What intensive care nurses need to know about postoperative management. AACN Advanced Critical Care Journal 23 (1), Park, S.J., Milano, C.A., Tatooles, A.J., Rogers, J.G., Adamson, R.M., Steidley, E., et al. (2012). Outcomes in advanced heart failure patients with left ventricular assist devices as destination therapy. Circulation: Heart Failure, 5 (2), 1-8. Refaat, M., Chemaly, E., Lebeche, D., Gwathmey, J. K., & Hajjar, R. J. (2008, October). Ventricular arrhythmia after left ventricular assist device implantation. PACE, 31, Slaughter, M. S., Pagani, F. D., Rogers, J. G., Miller, L. W., Sun, B., Russell, S. D., & Starling, R. C. (2010, April). Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. The Journal of Heart and Lung Transplantation, 29(45), S1-S39. Wever-Pinzon, O., Stehlik, J., Kfoury, A.G., Terrovitis, J.V., Diakos, N.A., Charitos, C., et al. (2012). Ventricular assist devices: Pharmacological aspects of a mechanical therapy. Pharmacology and Therapeutics, 134, MFMER slide-28

29 Contact Information Elissa Yaw, RN, CNP Mayo Clinic Department of Cardiovascular Surgery 2012 MFMER slide-29