LVADs, Supraglottic Airways and CPAP

Transcription

1 LVADs, Supraglottic Airways and CPAP David M. Landsberg, MD, FF/EMT-P, FACP, FCCP Chief of Medicine Crouse Hospital Associate Professor of Medicine and Emergency Medicine Upstate 38MD-1, 83MD-1, 98MD-4

2 I have no relevant conflicts to disclose

3 LVADs in CNY URMC has 160 LVADs in the community Approximately 40 in CNY 3 Artificial Hearts at URMC No Total Artificial Hearts in the community

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9 Jarvik Post-Auricular Cable White Pump Blue Internal Cable Green Connector Yellow Controller Grey Battery Black External Cables

10 Jarvik Post-Auricular Cable

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18 LOOK Connections intact? Green light?

19 LISTEN Hum? If no hum, back to Look If Look not helpful then forward to Feel

20 FEEL Control Box Temperature Thrombosis of pump or outflow cannula Dislodgement outflow cannula Distal Obstruction

21 Complications Major VAD Complications Bleeding Thrombosis Infection sepsis is leading cause of death in long-term VAD support RV dysfunction/failure Suckdown (low preload causes a nonpulsatle VAD to collapse the ventricle) Device failure/malfunction (highly variable by device type) Hemolysis (the VAD destroys blood cells)

22 Complications Other Common Issues Hypertension High afterload can limit VAD flow/ output Do not administer antihypertensive medications or nitrates unless instructed by a physician or VAD Coordinator Hypotension/ loss of Preload All VADs are preload dependent. A loss or reduction in preload will compromise VAD function and limit flow/ output

23 Complications Other Common Issues Depression/ Adjustment Disorders Living with a VAD is difficult to management for a lot of patients. A large percentage of patients experience symptoms of depression Portability/ Ergonomics The external VAD equipment is heavy and cumbersome limiting a patient s mobility and greatly impacting their quality of life.

24 Complications Bleeding & Thrombosis Careful control of anticoagulation is imperative Patients are often on both anticoagulants and platelet inhibitors Device thrombosis rare in pulsatile devices typically revealed by increased power and signs and symptoms of hemolysis

25 Complications Bleeding & Thrombosis Tx Assess for signs and symptoms of bleeding Neuro Assessment to rule out CVA Initiate IV therapy and administer fluid slowly to maintain preload Device Thrombus is treated with low dose lytics and/ or increasing anticoagulation therapy

26 Complications Infection The leading cause of mortality in VAD patients Higher incidence in pulsatile VADs Direct access into the body and into the blood stream Often recurrent and difficult to treat

27 Complications Treating Suckdown Initiate a peripheral IV and slowly give volume to increase preload If able and instructed by the VAD Coordinator, reduce the speed of the VAD Assess for signs and symptoms of bleeding and sepsis

28 Complications Hemolysis Blood cells are destroyed as they travel through the VAD More common in non pulsatile devices

29 Complications Treating Hemolysis Initiate a peripheral IV and slowly give volume If able and instructed by the VAD Coordinator, reduce the speed of the VAD If thrombus is suspected to be causing hemolysis, administer lytics and anticoagulants as able/ ordered

30 Alarms All VAD devices typically have two distinct alarms to indicate a problem and severity Advisory Alarms Critical/ Hazardous Alarms

31 Alarms Advisory Alarms are intermittent beeping sounds that have a corresponding YELLOW light that illuminates on the system controller Not critical but the device requires attention Likely due to low battery, cable disconnected, or device not functioning properly.

32 Alarms Hazardous or Critical alarms are a loud, continuous, shrill sound that have a corresponding RED light that illuminates on the system controller Indicating the device needs immediate attention Often because the pump has stopped or a problem is detected with the system controller Most likely intervention required is to change out the system controller

33 Field Management All VADs are dependent on adequate preload in order to maintain proper functioning Volume resuscitation in an unstable VAD patient is the first line of therapy before vasopressors but be cautious with fluid as to not over load the right ventricle in L VADs only.

34 Field Management Nitrates can be detrimental to a VAD patient because of the reduction in preload Results in decreased pump efficiency Consult with medical control before administering nitrates per protocol

35 Field Management Initiate IV therapy with all VAD patients if possible Use especially careful aseptic technique due to the patient s increased risks of infection

36 Field Management VAD patients are susceptible to other injuries unrelated to the VAD Contact the VAD Coordinator, they are your most valuable resource when encountering these patients Consult with medical control about transport

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38 Patient Transport This is emergency, resource and protocol driven decision making VAD patients require unique care that not all medical centers are equipped to handle. Transport to the implanting center when able or the closest VAD center Make sure when transporting to bring all VAD related equipment Secure VAD batteries and the controller to prevent dropping or damage Make sure to keep all cables tangle and kink free

39 LVAD Key Facts Let patient and/or caregiver lead. They will be your experts. Remember not to perform chest compressions because they could dislodge the pump, making the patient bleed to death. (Unless the patient is in obvious cardiac arrest and the pump isn t working. Use the assistance of the VAD coordinator to figure this out before starting any compressions). Perform all other BLS/ACLS protocols as written. Defibrillate/cardiovert as normal. Don t place pads over the device under the patient s skin.

40 LVAD Key Facts Remember that these patients typically have an extremely reduced pulse rate or none at all. A Doppler device and manual blood pressure cuff are the most accurate way to obtain blood pressure. The first sound heard is approximately equivalent to the mean arterial pressure, and mmhg is the acceptable range.

41 LVAD Key Facts Keep in mind that it may be difficult to obtain accurate O2 saturation because of little or no pulse. Be careful when removing/cutting off clothes to ensure you don t cut through the driveline, which is the power cord of the pump. Avoid kinking or twisting driveline when strapping the patient onto the stretcher. Keep batteries and controller in reach and secured to the patient during transport. Keep them dry.

42 LVAD Key Facts Take the patient s emergency travel bag when leaving the scene. It has an extra controller, batteries and the VAD coordinator s emergency contact number. Keep in mind that the most common complications are bleeding (nasal, gastrointestinal or intracranial), thromboemboli (pulmonary embolism, myocardial infarction or cerebrovascular accident), rightsided heart failure, pump malfunction and infection.

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44 Supraglottic Airways

45 King Airway

46 King Airway

47 King Airway

48 Laryngeal Mask Airway

49 Laryngeal Mask Airway

50 Laryngeal Mask Airway

51 Fast Trach LMA

52 CPAP

53 CPAP and Obstructive Lung Disease

54 CPAP and Recruitment

55 CPAP and Ventilation

56 Oxygenation versus Ventilation Now hold your breath Note what happens to the two waveforms SpO 2 EtCO 2 How long did it take the EtCO 2 waveform to go flat line? How long did it take the SpO 2 to drop below 90%?

57 Numeric reading: HR 100 Waveform:

58 Numeric reading: HR 100 Waveform:

59 End-tidal CO 2 (EtCO 2 ) Pulmonary Blood Flow Ventilation Right Ventricle Artery Oxygen Vein Left Atrium CO2 O 2 O 2 Perfusion

60 End-tidal CO 2 (EtCO 2 ) Reflects changes in Ventilation - movement of air in and out of the lungs Diffusion - exchange of gases between the air-filled alveoli and the pulmonary circulation Perfusion - circulation of blood

61 End-tidal CO 2 (EtCO 2 ) Monitors changes in Ventilation - asthma, COPD, airway edema, foreign body, stroke Diffusion - pulmonary edema, alveolar damage, CO poisoning, smoke inhalation Perfusion - shock, pulmonary embolus, cardiac arrest, severe dysrhythmias

62 Capnographic Waveform Waveforms on screen and printout may differ in duration On-screen capnography waveform is condensed to provide adequate information the in 4- second view Printouts are in real-time Observe RR on device

63 Capnographic Waveform Capnograph detects only CO 2 from ventilation No CO 2 present during inspiration Baseline is normally zero C D A B E Baseline

64 Capnogram Phase I Dead Space Ventilation Beginning of exhalation No CO 2 present Air from trachea, posterior pharynx, mouth and nose No gas exchange occurs there Called dead space

65 Capnogram Phase I Baseline A B I Baseline Beginning of exhalation

66 Capnogram Phase II Ascending Phase CO 2 from the alveoli begins to reach the upper airway and mix with the dead space air Causes a rapid rise in the amount of CO 2 CO 2 now present and detected in exhaled air Alveoli

67 Capnogram Phase II Ascending Phase C Ascending Phase Early Exhalation II A B CO 2 present and increasing in exhaled air

68 Capnogram Phase III Alveolar Plateau CO 2 rich alveolar gas now constitutes the majority of the exhaled air Uniform concentration of CO 2 from alveoli to nose/mouth

69 Capnogram Phase III Alveolar Plateau Alveolar Plateau C III D A B CO 2 exhalation wave plateaus

70 Capnogram Phase III End-Tidal End of exhalation contains the highest concentration of CO 2 The end-tidal CO 2 The number seen on your monitor Normal EtCO 2 is 35-45mmHg

71 Capnogram Phase III End-Tidal C D End-tidal A B End of the the wave of exhalation

72 Capnogram Phase IV Descending Phase Inhalation begins Oxygen fills airway CO 2 level quickly drops to zero Alveoli

73 Capnogram Phase IV Descending Phase C D A B IV Descending Phase Inhalation E Inspiratory downstroke returns to baseline

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75 Intubated with lost patency

76 Leak or Obstruction

77 CPR

78 Return of Spontaneous Circulation

79 COPD/Asthma

80 Hypoventilation

81 Hyperventilation

82 Resumption of Spontaneous Respiration

83 Rebreathing of Exhaled CO2

84 Esophageal Intubation

85 Incomplete ETT Seal

86 Esophageal Intubation or Apnea

87 Disadvantages Sampling tube obstruction Loose connection Suctioning through ETT

88 Rarely ET tube correct placement but EtCO2 = Zero IF. Equal clear lung sounds No resistance with the esophageal detection device (EDD) No epigastric sounds Direct visualization of the tube passing through the cords THEN = Cardiac Output Problem

89 Summary Where there is metabolism and ventilation there is CO 2 If the ET tube is correctly placed there should be a capnography reading Capnography is more than just ET tube confirmation Ventilation status Prediction of ventilatory failure Real time respiratory rate ph and cardiac output correlation

90 65 y/o cachectic female O2 dependent COPD Active smoker SOB 80% SaO2 on 5L, RR 35

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92 25 y/o male asthmatic 6 4, 240 lbs Severely dyspneic SaO2 90% on NRB, RR 32

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94 50 y/o morbidly obese male Lethargic 88 % SaO2 on RA 92% on 4L

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96 Progressively lethargic, becomes unresponsive.

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100 20 y/o male unrestrained driver, ejected BLS in progress by Fire on your arrival Unconscious, unresponsive Unequal pupils

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104 50 y/o male COPD Failed CPAP with progressive lethargy and hypoxia Intubated en route to ED VCV, BLEBS, EtCO2 40

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