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Management of Young Children Requiring Ventricular Assist Devices – It’s Not All
That VAD!
Ashleigh Butgereit Harlow, BSN, RN, CCRN
Clinical Instructor, Cardiac Intensive Care UnitChildren’s National Health System
Washington, D.C.
I do not have any relevant financial relationships with any commercial interests to disclose.
Our Center
• Children’s National Health System in Washington, D.C.
• Academic free-standing pediatric facility– 303 beds– 124 critical care beds
Objectives
• To share our center’s experiences in caring for young children requiring ventricular assist devices (VADs)
• Discuss indications and contraindications for VAD use
• To describe strategies for encouraging developmentally appropriate, safe activities during hospitalization
• To describe utilization of specialized dressing and slings for device securement and enhanced wound healing
Children’s National Heart Institute
• CICU and Heart and Kidney Unit– eCPR– Cardiac Transplant– Mechanical Circulatory Support
Does your center implant/manage pediatric VADs?A) yesB) no
Indications For Use of VADs In Young Children
Infants & Children ( >3kg) who are candidates for cardiac transplant and also have:• Severe biventricular dysfunction• Severe isolated left ventricular dysfunction• Need mechanical circulatory support as a
bridge to cardiac transplant or as bridge to recovery
Indications For Use of VADs In Young Children
The Berlin Excor pump is the only device approved for use in pediatric patients (Humanitarian Use Device)• Frequent neurological complications (~30% of patients)• Inability to treat as outpatient
Contraindications
• Not a candidate for cardiac transplant• Inability to tolerate systemic
anticoagulation• Anticipated need for MRI• Presence of mechanical aortic valve• Special population challenges:– Single ventricle physiology (40-60 % mortality)
Post-Operative Goals
Immediate• Stabilization in the
CICU• 2:1 ratio
Long-Term• CICU • Mobility• Growth and
development• Family-Centered
Care• VAD Safety
If your center cares for pediatric VAD patients, where are hemodynamically stable patients cared for following extubation?
A) ICU onlyB) ICU and Step Down UnitC) Step Down and Acute CareD) Acute CareE) My unit is an admission-to-discharge unit
Getting Dressed
Dressing Changes at Children’s National
Basic Berlin Dressing Change Supplies
Complex Berlin Dressing Change Supplies
Adhesive Remover Puracol
Sterile Towels Arglaes Silver Powder
Cover Sponges (4x4) Quik Clot
Gauze Sponges (4x4) Drawtex
Chloraprep Swab Sticks
Silver Mepilex Dressings
Suture Removal Kit
Duoderm Xtra Thin
3M Skin Prep Pads
Roll of Twill Tie
Mepilex Standard (4x4)
Tubifast
Acticoat Flextend
Hypertonic (3%) Saline
Dressing Changes at Children’s National
Remove old dressing carefully using adhesive removerSterile Procedure• Don clean gown, sterile gloves, hat, and mask• Create sterile field with sterile towels• Scrub pump and cannulas (to the Dacron) with CHG (begin
at most distal aspects)• Apply sterile towel under pump• Clean cannula insertion sites, periwound skin, and Dacron
with CHG; air dry• Irrigate sites with 3% saline; air dry• Apply puracol to open areas (if needed)• Apply strips of hemostatic dressing to any oozing sites as
needed• Wrap 1-inch strips of Acticoat flex around cannula sites• Apply pre-cut Mepilex to each cannula sites• Wrap 4x4 around each cannula site• Apply 4x4 rolled gauze under each cannula site and
between cannulas• Apply several flat 4x4s to cover cannula sites and then
cover sponges over entire area• Apply duoderm to both sides of trunk; apply Hypafix tape
across large dressing to duoderm• Apply small transparent dressing(s) to inferior aspects of
dressing to water proof area• Cut Tubifast to make a cummerbund (to fit around chest);
insert tie twill tape to pre-cut openings• Apply mechanical heart sling made by PT to keep device
secure
Skin ProtectionSkin-Friendly Dressings
Photos Courtesy of June Amling, MSN, RN, CNS, CWON, CCRN
The Perils of Poorly Healing Skin
Photos Courtesy of June Amling, MSN, RN, CNS, CWON, CCRN
…there is often light at the end of the “wound healing” tunnel!
Photos Courtesy of June Amling, MSN, RN, CNS, CWON, CCRN
Vigilance and Anticipatory Management
Photos Courtesy of June Amling, MSN, RN, CNS, CWON, CCRN
Anticoagulation
Anticoagulation and the Patient Experience
• Anticoagulation is required for patients receiving mechanical circulatory support
• Subcutaneous injections may be painful and distressing
• Pain adjuncts (Buzzy©, topical analgesia)
• IV Lovenox
• Risks of Anticoagulation
Safety Considerations
Device Securement
Photos Courtesy of Mandana Fisher, PT, DPT
Device Securement
When caring for active toddlers with a VAD, what bed/crib strategy do you employ?
A) Open Crib or BedB) Crib or bed with enclosure mechanismC) Open Crib or Bed with Safety Attendant (sitter)D) Other
Safe Ambulation
Image courtesy of Jeremy Rusnock Photography, LLC. Used with permission.
Procedure for Intra-hospital Transport with Berlin Heart Patient • Pt must not be carried • Bedside RN must inform attending and charge nurse
when leaving the unit • A power source must be identified at destination • Pt must be accompanied by 2 members of the VAD
Team• Pt must travel with the following:
o Monitor o Oxygen tank o Self-inflating bag o Mask o 2 clamps (to use if cannulas become disconnected) o ¼ x ¼ connector (to repair a broken drive line) o Sterile scissors o Emergency medications
In case of emergency, the transporting team will activate the code team and call the CICU attending.
Growth and Development
Normalizing the Hospital Experience
• Child life specialists
• Music Therapy• Art Therapy• Movement
Therapy
Think Outside of the Patient’s Room!
Socialization
Photos used with permission.
Socialization
Copyright St. Louis Children’s Hospital
• Peer interaction• Infection control
Photosused with permission.
In Conclusion…
• Encourage normal growth and development• Emphasizing safe ambulation and device
securement
I’d love to hear from [email protected]
References• American Academy of, P. (Ed.). (2013). Children, Adolescents, and the Media. Pediatrics, 132(5), 958-961. • Berlin Buddies - Berlin Heart Patients Bond While Awaiting Heart Transplant. (n.d.). Retrieved September 1, 2015. • Byrnes, J., Bhutta, A., Rettiganti, M., Gomez, A., Garcia, X., Dyamenahalli, U., . . . Prodhan, P. (2015). Steroid Therapy
Attenuates Acute Phase Reactant Response Among Children on Ventricular Assist Device Support. The Annals of Thoracic Surgery, 99, 1392-1398.
• Cies, J., Santos, L., & Chopra, A. (2014). IV Enoxaparin in Pediatric and Cardiac ICU Patients. Pediatric Critical Care Medicine, 95-103. doi:10.1097
• Eghtesady, P., Almond, C., Tjossem, C., Epstein, D., Imamura, M., Turrentine, M., . . . Canter, C. (2013). Post-transplant Outcomes of Children Bridged to Transplant With the Berlin Heart EXCOR Pediatric Ventricular Assist Device. Circulation, S24-S31. doi:10.1161
• Fraser, C., & Jaquiss, R. (2013). The Berlin Heart EXCOR Pediatric ventricular assist device: History, North American experience, and future directions. Ann. N.Y. Acad. Sci. Annals of the New York Academy of Sciences, 1291, 96-105. doi:10.1111
• George, C., Ameduri, R., Reed, R., Dummer, K., Overman, D., & Louis, J. (2013). Long-Term Use of Ventricular Assist Device as a Bridge to Recovery in Acute Fulminant Myocarditis. The Annals of Thoracic Surgery, 59-60.
• Jordan, L. (2015). Neurological Complications and Outcomes in the Berlin Heart EXCOR® Pediatric Investigational Device Exemption Trial. Journal of the American Heart Association, 4, 1-11. doi:10.1161
• Kirklin, J., Pearce, F., Dabal, R., & Carlo, W. (2014). Mechanical Circulatory Support: Strategies and Outcomes in Pediatric Congenital Heart Disease. Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac Surgery Annual, 17, 62-68.
• Kirklin, J. (2015). Advances in mechanical assist devices and artificial hearts for children. Current Opinion in Pediatrics, 27(5), 597-603.
• Lisa, K. (2010, August 1). Yoga as a Complementary Therapy for Children and Adolescents A Guide for Clinicians. Retrieved September 16, 2015.
• Patregnani, J. (2015). Monitoring the Harm Associated with Use of Anticoagulants in Pediatric Populations Through Trigger-Based Automated Adverse-Event Detection. The Joint Commission Journal on Quality and Patient Safety, 41(3), 108-115.
• Singh, T. (2013). Letter by Singh Regarding Article, "Berlin Heart EXCOR Pediatric Ventricular Assist Device for Bridge to Heart Transplantation in US Children" Circulation, 128. doi:10.1161
• Sinha, P., Deutsch, N., Ratnayaka, K., Lederman, R., He, D., Nuszkowski, M., . . . Jonas, R. (2014). Effect of mechanical assistance of the systemic ventricle in single ventricle circulation with cavopulmonary connection. The Journal of Thoracic and Cardiovascular Surgery, 147, 1271-1275.
• Weinstein, S., Bello, R., Pizarro, C., Fynn-Thompson, F., Kirklin, J., Guleserian, K., . . . Jaquiss, R. (2014). The use of the Berlin Heart EXCOR in patients with functional single ventricle. The Journal of Thoracic and Cardiovascular Surgery, 147(2), 697-705.