For patients on VA ECMO secondary to cardiogenic shock, providers may utilize LV Vents to offload the left ventricle. Why do we offload the ventricle? Because of the arterial outflow from the ECMO circuit increasing LV Afterload patients may experience pulmonary edema, LV distention and myocardial ischemia as well as increasing the risk of thrombus formation secondary to aortic valve dysfunction (Amancherla et al., 2021).
Varying options may be utilized in regard to the patients destination strategy
Bridge to Recovery: IABP or Impella
Bridge to Transplant: Atrial Septostomy
Post Cardiotomy: Direct LV Vent vs Device
When utilizing an IABP or an Impella as a vent for ECMO therapy, note that the device may have special considerations. Examples:
- IABP: Frequently not set to fill 100%. This is because we do not need complete balloon inflation for blood displacement and afterload reduction.
- Impella: Typically P2-P4 are max flow because this is adequate for LV decompression and at higher flows you may see a placement signal issue secondary to a lack of retrograde flow.
Nursing Considerations for Atrial Septal Defects (ASD) and Ventricular Septal Defects (VSD)
ASD are located the septum between the atria of the heart Patients born with ASD will have symptoms such as breathlessness and fatigue which can progress to atrial arrhythmias (Euan, 2004).
VSD are located in the septum between the ventricles of the heart.
Patients born with VSD will present with symptoms of heart failure and cyanosis, secondary to blood shunting. (Euan 2004).
Special Considerations to take into account for congenital patients with an active ASD/VSD :
- There may be assessment variances specifically geared towards left sided heart failure. Be mindful of changes to heart and lung auscultation and worsening symptoms of heart failure (Peyton et al., 2019)
- Accurate learning readiness assessments of the patient and family members are imperative for these patients to determine the appropriate communication and education techniques.
- These patients may have PA Catheters that are inserted under fluoroscopy, take special care to ensure it is locked to prevent migration.
- See Pharmacy Facts Below for education on micron filter use for congenital heart transplant patients.
LVAD Post-Operative Dressing Changes Starting on Post-op day (POD) 3, driveline dressings are changed daily using gauze dressings until POD8. From then on, VAD Centurion dressings are changed every 3 DAYS, unless otherwise ordered by a provider. If a patient has increased drainage or the patient develops a driveline infection, a gauze dressing is changed daily or as ordered by a provider. As with any dressing within the CVICU, if the VAD Driveline dressing becomes non-occlusive it should be changed IMMEDIATELY.
While we're talking about dressing changes.... Femoral line dressings are to be changed at a frequency of every 48 HOURS or PRN with drainage/ loss of occlusive nature.
Lines placed Brachial, Radial, Jugular etc. are changed at a frequency of every 7 DAYS or PRN .
Do not forget, it is Competency Season! All required competencies are due JUNE 16TH!
Filters for VSD/ASD Patients For all patients with a patent VSD/ASD as well as congenital patient, it is current practice to place medications through an IV infusion filter (0.2 Micron is the size, as pictured below). While this is true for MOST drugs, every drug cannot be run through a filter (even for congenital patients)
Examples of these medications include: Blood products, nitroglycerine, Insulin, and specific antibiotics and propofol.
Filters are placed after the manifold and proximal to the two way stopcock at the CVC site. There is a port on the filter for infusion of medications that are NOT compatible with the filter.
These filters are changed at the same frequency of IV Tubing (96 hours except for lipid containing drugs).
When caring for a patient with an active ASD/VSD or any congenital patient, please consult with the pharmacist what drugs you are running, to ensure the correct medications are running through a filter and those that are non-compatible with a filter are being administered safely without one.
Speaking of Drips.. Are you Charting yours Correctly? When charting your drips in eStar, drips must be charted with the dose AND the rate as pictured below. If you are only entering your volume infused (mL), this is not sufficient to verify drip rate and dose of the medication.
The verification of these medications can be done through manual entry, or by rate/dose verifying the medication then inputing your volumes.
By simply charting the volume, it can appear to advanced practice and physician providers that your patients are not on critical medications such as vasopressors, inotropes and thrombolytic medications.
Please elevate any questions to your CVICU leadership team.
As a JACHO requirement, admission assessments must be completed within 24 hours of admission. This includes the learning assessment. Because the nature of the CV patient does not always warrant the ability to perform an assessment, we have adjusted eStar to provide you a new option.
In the all-doc tab, you may now document implete admission requirements secondary to
- cognitive deficit (intubation or altered mental status)
this is a 24 hour place holder that gives the patient time to stabilize or family to arrive for completion of admission required documentation.
Please see JoAnna if you have any questions about this process!
On the VA ECMO platform, surgeons may utilize LV Vents to offload the left side of the heart, preventing severe complications.
Care for ASD/VSD patients requires special assessment skills and considerations.
VAD Centurion dressing changes are to be completed every 3 days, see policy for more.
Femoral dressings are changed every 48 HOURS.
0.2 Micron filters are required for congenital patients, or patients with ASD/VSD, ask pharmacy if you have questions about specific drugs.
You must chart the dose AND the volume of your drips every hour and with changes.
Admission requirements must be completed within 24 hours, see news letter for specific updates.
Do your competencies!!!
Upcoming Unit Involvement Opportunities for CVICU
References:
Amancherla, K., Menachem, J. N., Shah, A. S., Lindenfeld, J., & O'leary, J. (2021). Limited Balloon Atrial Septostomy for Left Ventricular Unloading in Peripheral Extracorporeal Membrane Oxygenation. Journal of cardiac failure, 27(4), 501–504. https://doi.org/10.1016/j.cardfail.2020.12.014
Ashley EA, Niebauer J. Cardiology Explained. London: Remedica (2004) Chapter 14, Adult congenital heart disease. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2212/
Peyton, C., Bedard, D., Williams, M., Wallrich, M. (2019). Critical Care Nursing of the Adult with Congenital Heart Disease. In: da Cruz, E., Macrae, D., Webb, G. (eds) Intensive Care of the Adult with Congenital Heart Disease. Congenital Heart Disease in Adolescents and Adults. Springer, Cham. https://doi.org/10.1007/978-3-319-94171-4_23
JJ Russo, N Aleksova, I Pitcher, E Couture, S Parlow, M Faraz, et al.(2019)
Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock
J Am Coll Cardiol, 73. pp. 654-662
