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

Environment of Care

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 you!aharlow@childrensnational.org

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.