Ventricular Assist DeviceVentricular Assist DeviceExit Site CareExit Site Care

Nicole Graney, MSN, CNS-BCNicole Graney, MSN, CNS-BCVAD CoordinatorVAD Coordinator

Advocate Christ Medical CenterAdvocate Christ Medical Center

Ventricular Assist DeviceVentricular Assist DevicePercutaneous LeadPercutaneous Lead

Referred to also as:Referred to also as:

DrivelineDriveline

Perc LeadPerc Lead

This lead connects the This lead connects the implanted device to the implanted device to the external controller which external controller which

provides power to the provides power to the pump and controls pump and controls

operation.operation.

Thoratec Corporation. HeartMate II Patient

Handbook, 2008.

Percutaneous LeadPercutaneous Lead

The outside of the lead is covered with a special material (velour) that allows skin cells grow into it.

A well-healed exit site can lower the risk of infection.

Exit SiteExit Site

The exit site is the The exit site is the location where the location where the percutaneous lead percutaneous lead

goes out through the goes out through the skinskin

Caring for the Perc Lead Exit SiteCaring for the Perc Lead Exit Site

Keep the exit site clean, dry and covered. Keep the exit site clean, dry and covered. Ensure patient and caregiver performing proper hand Ensure patient and caregiver performing proper hand

washing and “aseptic technique” when changing bandage washing and “aseptic technique” when changing bandage or handling the exit site.or handling the exit site.

Keep perc lead stabilized using Stabilization Belt.Keep perc lead stabilized using Stabilization Belt. Protect the system controller from falling or from pulling on Protect the system controller from falling or from pulling on

the lead.the lead. Don’t allow the perc lead to catch or snag on anything that Don’t allow the perc lead to catch or snag on anything that

will pull or move the lead.will pull or move the lead. Check lead daily for signs of damage.Check lead daily for signs of damage. Report any concerns of damage or infection to patient’s Report any concerns of damage or infection to patient’s

VAD Coordinator.VAD Coordinator.

Assessment of Exit SiteAssessment of Exit Site

Tissue in-growthTissue in-growth DrainageDrainage Surrounding TissueSurrounding Tissue

Assessment of Exit SiteAssessment of Exit Site

Most VAD infections began at the Most VAD infections began at the perc lead exit site.perc lead exit site.

Accurate assessments allow the Accurate assessments allow the health care provider to identify and health care provider to identify and promptly treat driveline infections.promptly treat driveline infections.

If any concerns, please contact If any concerns, please contact patient’s VAD coordinator.patient’s VAD coordinator.

Tissue In-growthTissue In-growth

Refers to amount of tissue growing into the perc Refers to amount of tissue growing into the perc lead.lead.

If complete in-growth, should not be able to If complete in-growth, should not be able to retract back on abdomen and expose any velourretract back on abdomen and expose any velour Can be describe in percentagesCan be describe in percentages

Anywhere from 0 to 100 %Anywhere from 0 to 100 % Problem: Percentages may differ between person Problem: Percentages may differ between person

assessingassessing Can be described as Partial or Complete Can be described as Partial or Complete

Can specify where tissue in-growth is using hours on a Can specify where tissue in-growth is using hours on a clock using circumference of driveline as the clock.clock using circumference of driveline as the clock.

Complete in-growth from 2-6 o’clock positionComplete in-growth from 2-6 o’clock position

Tissue In-growthTissue In-growth

100 % Tissue In-100 % Tissue In-growthgrowth

Or Or

Complete Tissue Complete Tissue

In-growthIn-growth

DrainageDrainage

Important to NoteImportant to Note AmountAmount ColorColor OdorOdor ConsistencyConsistency

Surrounding TissueSurrounding Tissue

Appearance of Appearance of surrounding tissue surrounding tissue

may indicate may indicate presence of early presence of early infection, even infection, even

without drainage or without drainage or fever.fever.

Note any erythema, edema, Note any erythema, edema, blisters, hypergranulation blisters, hypergranulation

tissue etc.tissue etc.

InfectionInfection

Infection is one of the common causes Infection is one of the common causes of mortality in patient’s with VADs.of mortality in patient’s with VADs.

The treatment of VAD related infections The treatment of VAD related infections negatively impacts patient’s quality of negatively impacts patient’s quality of life and length of survival with VAD. life and length of survival with VAD.

Prevention of infection is one of the Prevention of infection is one of the primary goals of patient management.primary goals of patient management.

Risk for InfectionsRisk for Infections

Patients are at an increased risk for Patients are at an increased risk for infection.infection.

Chronic HF, poor nutrition, advanced age, Chronic HF, poor nutrition, advanced age, other co-morbidities (DM, COPD etc.).other co-morbidities (DM, COPD etc.).

Presence of foreign body (VAD and perc Presence of foreign body (VAD and perc lead), trauma to exit site, tension to lead), trauma to exit site, tension to wound edges, poor dressing care wound edges, poor dressing care technique.technique.

Signs of Symptoms of InfectionSigns of Symptoms of Infection

Localized Exit Site:Localized Exit Site: Redness, warmth, tendernessRedness, warmth, tenderness With or without positive culturesWith or without positive cultures New or increased drainageNew or increased drainage

Severe Exit Site Infections or Pocket Infections:Severe Exit Site Infections or Pocket Infections: Fever, Elevated White Blood Cell CountFever, Elevated White Blood Cell Count Purulent drainagePurulent drainage Pain at exit site or over devicePain at exit site or over device Positive wound culturesPositive wound cultures Fluid surrounding perc lead up to the deviceFluid surrounding perc lead up to the device Patient may become septic as a resultPatient may become septic as a result Fluid over device, erythema over pocketFluid over device, erythema over pocket

Progression of InfectionProgression of InfectionLocalizedLocalized

TreatmentTreatmentLocalizedLocalized

Increase frequency of driveline Increase frequency of driveline dressing changes if drainage presentdressing changes if drainage present

Immobilize perc leadImmobilize perc lead Start antibiotics if culture positiveStart antibiotics if culture positive Monitor frequently as outpatientMonitor frequently as outpatient Initiate aggressive wound care Initiate aggressive wound care

modalities: silver impregnated modalities: silver impregnated dressings, ultrasound mist therapy.dressings, ultrasound mist therapy.

Progression of InfectionProgression of InfectionSevere Exit Site/Pocket Severe Exit Site/Pocket

InfectionInfection

Treatment Treatment Severe Exit or Pocket Severe Exit or Pocket

Infections Infections HospitalizationHospitalization IV antibioticsIV antibiotics Aggressive Wound Care ModalitiesAggressive Wound Care Modalities Surgical Drainage of fluid collectionSurgical Drainage of fluid collection

Device Infection/SepsisDevice Infection/Sepsis

TreatmentTreatmentDevice Infection/SepsisDevice Infection/Sepsis

Surgical implantation of antibiotic Surgical implantation of antibiotic bedsbeds

Expose device to allow for constant Expose device to allow for constant drainagedrainage

Device Exchange as last resortDevice Exchange as last resort

Complications of Complications of Persistent Exit Site InfectionsPersistent Exit Site Infections

SepsisSepsis Exposure of deviceExposure of device StrokeStroke DeathDeath

TraumaTrauma

Trauma to perc lead either due to Trauma to perc lead either due to pulling, tearing, or dropping of pulling, tearing, or dropping of equipment may lead to infection, equipment may lead to infection, damage of equipment, or pump damage of equipment, or pump stoppage.stoppage.

Perc Lead FracturePerc Lead Fracture

If complete severing of electrical If complete severing of electrical leads, the pump will STOP!leads, the pump will STOP!

Patients may not survive pump Patients may not survive pump stoppage, or may go into cardiogenic stoppage, or may go into cardiogenic shockshock

Perc Lead FracturePerc Lead Fracture

Perc Lead FracturePerc Lead Fracture

Questions???Questions???