Ventricular Assist Device in the ICU
“Mechanical circulatory support aims to preserve life, restore, circulation provide optimal blood supply to metabolizing tissues, normalize organ function, and allow the heart to recover from an acute insult, and acute decompensation, or a progressive decline of a chronic disorder, without adding further compromise.”
1. Timing of intervention: short term vs. long term: Bridge to recover, to surgery, to transplantation, or to decision
2. Device and patient management: Goal of device implantation is to ensure optimal organ perfusion and ventricular decompression. Total systemic circulation output should exceed 2.2 L/min/m2, SVO2 more than 70%
2a. To achieve this, preload must be optimize
- Diuresis to prevent third spacing
- Maintain adequate intravascular volume with fluids, albumin, blood products to correct anemia
2b. Improve/preserve right ventricular function with diuretics,
arrhythmia treatment, avoiding, perioperative myocardial
ischemia, stunning, acidosis, and transfusions
3. Infection: A significant source of morbidity and mortality is infection. Prevent infection by removing indwelling lines and catheters as soon as possible, antibiotic prophylaxis, meticulous sterile techniques and dressing changes, driveline stablilization, early extubation and mobilization, and nutrition support.
4. Anticoagulation: All devices require heparin in the first 24-48 hours post implantation or after cessation of postoperative bleeding. Temporary devices should continue with heparin until decision is made. Long term devices should be converted from heparin to anticoagulant or antiplatelet pending type of device implanted.
Reference: Pitsis AA, et al. Update on ventricular assist device management in the ICU. Curr Opinion in Crit Care. 2008;14:569-578.
