Management of Young Children Requiring Ventricular Assist Devices

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 Unit Children’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 – e. CPR – Cardiac Transplant – Mechanical Circulatory Support

Does your center implant/manage pediatric VADs? A) yes B) no

Indications For Use of VADs In Young Children Infants & Children ( >3 kg) 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 only B) ICU and Step Down Unit C) Step Down and Acute Care D) Acute Care E) 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 (4 x 4) Quik Clot Gauze Sponges (4 x 4) Drawtex Chloraprep Swab Sticks Silver Mepilex Dressings Suture Removal Kit Duoderm Xtra Thin 3 M Skin Prep Pads Roll of Twill Tie Mepilex Standard (4 x 4) Tubifast Acticoat Flextend Hypertonic (3%) Saline

Dressing Changes at Children’s National Remove old dressing carefully using adhesive remover Sterile 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 4 x 4 around each cannula site • Apply 4 x 4 rolled gauze under each cannula site and between cannulas • Apply several flat 4 x 4 s 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 Protection Skin-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 Bed B) Crib or bed with enclosure mechanism C) Open Crib or Bed with Safety Attendant (sitter) D) Other

Safe Ambulation 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. Image courtesy of Jeremy Rusnock Photography, LLC. Used with permission.

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

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