Medical and nursing care of the child on mechanical circulatory support.

OBJECTIVES: To review the medical and nursing care of children receiving mechanical circulatory support as part of the Pediatric Cardiac Intensive Care Society/Extracorporeal Life Support Organization Joint Statement on Mechanical Circulatory Support. DATA SOURCES/STUDY SELECTION/DATA EXTRACTION/DATA SYNTHESIS: This is a general review of current issues of medical and nursing care of children on mechanical circulatory support. It consists of knowledge gained from practical experience combined with supporting evidence and/or discussion of controversies for which evidence exists or is inconclusive. The scope of this review includes assessment and monitoring, cardiovascular, pulmonary, and renal and fluid management, as well as infection prevention and treatment, neurological, and nutritional considerations. Physical and psychological care is discussed, as well as ethical and practical issues regarding termination of support. CONCLUSIONS: There are unique aspects to the medical and nursing care of a patient requiring mechanical circulatory support. Preserving the possibility for cardiac recovery when possible and preventing damage to noncardiac organs are essential to maximizing the probability that patients will have quality survival following support with a mechanical circulatory support device.

Developing and maintaining competency with circulatory assist devices: how to meet the challenge.

Heart failure is the only cardiovascular disease that is increasing in prevalence in developing countries. As a result, circulatory assist devices are being used more both as a bridge to heart transplantation and as destination therapy in patients with a failing heart. Nurses must become knowledgeable about these options for their patients. Developing and maintaining competency can be challenging as more devices become available. The principles of adult learners were used by one academic medical center to set up a new circulatory assist program and to maintain ongoing competency among staff working with patients who have these devices.

Mechanical circulatory support for the pediatric patient.

In adult patients, mechanical circulatory support (MCS) devices are part of the standard of care for heart failure. There are several options available that clinicians may use to provide support for their patients and thus the choice of devices can be tailored to their individual needs. Unfortunately, this is not the case for pediatric patients with heart failure, where the options for MCS modalities are far more limited because of size constraints and regulatory hurdles. Furthermore, the pathophysiology of heart failure in children is not identical to that of adults; thus, the device selection and configuration require different considerations. Management of pediatric patients on MCS requires a highly specialized team of pediatric professionals. The nurse caring for a child on MCS is an active participant in all aspects of the patient's care and must have an in-depth understanding of the patient's underlying physiology, the circulatory physiology of the MCS system, the reason for mechanical support, and the goal of support.

Uso de bomba centrífuga no pós-operatório de cirurgia cardíaca / Use of centrifugal pump in the postoperative period of cardiac surgery

Nos casos de choque cardiogênico após cirurgia cardíaca com auxílio da circulaçao extra corpórea refratários às drogas e ao balao intra-aórtico, as bombas centrífugas têm sido a primeira opçao em vários Serviços. Esse fato deve-se à facilidade de manuseio, de instalaçao, custo razoável, grande disponibilidade, e alto grau de eficiência. O objetivo deste trabalho é o relato da experiência do Instituto do Coraçao com 8 pacientes submetidos a essa terapêutica, no período de maio de 1990 a dezembro de 1991. Nesses 8 doentes foi utilizado previamente balao intra-aórtico e feito uso maciço de drogas vasoativas. A idade variou de 54 a 66 anos. Três foram submetidos a revascularizaçao do miocárdio, 2 a correçao de aneurisma de ventrículo esquerdo, 2 atroca de valva mitral e l atransplante cardíaco. Em 7 a assistência foi de ventrículo esquerdo e em l de direito. A duraçao da assistência variou de 18 a 126 horas. Ocorreram três óbitos em assistência, sendo que dois eram pacientes em "ponte" para transplante que nao obtiveram doador, e um morreu por complicaçoes de sangramento e insuficiência renal aguda. Dos 5 (62,5 por cento) pacientes retirados da assistência, 2 faleceram tardiamente sendo l com pulmao de choque e 1 com complicaçao neurológica e insuficiência renal. Quando comparamos a evoluçao clínica com o pico de CKMB, verificamos que os 3 pacientes com pico maior que 80 faleceram, 2 em assistência e l tardiamente. Dos 5 doentes com pico de CKMB menor que 80, 4 foram retirados de assistência, com 3 sobreviventes tardios, e o único que morreu em assistência foi por problemas de sangramento. Os 3 (35 por cento) pacientes sobreviventes estao no 5(, 9( e 19( meses de seguimento, 2 em classe funcional II e 1 em classe II. A utilizaçao precoce, antes de complicaçoes irreversíveis, da assistência circulatória, deverá permitir resultados progressivamente melhores, nesse grupo de pacientes de alto risco.

Symbion acute ventricular assist device: nursing challenge.

A cardiac patient is rapidly deteriorating and facing imminent death. The medical team decides to insert an experimental ventricular assist device (VAD) to perform the work of the dying heart. How can the critical care nurse best care for a patient with this challenging and unyielding diagnosis?

Nursing care of a patient requiring prolonged mechanical circulatory support.

Four cardiac transplant candidates were supported with ventricular assist devices for periods ranging from 53 to 90 days (mean, 75 days). The patients were men who ranged in age from 36 to 49 years (mean, 44.5 years). Two patients had Pierce-Donachy biventricular assist devices (BVADs) and two patients had Novacor left ventricular assist systems (LVASs). Complications included infection (3 patients), development of antibodies (2 patients), bleeding (2 patients), and pump inflow obstruction (1 patient). All patients were maintained on an anticoagulation regimen which included warfarin and dipyridamole. They were extubated and ambulatory for most of the period of mechanical support. Thromboembolic complications did not develop in any of these patients, and they did not acquire infections which involved the mediastinum. They were successfully transplanted and discharged 11 to 25 days after transplantation. Although major complications were common in this small group of patients, all four patients achieved hemodynamic stability and became excellent candidates for cardiac transplantation. With proper patient selection and meticulous nursing care, current mechanical circulatory support technology is capable of maintaining patients consistently for periods of greater than 50 days.

Nursing care of the patient with a pneumatic ventricular assist device.

Recent technologic advances have led to the development of safe and effective mechanical ventricular assist devices for clinical use. Pneumatic assist devices are being used at an increasing rate at a limited number of institutions throughout the country. One of the major factors in influencing survival of these critically ill patients is establishing standards of nursing care. We recently reviewed our experience of 41 patients who received a Pierce-Donachy ventricular assist device to evaluate the effectiveness of nursing care being provided to these patients. This article includes our most recent protocols of nursing care, which have evolved over the past 6 years. Nursing interventions to prevent or treat common complications such as bleeding, renal failure, and infection are discussed.

Left ventricular assist device as a bridge to heart transplantation: a case study.

Stanford University Medical Center has successfully utilized a left ventricular assist device as bridge support for 9 days in a 52-year-old man awaiting heart transplantation. During this time he developed a pericardial tamponade, but no other serious medical complications occurred. Major nursing care issues focused on pain control, vigorous pulmonary toilet, and left ventricular assist device timing. This article outlines the responsibilities of critical care nurses and what was learned from the experience. The recipient was discharged home 106 days after heart transplantation.