Difference between revisions of "Insertion of ventricular assist device"

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(surgical considerations)
 
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| airway = ETT
| airway = ETT
| lines_access = Large bore IV, central access, arterial line
| lines_access = Large bore IV, central access, arterial line
| monitors = Standard ASA, arterial line monitor, CVP, TEE
| monitors = Standard ASA, arterial line monitor, CVP, PA catheter, TEE
| considerations_preoperative =  
| considerations_preoperative =  
| considerations_intraoperative = Typically critically low EF requiring titrated induction
| considerations_intraoperative = Typically critically low EF requiring titrated induction. LVAD may have RH failure requiring RV support
| considerations_postoperative =  
| considerations_postoperative =  
}}
}}
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** Also can consider infusions for insulin, dexmedetomidine, ketamine, cefazolin, TXA, heparin
** Also can consider infusions for insulin, dexmedetomidine, ketamine, cefazolin, TXA, heparin
* Arterial line setup
* Arterial line setup
* Central line setup
* Central line setup w/ PA catheter
* TEE setup
* TEE setup


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** Infusion line (e.g. single lumen catheter)
** Infusion line (e.g. single lumen catheter)
** CVP monitoring
** CVP monitoring
**PA catheter monitoring
* TEE
* TEE


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=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
* CPB often used (full heparinization), though cardioplegia can usually be avoided
* For LVAD, as RPMs are increased, right heart may struggle to keep up with increased cardiac output
** Consider hyperventilation, FiO2 100%, inhaled nitric oxide, milrinone, dobutamine for RV contractility augmentation
* Aortic root vent and Trendelenburg after VAD is inserted to avoid air embolism


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
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=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
ICU
ICU, typically remain intubated


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

Latest revision as of 13:07, 19 August 2022

Insertion of ventricular assist device
Anesthesia type

GA

Airway

ETT

Lines and access

Large bore IV, central access, arterial line

Monitors

Standard ASA, arterial line monitor, CVP, PA catheter, TEE

Primary anesthetic considerations
Preoperative
Intraoperative

Typically critically low EF requiring titrated induction. LVAD may have RH failure requiring RV support

Postoperative
Article quality
Editor rating
In development
User likes
0

A ventricular assist device (VAD) is a pump designed to assist the left or right ventricle in severe heart failure. These devices may help the left ventricle (LVAD), the right ventricle (RVAD), or bilateral ventricles (BiVAD). The device may be placed as a permanent solution or as a bridge to cardiac transplant.

Overview

Indications

Severe heart failure

Surgical procedure

LVAD

Surgeons will perform sternotomy for exposure and either cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO). The device is placed at the apex of the left ventricle with an outflow graft anastomosed to the ascending aorta.

Preoperative management

Patient evaluation

System Considerations
Airway
Neurologic
Cardiovascular Critically low EF (15-20%) is not atypical. May also have underlying CAD, pulmonary HTN, and Grade 3 RHF
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Review cardiac studies including TTE, cardiac catheterization, etc.

Operating room setup

  • Infusions: norepinephrine and epinephrine
    • Also can consider infusions for insulin, dexmedetomidine, ketamine, cefazolin, TXA, heparin
  • Arterial line setup
  • Central line setup w/ PA catheter
  • TEE setup

Patient preparation and premedication

Regional and neuraxial techniques

N/A

Intraoperative management

Monitoring and access

  • Arterial line monitoring
  • Central access
    • large bore catheter (e.g. Cordis, MAC, etc)
    • Infusion line (e.g. single lumen catheter)
    • CVP monitoring
    • PA catheter monitoring
  • TEE

Induction and airway management

Pre-induction arterial line typically indicated. Very careful titrated induction due to critically low EF.

Positioning

Supine

Maintenance and surgical considerations

  • CPB often used (full heparinization), though cardioplegia can usually be avoided
  • For LVAD, as RPMs are increased, right heart may struggle to keep up with increased cardiac output
    • Consider hyperventilation, FiO2 100%, inhaled nitric oxide, milrinone, dobutamine for RV contractility augmentation
  • Aortic root vent and Trendelenburg after VAD is inserted to avoid air embolism

Emergence

Postoperative management

Disposition

ICU, typically remain intubated

Pain management

Potential complications

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Tony Wang

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