Page 11 - VAD Guidelines
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Pediatric Ventricular Assist Device (VAD) Guidelines

               emergent states of severe bleeding, they should be considered a last resort and administered slowly
               when necessary and after discussion with the surgeon. Bleeding is a serious adverse event of VAD
               therapy, however it is generally amenable to surgical re-intervention while procoagulants dramatically
               increase the risk of thrombosis which lacks adequate interventions. Hemoglobin should be maintained
               above 9 mg/dl and transfusion should be administered as needed, however rapid infusions should be
               avoided when possible as to avoid lung injury and acute increases in PVR.
               Hypertension
               Hypertension is common post device implantation, and when it occurs, continuous flow VAD output and
               hence systemic cardiac output can be compromised. In addition, adult studies have directly linked
               hypertension in continuous flow VAD patients with increased risk of both ischemic and hemorrhagic
                     4
               stroke . Control of hypertension is thus a critically important element to both post-operative and
               chronic care.  Normal values and goals for blood pressure control can be found both in Appendix 3 as
               well as Hypertension section in VAD complications for management.
               Infection Prophylaxis

               All patients require broad spectrum anti-microbial coverage following VAD implantation.  Patients with
               standard infectious risk based on pre-implant MRSA screening require operative as well as 48 hours of
               post-operative treatment with Cefuroxime. Patients with high infectious risk (i.e. pre-VAD ECMO, pre-
               VAD active infection, etc.) may require more prolonged treatment, and their regimen should be
               coordinated with the Infectious Disease, VAD, and ICU teams.  Patients with positive pre-implant MRSA
               screen should receive additional treatment with Vancomycin for 48 hours with dosing based on trough
               levels.
               RV support
               Right ventricular dysfunction and failure is at greatest risk in the immediate post-operative stage of
               implant recovery. Causes are multifaceted including the underlying etiology of heart failure, bypass
               related myocardial injury, volume shifts, and changes in pulmonary mechanics. Post-operative support
               should therefore be focused on maintaining right ventricular output and support.  Support with
               Milrinone 0.5 mcg/kg/min, Epinephrine 0.02-0.04 mcg/kg/min, and inhaled NO 20 ppm should be
               maintained for the initial 24 hours post-operatively with increased support as determined by patient
               hemodynamic requirements.  Attempts to wean support should be made in a stepwise fashion starting
               no earlier than 24-48 hours post-implant in order of inhaled NO followed by Epinephrine and finally
               Milrinone.  Patient and course-specific changes in immediate post-implant management should be
               tailored as determined in a coordinated fashion by the Cardiac Surgery, VAD, and ICU teams.
               Sedation
               Opioid are the first line of therapy for sedation in the post-VAD patient.  Titrations should be made as
               necessary for the patient’s level of illness and stability.  In the stable intubated patient, an SBS of 0 to -1
               should be attempted.  If a second line agent is necessary, consider Dexmedetomidine.  Benzodiazepines
               should be avoided for their side effect profile of hypotension, respiratory depression, and delirium. If
               Dexmedetomidine is used, care should be taken to slowly titrate as to avoid bradycardia and resultant
               negative effects on right ventricular function.

               Ventilation
               Attempts to maintain lung expansion and achieve functional residual capacity should be made if the
               patient is stable, attempts to wean the ventilator to minimal settings, and thus decrease the risk of lung




               Updated 3/24/2019                                                                      page 11
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