Page 10 - VAD Guidelines
P. 10

Pediatric Ventricular Assist Device (VAD) Guidelines

               Initial ICU Support (First 48 hours)

               Anticoagulation should be considered 6 hours post implant (or sooner if fibrin deposits or clots are
               observed in paracorporeal support) provided post-surgical hemostasis has been achieved and the
               following criteria have been satisfied:
                   •  Fibrinogen level >100
                   •  Platelet count >100
                   •  Chest tube output <3ml/kg/hr x6 hours consecutively

               Selection of systemic anticoagulant agent of choice is dependent upon multiple factors including pre-
               implant coagulation studies, patient age and likelihood of developmental hemostasis, and device
               selection. Though any anti-coagulation guideline is subject to modification as indicated by patient
               factors, heparin-based agents are utilized in the durable VADs (Heartware, HeartMate 3, Syncardia) as
               well as Impella while Bivalirudin is used in paracorporeal devices (PediMag, CentriMag, Berlin).
               Comprehensive anti-coagulation guidelines for both Heparin and Bivalirudin regimen are provided in
               Appendix 2. Of critical importance to any anti-coagulation regimen is the reliability of lab monitoring for
               dose titrations. Therefore, the use of heparin should be avoided for any line used for anti-coagulation
               blood draws, preferably for the life of the line. Standard practice at Children’s Health has been to utilize
               heparin-free arterial line fluid for this purpose. However, PICC lines placed for patients requiring
               systemic anti-coagulation for heart failure risk or in patients suspected to require mechanical support
               should similarly be heparin-free from the time of line placement and for the life of the line.
               Chest Tube

               Chest tube removal will be directed by CT surgery with tentative plan to remove when output is
               <3ml/kg/day and the patient has ambulated to bedside chair.
               Patients who remain bedbound will maintain chest tubes until output is less than 3ml/kg/day and are
               approaching one week post-implant.
               Fluid Management

               Initiation of post-implant diuresis should be planned within initial 24-48 hours as tolerated
               hemodynamically with goal of fluid restriction to 60% of maintenance. Maintenance of “ideal” central
               venous pressures ranging from 5-12 should be attempted as tolerated. Given evidence that central
               venous hypertension induces renal and hepatic end-organ dysfunction efforts should be focused on
               management of right ventricular support (as above) and prevention of hypervolemia.
               Control of post-operative bleeding is of paramount importance and is second only to adequate cardiac
               output and perfusion. Though control of bleeding begins in the operating room, acute management
               continues for hours into the ICU course.  Administration of blood products, factors, and medications to
               induce hemostasis should be pursued as necessary, as correction of post-operative coagulopathy must
               precede initiation of systemic anticoagulation. Initiation of anticoagulation should be delayed until
               hemostasis has been achieved (see anticoagulation guidelines for criteria) and should be a decision
               made by the multidisciplinary team including CICU, CT Surgery, and VAD team members. Quality and/or
               quantity of chest tube output following initiation of anticoagulation should be monitored, and
               recurrence of significant bleeding following initiation of anticoagulation should prompt its cessation.
               Though rapid acting pro-coagulants such as recombinant Factor 7 (Novo 7) can be used in the setting of

               Updated 3/24/2019                                                                      page 10
   5   6   7   8   9   10   11   12   13   14   15