Page 10 - VAD Guidelines

Pediatric Ventricular Assist Device (VAD) Guidelines

Initial ICU Support (First 48 hours)

Anticoagulation
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
1–3
management of right ventricular support (as above) and prevention of hypervolemia.
Hemostasis
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