Technique for minimizing and treating driveline infections.

Left ventricular assist devices (LVADs) are increasingly utilized in the management of advanced heart failure. A transcutaneous driveline is necessary to power the LVAD, and although this technology has improved over the years in terms of smaller size and increased durability, driveline complications continue to develop in up to 20% of all devices implanted. Driveline infections are associated with significant morbidity and mortality. As more patients live longer with ventricular assist devices, minimizing driveline infections is paramount. A systematic, multidisciplinary approach can be used to develop a strategy to prevent, recognize and treat driveline infections. In this paper, we describe our approach to driveline management which has resulted in zero driveline infections between January 2012 and March 2014.

Gastrointestinal bleeding in patients with ventricular assist devices: what every cardiac nurse should know.

Patients with end-stage heart failure are increasingly being treated with implantation of a long-term ventricular assist device. As the use of these devices has grown, health care providers have been faced with managing clinically significant gastrointestinal bleeding in this population. Gastrointestinal bleeding is not uncommon and is reported to occur in 13% to 44% of patients treated with ventricular assist devices. Interestingly, because patients with ventricular assist devices are housed on units accustomed to managing the device, cardiac nurses are often asked about the management of gastrointestinal bleeding. This article describes the possible causes of, the array of diagnostic procedures for, and treatments for this complication. It is critical to develop an understanding of this topic so cardiac nurses can partner with other subspecialty groups to manage this population.

Variability in infection control measures for the percutaneous lead among programs implanting long-term ventricular assist devices in the United States.

Ventricular assist devices (VADs) are a surgical treatment for heart failure. These devices may be implanted as a bridge to transplant or as destination therapy. After surgical recovery and education regarding device care, patients are discharged home. Meticulous care of the driveline must be taken to prevent infection and trauma of the site throughout the perioperative event and for the duration of support. Currently a standardized protocol for care of the driveline and exit site does not exist. VAD coordinators from across the country discussed the variability in care at different centers in the United States through a series of conference calls. A survey consisting of 16 questions was developed. The survey included questions on preoperative antibiotic recommendations, driveline placement and exit site suturing, frequency of dressing changes, and showering practices. VAD coordinators shared center-specific dressing protocols and any driveline success stories. This survey was sent to 73 centers; 38 centers (52%) responded. The purpose of the survey was to define current practice in order to move toward a standard of practice or protocol based on expert opinion for VAD driveline care and to assess the need for future studies.

Factors associated with the level of backrest elevation in a thoracic cardiovascular intensive care unit.

BACKGROUND: Ventilator-associated pneumonia is a complication of mechanical ventilation that is associated with increased length of stay, morbidity, mortality, and costs. Evidence-based guidelines to reduce the risk of ventilator-associated pneumonia recommend use of 30º to 45º backrest elevation. Despite recommendations, patients continue to be cared for in positions with a lower backrest elevation. Hemodynamic stability may be a factor in the lack of adherence, yet few data exist to confirm this hypothesis. OBJECTIVE: To determine the relationship between backrest elevation and hemodynamic instability among patients in a thoracic cardiovascular intensive care unit. METHODS: A sample of 100 patients was studied. Patients were randomly selected by time of day. A protractor was used to measure patients' backrest elevation. Mean blood pressure, time of day, and fluid and vasopressor use also were recorded. RESULTS: Lower backrest elevation was associated with use of vasopressors (P = .001). Patients who received hemodynamic support also had a lower backrest elevation than did patients not receiving these therapies (mean, 19º vs 26º ; P = .01). Patients with a mean blood pressure of 64 mm Hg or less had a mean backrest elevation of 17º versus 24º for patients with a mean blood pressure greater than 65 mm Hg (P = .01). Back-rest elevations did not differ between shifts. CONCLUSION: That backrest elevation is associated with lower mean blood pressure and vasopressor use suggests that nurses are not adhering to recommended levels of backrest elevation so as to maintain hemodynamic stability. Further studies are needed to elucidate reasons for lack of adherence to recommended levels of backrest elevation.

Management of patients with preformed reactive antibodies who are awaiting cardiac transplantation.

Patients with elevated levels of preformed reactive antibodies to HLA antigens have higher rates of organ rejection than do patients without such antibodies. Consequently, before proceeding with transplantation, many medical centers do prospective cross-matching, that is, mix lymphocytes from the organ donor with sera from the prospective organ recipient, to determine whether a higher rejection rate or an immediate episode of rejection will occur. The problem has been compounded by the increased frequency of preformed reactive antibodies in patients with ventricular assist devices who are awaiting cardiac transplantation. Performing a prospective cross-match can be time-consuming and often is impossible because of the unstable condition of the organ donor or travel logistics, leading to increased costs for transplantation and longer waiting times for recipients. A variety of treatments are used in cardiac transplantation programs in attempts to reduce the concentration of preformed reactive antibodies. Each of these treatments has accompanying complications and considerations for the transplant team. Each treatment must also be assessed for therapeutic response. Options for managing patients with preformed antibodies and a case report are presented.