Guidelines for Managing an LVAD Code
In patients with a Left Ventricular Assist Device (LVAD) experiencing a code situation, immediate assessment of device function and hemodynamic status should be prioritized, with prompt communication with the LVAD center as the cornerstone of management. 1
Initial Assessment and Stabilization
- Begin by assessing the patient's level of consciousness, airway, breathing, and circulation while simultaneously checking LVAD function (audible hum, alarms, power source) 1, 2
- Immediately contact the responsible LVAD center for guidance while initiating emergency protocols 1
- Include family caregivers in emergency management as they are often knowledgeable about device function and emergency protocols 1
- Perform initial assessment considering common conditions such as arrhythmias, infection, or hypovolemia before focusing on LVAD-specific issues 1
Device Assessment
- Check for audible LVAD "hum" by auscultation to confirm pump function 3
- Inspect the driveline exit site for signs of infection or trauma 1
- Record and interpret device parameters (flow, power, speed) 3
- Assess for LVAD alarms and identify their specific meaning 4
- Verify power source connection and battery status 1
Hemodynamic Assessment
- Blood pressure measurement may be challenging due to diminished arterial pulsatility; use Doppler methods if necessary 1, 5
- Monitor for signs of inadequate circulation despite functioning LVAD (altered mental status, cool extremities) 5
- Assess for signs of right ventricular failure which can compromise LVAD function 6
- Evaluate for hypovolemia which can trigger low flow alarms 1
Managing Specific Emergencies
Pump Thrombosis
- Monitor for elevated lactate dehydrogenase (>2.5 times upper limit of normal) as an early indicator 1
- Coordinate management with the MCS center for potential thrombolysis or device exchange 1
Ventricular Arrhythmias
- Ventricular arrhythmias occur in up to one-third of LVAD patients and require prompt management 1
- An ICD can be beneficial in patients with an LVAD and sustained ventricular arrhythmias (Class IIa recommendation) 1
- Although some patients tolerate VT/VF with an LVAD, others experience decreased flow as the right ventricle is unsupported, leading to syncope and hypoperfusion 1
Stroke
- Assess for both ischemic and hemorrhagic stroke with urgent head CT 1
- Evaluate anticoagulation status with PT/PTT and INR 1
- Obtain neurology/neurosurgical consultation for management recommendations 1
- Check device positioning with chest CT or CXR to rule out cannula kinking or device obstruction 1
Infection
- Driveline infections are common (approximately 30% incidence at 3 years) and can lead to sepsis 1
- Trauma to the driveline exit site is the leading cause of infection 1
- Ensure proper immobilization of the percutaneous lead and meticulous exit-site care 1
Resuscitation Considerations
- Standard ACLS protocols may need modification for LVAD patients 5, 2
- Time to restart LVAD function is a critical performance indicator in resuscitation scenarios 2
- Specialized training through Mechanical Life Support courses significantly improves outcomes in simulated LVAD emergencies 2
- For flights longer than 2 hours, support stockings should be considered to prevent thromboembolic events 1
Documentation and Communication
- Ensure patient identification card, device information, and emergency contact information are readily available 1
- Maintain a list of names and phone numbers of the patient's cardiologist and other relevant clinicians 1
- Have the last discharge letter from hospital and device interrogation print-out accessible 1
Prevention and Preparation
- Ensure patients have sufficient medication for their entire journey with extra supplies for unforeseen delays 1
- Keep medications in carry-on luggage for flights in case of loss of checked baggage 1
- Maintain adequate fluid intake to avoid low flow alarms from the LVAD pump 1
- Locate the closest LVAD centers within travel destinations as possible emergency contacts 1