Advanced cardiovascular life support algorithm for the management of the hospitalized unresponsive patient on continuous flow left ventricular assist device support outside the intensive care unit

Abstract

Over the past decade, continuous flow left ventricular assist devices (CF-LVADs) have become the mainstay of therapy for end stage heart failure. While the number of patients on support is exponentially growing, at present there are no American Heart Association or European Society of Cardiology Advanced Cardiovascular Life Support guidelines for the management of this unique patient population. We propose an algorithm for the hospitalized unresponsive CF-LVAD patient outside of the intensive care unit setting. Key elements of this algorithm are: creation of a dedicated LVAD code pager and LVAD code team; early assessment and correction of LVAD malfunction; early determination of blood flow using Doppler technique in carotid and femoral arteries; prompt administration of external chest compressions in the absence of Doppler flow; bedside veno-arterial extracorporeal membranous oxygenation support if no response to resuscitation measures; and early consideration for stroke.

Inpatient Cardiac Rehabilitation of LVAD Patients—Updated Recommendations from the Working Group of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases

“…It should be remembered here that the pulse cannot always be felt in LVAD patients due to their continuous-flow devices, and that blood flow can therefore only be diagnosed accurately using the Doppler method (e.g., in carotid or femoral arteries). 78 In a reanimation emergency, not only must heart-lung reanimation be performed immediately, it should also be ascertained whether or not the cause was a technical problem in the LVAD system which can be fixed quickly. 79,80 A quick way of testing the functional capacity of the LVAD is auscultation via the pump (humming), or by placing the hand over this area (vibrating).…”

“…79,80 A quick way of testing the functional capacity of the LVAD is auscultation via the pump (humming), or by placing the hand over this area (vibrating). 78 For all systems, in an emergency the power supply (rechargeable batteries/ mains) and the connection from the controller to the patient (driveline) should immediately be checked, and if interrupted immediately be reconnected. It may also be necessary to exchange the controller.…”

“…For this reason, the latter should never be longer than 3 to 5 minutes. 78 Cardiac rhythm is generally evaluable without restriction. An electric cardioversion or defibrillation is possible during operation of the device without disconnecting the controller 81 and should be performed if a paceable or shockable rhythm is identified in an unresponsive LVAD patient.…”

Advances in Cardiopulmonary Life-Support Change the Meaning of What It Means to be Resuscitated

“…Furthermore, LVAD patients frequently do not have a palpable arterial pulse or easily measurable blood pressure if pulse pressure drops substantially. 23 As a result, health care providers may be uncertain about the safety and role of ACLS in patients with an LVAD, and there may be concerns about when to begin resuscitation attempts to avoid potential hazards of inappropriate attempts. The American Heart Association has published consensus guidelines that contain an algorithm for approaching ALCS and resuscitation in the setting of an LVAD, and that acknowledge and attempt to address these potential harms.…”

Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association

“…absence of meaningful forward flow can be inferred, and chest compressions should be initiated. 21 Acquisition of additional data should not delay application of appropriate resuscitative measures in acutely ill/unresponsive patients with MCS devices.…”