Infection in Ventricular Assist Device VAD

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Infection in Ventricular Assist Device (VAD)

• 2003/3/17
• Present by Ri???
• Supervisor P???

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What is VAD ?

• Ventricular assist device

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Devices for circulatory support

• 1. IABP
• Intraaortic Balloon Pump
• 2. ECMO
• Extracorporeal Membrane Oxygenation
• 3. VAD
• Ventricular Assist Device
• LVAD,RVAD,BVAD
• 4. Artificial heart

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Indication

• For circulatory support
• Progressive low output refractory to medical
  treatment
• CPR
• Unable to wean from cardiopulmonary bypass

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Ventricular assist device (VAD)

• Prolonged support
• Bridge to transplantation
• Waiting for myocardial recovery
• Ambulation
• Implantable---Heartmate ,Norvacor (LVAD)
• Not implantable---Thoratec (BVAD)
• More physiological function

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Three portion of VAD

• 1. blood pump
• 2. cannula
• 3. Dual drive console
• Provide air pressure to blood pump

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Heartmate
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(No Transcript)
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Thoratec VAD
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Morbidity and outcome after mechanical
ventricular support using Thoratec, Novacor, and
HeartMate for bridging to heart
transplantation.Artif Organs. 2000
Jun24(6)421-6.

• Thoratec system
• a bridge to heart transplantation for patients
  with biventricular heart failure
• Novacor or HeartMate system
• long-term circulatory support.

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Inclusion criteria -Thoratec

• 1. Approved transplantation candidate
• 2. on a regimen of inotropic agents and IABP
• 3. Cardiogenic shock (CI lt 2.01 L/min/m2)
• wedge pressure gt 20 mmHg

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Exclusion criteria -Thoratec

• 1. age gt 70 yrs
• 2. congenital heart disease
• 3. CRF (Cr gt 5 mg/dL)
• 4. pulmonary dysfunction (emphysema, recent
  infarction)
• 5. Fix pulmonary vascular resistance greater than
  8 wood units
• 6. COPD

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Exclusion criteria -Thoratec

• 7. symptomatic cerebrovascular disease
• 8. blood dyscrasia
• 9. Severe hepartic dysfunction (total
  bilirubingt10 mg/dL)
• 10. Myocardial infarction within 7 days

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Complication -Thoratec

• 1. Bleeding
• 2. tamponate
• 3. Right ventricular failure
• 4. Thromboembolism
• 5. Infection
• 6. Arrhythmia
• 7. Renal and hepatic failure
• 8. hemolysis

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Infection

• Background
• Ventricular assist devices (VAD) are associated
  with a high risk of infection including
  nosocomial bloodstream infections (BSI).
• Although reports have suggested acceptable rates
  of survival of patients with VAD, there is little
  information regarding the mechanism and etiology
  of bacteremia in these patients.

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Infection -Thoratec

• Risk Factors
• Insufficient handwashing
• Preoperative infection
• Prolonged hospitalization or intubation
• Immobility
• Indwelling catheters/Invasive hemodynamic
  monitoring
• VAD sites and other surgical wounds
• Poor nutritional status
• Bleeding requiring reoperation

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Nosocomial Bloodstream Infections in Patients
With Implantable Left Ventricular Assist
Devices(Ann Thorac Surg 20017272530) 2001
by The Society of Thoracic Surgeons

• Table 3. Potential Risk Factors for Nosocomial
  Bloodstream Infection (BSI) in Patients With Left
  Ventricular Assist Devices
• a HeartMate vented electric.
• b HeartMate pneumatic.

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Infection -Thoratec

• Assessment Areas of Concern
• Elevated temperature
• Elevated WBC or differential shift
• Sinus tachycardia
• Bounding peripheral pulses
• Hypotension
• Low systemic vascular resistance (SVR)
• Low chamber pressures
• High VAD output
• Redness or drainage from invasive lines or VAD
  sites

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Prevalence
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(No Transcript)
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Infectious Complications in Patients With the
Novacor Left Ventricular Assist
SystemTransplantation Proceedings, 33, 19691971
(2001)
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Nosocomial Bloodstream Infections in Patients
With Implantable Left Ventricular Assist
Devices(Ann Thorac Surg 20017272530) 2001
by The Society of Thoracic Surgeons

• Pathogens Accounting for 140 Nosocomial
  Bloodstream Infections In 104 Patients With Left
  Ventricular Assist Devices
• a. Seven patients were methicillin-resistant.
• b. Five patients were vancomycin-resistant.

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Nosocomial Bloodstream Infections in Patients
With Implantable Left Ventricular Assist
Devices(Ann Thorac Surg 20017272530) 2001
by The Society of Thoracic Surgeons

• The most common pathogens causing BSI were
• coagulase-negative staphylococci
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Enterococci
• Candida spp.

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Management
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Infection Management -Thoratec

• Good handwashing
• Prophylatic Abx
• Remove all invasive lines and indwelling
  catheters as soon as possible
• Extubate and mobilize early
• Monitor WBC, differential, and temperature
• Blood, urine, sputum culture for temperature
  gt38.3?
• Treat only clinically significant infections
• Increase frequency of VAD dressing changes
  (driveline infection)
• Drug therapy to increase SVR and blood pressure

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Prophylactic Antibiotics -Thoratec

• no pre-op infection
• Cephalosporin for 48-72 hrs
• pre-op infection
• Continue preoperative Abx
• add Cephalosporon or Vancomycin if not covered
• Treat only culture organisms
• Stop prophylatic Abx, for no clinical sign of
  infection
• Several centers continue prophylatic Abx until
  the pt is extubated and chest tubes removed

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Prophylatic Antobiotics -Thoratec

• 1. IV vancomycin Gentamicin for 48 hrs
• 2. Selective GI decontamination to eliminate all
  but anaerobic flora. (Clistin, nystatin,
  gentamicin). Administered to intubated pt in a
  Orabase formula, coating the gums and mouth, and
  by nasogastric tube or mouth therefer q6h for 3
  wks, then q12h until TX

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Infectious Complications in Patients With the
Novacor Left Ventricular Assist
SystemTransplantation Proceedings, 33, 19691971
(2001)

• Abx prophylaxis
• Ampho B 1 g qid norfloxacin 400 mg bid (started
  3 days before implant)
• Vanco 15 mg/kg iv starting 1 hour before implant
  continuing for 48 to 72 hours (500 mg qid)
• Combination Abx with bacteremia/fungemia
• at least 6 weeks or until the transplant procedure

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VAD wound care -Thoratec

• Strict aseptic technique ALWAYS
• Dry occlusive dressing AlWAYS
• Chlorhexidine or other antibacterial agent, or
  Betadine Solution (NO OINTMENT)
• NO ACETONE
• Dressing change daily and as needed
• Immobilize cannulae with tape, montgomery strapes
  or telemetry pouches

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VAD wound care -Thoratec

• Cannula Site Infection
• 1. Culture cannula site
• 2. Increase frequency of VAD dressing changes
• 3. Antibiotic irrigation to site
  Vancomycin(100mg/1000ml NS) or diluted
  antibiotics solution specific to the infection
• 4. Irrigate until return drainage is clear or
  bloody
• 5. Antibiotic irrigation can prevent the need for
  oral or intravenous antibiotics
• Major driveline infection are not common

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Infectious complications in left ventricular
assist device recipients.Clin Infect Dis 1997
Jan24(1)18-23 Fischer SA, Trenholme GM,
Costanzo MR, Piccione W.Section of Infectious
Disease, Rush Medical College, Chicago, Illinois,
USA.

• LVAD infections can be successfully treated
  without device removal.
• Cardiac transplantation can be performed in
  individuals with LVAD-related bloodstream
  infection.

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Management of left ventricular assist device
infection with heart transplantation.Ann Thorac
Surg 1997 Jul64(1)142-7 Section of Cardiac and
Thoracic Surgery, Temple University Health
Sciences Center, Philadelphia, Pennsylvania, USA.

• Patients with LVAD infection are too seriously
  ill to allow LVAD removal or delay of HT
• Transplantation in the face of infection is an
  effective treatment option.

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Prognosis
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Nosocomial Bloodstream Infections in Patients
With Implantable Left Ventricular Assist
Devices(Ann Thorac Surg 20017272530) 2001
by The Society of Thoracic Surgeons

• Table 4. Impact of Nosocomial Bloodstream
  Infection (BSI) on Survival in Patients With Left
  Ventricular Devices

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Infections During Left Ventricular Assist Device
Support DoNot Affect Posttransplant
OutcomesPrashant Sinha, MEng Jonathan M. Chen,
MD Margaret Flannery, RN Brian E. Scully,
MDMehmet C. Oz, MD Niloo M. Edwards, MD
Circulation. 2000 Nov 7102(19 Suppl 3)III194-9

• A high incidence of infection during device
  support did not have an impact on pretransplant
  or posttransplant mortality, posttransplant
  infectious rate, or overall patient survival.
• Infections During Left Ventricular Assist Device
  Support Do Not Affect Posttransplant Outcomes

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Total conclusion

• Ventricular assist devices (VAD) are currently
  approved for use as a bridge for transplantation.
• Strategies for prevention of infection in LVAD
  recipients should focus on the drive line exit
  site until technical advances can achieve a
  totally implantable device.
• Patients with implantable LVAD have a high
  incidence of BSI, which are associated with a
  significantly increased mortality.
• Patients with LVAD infection are too seriously
  ill to allow LVAD removal or delay of HT.

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Total conclusion

• bacteremia/fungemia
• not preclude successful bridging to HT
• must be considered an indication for urgent
  transplantation.
• Treat only culture organisms
• Transplantation in the face of infection is an
  effective treatment option

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Reference

• Malani PN, Dyke DB, Pagani FD, Chenoweth CE.
• Nosocomial infections in left ventricular
  assist device recipients.Clin Infect Dis. 2002
  May 1534(10)1295-300.
• Vilchez RA, Kormos R, Kusne S. Left ventricular
  assist device.N Engl J Med. 2002 Mar
  28346(13)1023-5 author reply 1023-5. No
  abstract available.
• Vilchez RA, McEllistrem MC, Harrison LH, McCurry
  KR, Kormos RL, Kusne S. Relapsing bacteremia in
  patients with ventricular assist device an
  emergent complication of extended circulatory
  support.Ann Thorac Surg. 2001 Jul72(1)96-101.
• Sinha P, Chen JM, Flannery M, Scully BE, Oz MC,
  Edwards NM. Infections during left ventricular
  assist device support do not affect
  posttransplant outcomes.Circulation. 2000 Nov
  7102(19 Suppl 3)III194-9.
• Minami K, El-Banayosy A, Sezai A, Arusoglu L,
  Sarnowsky P, Fey O, Koerfer Morbidity and
  outcome after mechanical ventricular support
  using Thoratec, Novacor, and HeartMate for
  bridging to heart transplantation.Artif Organs.
  2000 Jun24(6)421-6.

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Reference

• Herrmann M, Weyand M, Greshake B, von Eiff C,
  Proctor RA, Scheld HH, Peters G. Left
  ventricular assist device infection is associated
  with increased mortality but is not a
  contraindication to transplantation.Circulation.
  1997 Feb 1895(4)814-7.
• Fischer SA, Trenholme GM, Costanzo MR, Piccione
  W. Infectious complications in left ventricular
  assist device recipients.Clin Infect Dis. 1997
  Jan24(1)18-23.
• McCarthy PM, Schmitt SK, Vargo RL, Gordon S, Keys
  TF, Hobbs RE. Implantable LVAD infections
  implications for permanent use of the device.Ann
  Thorac Surg. 1996 Jan61(1)359-65 discussion
  372-3.
• Sinha P, Chen JM, Flannery M, Scully BE, Oz MC,
  Edwards NM. Infections during left ventricular
  assist device support do not affect
  posttransplant outcomes.Circulation. 2000 Nov
  7102(19 Suppl 3)III194-9.

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Thank you for your attention!!

• PS ???????????Thoratec??,Thank you!!