Ventricular Assist Device Exit Site Care

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Ventricular Assist DeviceExit Site Care

• Nicole Graney, MSN, CNS-BCVAD Coordinator
• Advocate Christ Medical Center

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Ventricular Assist DevicePercutaneous Lead

• Referred to also as
• Driveline
• Perc Lead
• This lead connects the implanted device to the
  external controller which provides power to the
  pump and controls operation.

Thoratec Corporation. HeartMate II Patient
Handbook, 2008.
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Percutaneous Lead

• The outside of the lead is covered with a special
  material (velour) that allows skin cells grow
  into it.
• A well-healed exit site can lower the risk of
  infection.

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Exit Site

• The exit site is the location where the
  percutaneous lead goes out through the skin

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Caring for the Perc Lead Exit Site

• Keep the exit site clean, dry and covered.
• Ensure patient and caregiver performing proper
  hand washing and aseptic technique when
  changing bandage or handling the exit site.
• Keep perc lead stabilized using Stabilization
  Belt.
• Protect the system controller from falling or
  from pulling on the lead.
• Dont allow the perc lead to catch or snag on
  anything that will pull or move the lead.
• Check lead daily for signs of damage.
• Report any concerns of damage or infection to
  patients VAD Coordinator.

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Assessment of Exit Site

• Tissue in-growth
• Drainage
• Surrounding Tissue

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Assessment of Exit Site

• Most VAD infections began at the perc lead exit
  site.
• Accurate assessments allow the health care
  provider to identify and promptly treat driveline
  infections.
• If any concerns, please contact patients VAD
  coordinator.

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Tissue In-growth

• Refers to amount of tissue growing into the perc
  lead.
• If complete in-growth, should not be able to
  retract back on abdomen and expose any velour
• Can be describe in percentages
• Anywhere from 0 to 100
• Problem Percentages may differ between person
  assessing
• Can be described as Partial or Complete
• Can specify where tissue in-growth is using hours
  on a clock using circumference of driveline as
  the clock.
• Complete in-growth from 2-6 oclock position

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Tissue In-growth

• 100 Tissue In-growth
• Or
• Complete Tissue
• In-growth

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Drainage

• Important to Note
• Amount
• Color
• Odor
• Consistency

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Surrounding Tissue

• Appearance of surrounding tissue may indicate
  presence of early infection, even without
  drainage or fever.
• Note any erythema, edema, blisters,
  hypergranulation tissue etc.

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Infection

• Infection is one of the common causes of
  mortality in patients with VADs.
• The treatment of VAD related infections
  negatively impacts patients quality of life and
  length of survival with VAD.
• Prevention of infection is one of the primary
  goals of patient management.

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Risk for Infections

• Patients are at an increased risk for infection.
• Chronic HF, poor nutrition, advanced age, other
  co-morbidities (DM, COPD etc.).
• Presence of foreign body (VAD and perc lead),
  trauma to exit site, tension to wound edges, poor
  dressing care technique.

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Signs of Symptoms of Infection

• Localized Exit Site
• Redness, warmth, tenderness
• With or without positive cultures
• New or increased drainage
• Severe Exit Site Infections or Pocket Infections
• Fever, Elevated White Blood Cell Count
• Purulent drainage
• Pain at exit site or over device
• Positive wound cultures
• Fluid surrounding perc lead up to the device
• Patient may become septic as a result
• Fluid over device, erythema over pocket

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Progression of InfectionLocalized
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TreatmentLocalized

• Increase frequency of driveline dressing changes
  if drainage present
• Immobilize perc lead
• Start antibiotics if culture positive
• Monitor frequently as outpatient
• Initiate aggressive wound care modalities silver
  impregnated dressings, ultrasound mist therapy.

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Progression of InfectionSevere Exit Site/Pocket
Infection
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Treatment Severe Exit or Pocket Infections

• Hospitalization
• IV antibiotics
• Aggressive Wound Care Modalities
• Surgical Drainage of fluid collection

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Device Infection/Sepsis
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TreatmentDevice Infection/Sepsis

• Surgical implantation of antibiotic beds
• Expose device to allow for constant drainage
• Device Exchange as last resort

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Complications of Persistent Exit Site Infections

• Sepsis
• Exposure of device
• Stroke
• Death

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Trauma

• Trauma to perc lead either due to pulling,
  tearing, or dropping of equipment may lead to
  infection, damage of equipment, or pump stoppage.

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Perc Lead Fracture

• If complete severing of electrical leads, the
  pump will STOP!
• Patients may not survive pump stoppage, or may go
  into cardiogenic shock

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Perc Lead Fracture
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Perc Lead Fracture
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Questions???