I'm an outpt APN who works in mulitple dialysis units. We have been asked recently to accept LVAD pts who would live at home and dialyze at the outpt unit while awaiting a heart tx. Has anyone heard of this? Just curious what suggestions you would have. Bear in mind, that there is no ACLS available, just BLS and 911. There are one-two RNs on duty who are NOT critical care nurses.

LVADs have been used in the outpatient setting for years now, at least since 2000. Dialysis nurses wouldn't be expected to troubleshoot or really have anything to do with the LVAD, the main consideration in terms of dialysis would be that these patients are end stage cardiomyopathy patients, but a patient with an EF of 10% and an LVAD is still better than an EF of 10% with no LVAD.

Thanks.

They will more than likely have a family member or caregiver with them who has had extensive training. The patient may also be a great source to educate you and put you at ease. This is also what has to be done when EMS is called since most EMTs or Paramedics will not have had any education on these devices.

I guess my concerns are that

a. This is outpt dialysis - the pts come by themselves - no family/caregivers present.

b. This is rural area - transplant center is 200 miles away in Chicago.

c. There are only 2 RNs present in the building for 32 pts.

d. By the time they get too dry and pass out, it could be a little late to start thinking about "what we should do."

Have you addressed these issues with the Nephrologist and local physican who might be writing the dialysis orders? Our dialysis center sees many different patients each with their own unique medical issues and concerns. Some will come with extra orders. Someone from the medical center who is monitoring their care may even be able to offer some advice. This is a known situation. There are probably several other patients you see everyday who are on the verge of some serious medical emergency that present with no warning and some may even be close to needing an LVAD but may not qualify for other reasons.

To quote MunoRN:

but a patient with an EF of 10% and an LVAD is still better than an EF of 10% with no LVAD.

In the time it takes to ask these questions on an internet forum, you could be calling for reliable resouces and education material. But, at least it gets others to think about some of the situations they can come in contact with.

This patient probably knows the risks he is taking by living so far away but may be will to assume them just to spend time at home for whatever time he has left.

I guess my concerns are that

a. This is outpt dialysis - the pts come by themselves - no family/caregivers present.

b. This is rural area - transplant center is 200 miles away in Chicago.

c. There are only 2 RNs present in the building for 32 pts.

d. By the time they get too dry and pass out, it could be a little late to start thinking about "what we should do."

d. If they pass out because they are too dry, you do the same things that you would for a person without a VAD. If anything, you know that you've got a good, working pump that will keep on pumping. Not necessarily true for all your patients!

The patient WILL have an emergency number on a business card or such that you can call 24/7 and they can talk you through a battery change or what have you. Support is just a phone call away no matter where you are.

I'm an outpt APN who works in mulitple dialysis units. We have been asked recently to accept LVAD pts who would live at home and dialyze at the outpt unit while awaiting a heart tx. Has anyone heard of this? Just curious what suggestions you would have. Bear in mind, that there is no ACLS available, just BLS and 911. There are one-two RNs on duty who are NOT critical care nurses.

LVAD patients are not really that difficult to care for. And the VAD's themselves can give you indications regarding issues like fluid status.

What I would recommend would be contacting the VAD center where these patients were implanted and asking for education regarding the principles of VAD's, training on the types of VAD's you would see and emergency management. I am friends with many of the VAD coordinators at my center and they do community teaching all the time. When a VAD is implanted in an area where first responders have never experienced VAD's, they go and inservice them. They also do some teaching at hospitals local to the VAD's home to show them basic ideas of how to handle issues. There is also someone always on call to address VAD issues.

I'll be honest, carrying for VAD patients is very interesting. And not as bad as others seem to think.And now that the Heartmate II has received FDA approval for destination therapy (for those who will never be transplanted), you may hear more about them.

PM me if I can help in anyway.

Thank you for all the info guys. I really appreciate it. None of these pts have even had an LVAD placed so nope I'm not searching the Internet looking for assistance while my pt is floundering lol.

We have recently started sending our VAD patients (both LVAD and biVAD) to outpatient dialysis. We chose one center and provided them with training and equipment. I know some VAD centers do not even provide monitors but just have the patients on battery during dialysis.

VADs are intended to permit people with heart failure to live as near a "normal" life as possible. That includes going to wherever. As the technology has improved, the restrictions on patients requiring 24/7 caregivers etc have been lifted. However; most patients, even those going to outpatient dialysis, have spouses that will accompany them. It's a win-win; the dialysis center gets a steady flow of VAD patients (well only

As mentioned by someone else, your patient's VAD center is going to be your best friend. They can coordinate with the device manufacturer to provide literature and education if you want it before accepting the patient.

Assuming the patient has a Heartmate II rotary pump - the main issues we had in setting up were:

1. Regular automated blood pressure cuffs generally don't work because the patients have minimal pulsatility. We send out patients home with handheld dopplers to measure their BP so we considered having them take it to dialysis but ended up getting the automated Terumo blood pressure cuff that has a "low pulsatility" mode.

2. Fluid management - this is where we decided to give the dialyis center a monitor for the pt to hook up to. They can read the flows constantly and very easily tell by either the flow or another parameter (PI, or pulsatility index) if the pt is getting hypovolemic. Honestly though clinical signs are your best sign - if they are lightheaded, get palpitations (low volume can irritate the ventricle and give you PVCs), back off on the fluid removal.

The things I can tell you as reassurance - the patients know how they usually feel. They are very used to being overloaded and then "underloaded".. and they can tell the difference. If they are sitting talking to you and warm and perfused, they're ok. Our dialysis staff were clear that they were not responsible for the VAD, and the patient was clear on that too -they were responsible for their device. One of our VAD coordinators went down for the first treatment as reassurance for both the dialysis staff and the patient. We're lucky that the center is down the road from our hospital, but if there was a patient we were worried about, we'd be doing the outpatient dialysis in our hospital facility and not sending them off campus.

Thoratec's website has an "eUniversity" that allows you to sign up, get manuals, watch presentation, watch videos, do learning modules and quizzes etc if interested.

Again, though, use the patient's VAD coordinator - that's what they are there for. We do community/EMS/PCP/dialysis education all the time. I'm actually very surprised this is a potential plan and you haven't yet been contacted by the VAD coord.

If you need anything, or don't know who the VAD coordinator is to contact, send me a PM with the hospital name and I can probably tell you.

It might be a good idea to invest in some dopplers so you can check pressures... also the pt. will know how to manage their VAD so.. =) it couldn't hurt to have a family member tag along just in case

you do what you accept to do. My opinion only. They belong in a dialysis center within a hospital setting. An arrest is an arrest and the poor Renal RN taking care of the pt. is accepting the responsibility. Family member/caregiver or not the RN is ultimately going to be accountable. We all know that some family members are ready to sue in a heart beat. Even if that heart beat is only 10% EF and is knocking on gates.

By the time the patient is in the outpatient setting the VAD is pretty much on auto pilot. To keep this simple, the worst error that one could make is to make the patient "too dry" intravascularly as then the VAD could completely empty the left ventricle and cause a "suck down" event.