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Moskowitz A, Pocock H, Lagina A, Chong Ng K, Scholefield BR, Zelop CM, Bray J, Rossano J, Johnson NJ, Dunning J, Olasveengen T, Raymond T, Morales DLS, Carlese A, Elias M, Berg KM, Drennan I. Resuscitation of Patients with Durable Mechanical Circulatory Support with Acutely Altered Perfusion or Cardiac Arrest: A Scoping Review. Resuscitation 2024:110389. [PMID: 39245405 DOI: 10.1016/j.resuscitation.2024.110389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 08/26/2024] [Accepted: 08/31/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND There is an increasing prevalence of durable mechanical circulatory supported patients in both the in-and-out of hospital communities. The scientific literature regarding the approach to patients supported by durable mechanical circulatory devices who suffer acutely impaired perfusion has not been well explored. METHODS The International Liaison Committee on Resuscitation Advanced, Basic, and Pediatric Life Support Task Forces conducted a scoping review of the literature using a population, context, and concept framework. RESULTS A total of 32 publications that included patients who were receiving durable mechanical circulatory support and required acute resuscitation were identified. Most of the identified studies were case reports or small case series. Of these, 11 (34.4%) included patients who received chest compressions. A number of studies reported upon delays in the application of chest compressions resulting from complexity due to the expected pulselessness in some patients with continuous flow left-ventricular assist devices as well as from concern regarding potential dislodgement of the mechanical circulatory support device. Three observational studies identified worse outcomes in durable mechanical circulatory support receiving patients with cardiac arrest and acutely impaired perfusion who received chest compressions as compared to those who did not, however those studies were at high risk of bias. Of 226 patients across 11 studies and two published scientific abstracts who sustained cardiac arrest while supported by durable MCS and underwent chest compressions, there were no reported instances of device dislodgement and 71 (31.4%) patients had favorable outcomes. CONCLUSIONS There is a scarcity of evidence to inform the resuscitation of patients with durable mechanical circulatory support (MCS) experiencing acute impairment in perfusion and cardiac arrest. Reports indicate that delays in resuscitation often stem from rescuers' uncertainty about the safety of administering chest compressions. Notably, no instances of device dislodgement have been documented following chest compressions, suggesting that the risk of harm from timely CPR in these patients is minimal.
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Affiliation(s)
- Ari Moskowitz
- Division of Critical Care, Montefiore Medical Center, the Bronx, New York United States; Bronx Center for Critical Care Outcomes and Resuscitation Research, the Bronx, New York, United States.
| | - Helen Pocock
- South Central Ambulance NHS Foundation Trust, Bicester, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anthony Lagina
- Wayne State University, Detroit, Michigan, United States
| | | | | | - Carolyn M Zelop
- Valley Health System, Paramus, New Jersey, Untied States; NYU Grossman School of Medicine, New York City, New York, United States
| | | | - Joseph Rossano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Nicholas J Johnson
- Department of Emergency Medicine & Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Joel Dunning
- James Cook University Hospital, Middlesbrough, United Kingdom
| | | | - Tia Raymond
- Medical City Children's Hospital, Dallas, Texas
| | - David L S Morales
- Heart Institute at Cincinnati Childrens Hospital, Cincinnati, United States
| | - Anthony Carlese
- Division of Critical Care, Montefiore Medical Center, the Bronx, New York United States
| | - Marie Elias
- Montefiore Medical Center Health Sciences Library, the Bronx, New York, United States
| | - Katherine M Berg
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
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Larson EL, Woo J, Moon G, Liu K, Vergel M, Jenkins R, Jiang K, Darby Z, Margolis A, Kilic A. Emergency Medical Services Protocols for Assessment and Treatment of Patients with Ventricular Assist Devices. Prehosp Disaster Med 2024; 39:136-141. [PMID: 38445327 DOI: 10.1017/s1049023x2400013x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND Patients with ventricular assist devices (VADs) represent a growing population presenting to Emergency Medical Services (EMS), but little is known about their prehospital care. This study aimed to characterize current EMS protocols in the United States for patients with VADs. METHODS States with state-wide EMS protocols were included. Protocols were obtained from the state EMS website. If not available, the office of the state medical director was contacted. For each state, protocols were analyzed for patient and VAD assessment and treatment variables. RESULTS Of 32 states with state-wide EMS protocols, 21 had VAD-specific protocols. With 17 (81%) states noting a pulse may not be palpable, protocols recommended assessing alternate measures of perfusion and mean arterial pressure (MAP; 15 [71%]). Assessment of VAD was advised through listening for pump hum (20 [95%]) and alarms (20 [95%]) and checking the power supply (15 [71%]). For treatment, EMS prehospital consultation was required to begin chest compression in three (14%) states, and mechanical (device) chest compressions were not permitted in two (10%) states. Contact information for VAD coordinator was listed in a minority of five (24%) states. Transport of VAD equipment/backup bag was advised in 18 (86%) states. DISCUSSION This national analysis of EMS protocols found VAD-specific EMS protocols are not universally adopted in the United States and are variable when implemented, highlighting a need for VAD teams to partner with EMS agencies to inform standardized protocols that optimize these patients' care.
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Affiliation(s)
- Emily L Larson
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - JiWon Woo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Gyeongtae Moon
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Kathy Liu
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Matthew Vergel
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Reed Jenkins
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Kelly Jiang
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Zachary Darby
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Asa Margolis
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
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Esangbedo ID, Yu P, Choudhury TA, Tume SC, Lasa JJ. Ventricular Assist Device Training and Emergency Management Among Pediatric Cardiac Intensive Care Physicians - Multicenter Cross-Sectional Survey. World J Pediatr Congenit Heart Surg 2024; 15:202-208. [PMID: 38128949 DOI: 10.1177/21501351231205804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Background/Aim: Pediatric cardiac intensive care physicians practicing at centers that implant ventricular assist devices (VAD's) are exposed to increasing numbers of VAD patients, with a significant number of VAD-days. We aimed to delineate pediatric cardiac critical care practices surrounding routine and emergency management of VADs. Methodology: We administered a multicenter cross-sectional survey of pediatric cardiac intensive care unit (CICU) physicians in the United States and Canada. Survey distribution occurred between August 31st and October 26th 2021. Results: A total of 254 CICU physicians received a formal invitation to participate, with 108 returning completed surveys (42.5% response rate). Responses came from CICU attending physicians at 26 separate institutions. Respondents' level of experience was well distributed across junior, mid-level, and senior staff: less than 5 years (38%), 5-9 years (25%), and >/= 10 years (37%). Most respondents had received formal training in the management of VAD patients (n = 93, 86.1%), with training format including fellowship (61%), simulation (36%), and national/international conferences (26.5%). Dedicated advanced cardiac therapies teams were available at the institutions of 97.2% of respondents. A total of 78/108 (72.2%) described themselves as "comfortable" or "very comfortable" in pediatric VAD management. While 63% (68/108) of respondents reported that they had never performed (or overseen the performance of) chest compressions in a pediatric patient with a VAD, 37% (40/108) reported performing CPR at least once in a VAD patient. Conclusion: With no existing international guidelines for emergency cardiovascular care in the pediatric VAD population, our survey identifies an important gap in resuscitation recommendations.
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Affiliation(s)
- Ivie D Esangbedo
- Division of Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Priscilla Yu
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarif A Choudhury
- Division of Critical Care Medicine, Division of Cardiology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Sebastian C Tume
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Javier J Lasa
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Berry AE, Bearl DW. Rethinking status 1A criteria in pediatric cardiac transplantation: A case for the prioritization of patients with single ventricle anatomy supported by ventricular assist devices. Front Pediatr 2023; 11:1057903. [PMID: 36911016 PMCID: PMC9998663 DOI: 10.3389/fped.2023.1057903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Over the past 2 years advancements in the techniques and technology of pediatric heart transplantation have exponentially increased. However, even as the number of pediatric donor hearts has grown, demand for this limited resource continues to far outpace supply. Thus, lifesaving support in the form of ventricular assist devices (VAD) has become increasingly utilized in bridging pediatric patients to cardiac transplant. In the current pediatric heart transplant listing criteria, adopted by the United Network for Organ Sharing (UNOS) in 2016, all pediatric patients with a VAD are granted 1A status and assigned top transplant priority regardless of their underlying pathology. However, should this be the case? We suggest that the presence of a VAD alone may not be sufficient for status 1A listing. In doing so, we specifically highlight the heightened acuity, resource utilization, risk profile, and diminished outcomes in patients with single ventricle physiology supported with VAD as compared to patients with structurally normal hearts who would both be listed under 1A status. Given this, from a distributive justice perspective, we further suggest that the lack of granularity in current pediatric cardiac transplant listing categories may inadvertently lead to an inequitable distribution of donor organs and hospital resources especially as it pertains to those with single ventricle anatomy on VAD support. We propose revisiting the current listing priorities in light of improved techniques, technology, and recent data to mitigate this phenomenon. By doing this, pediatric patients with single ventricle disease might be more equitably stratified while awaiting heart transplant.
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Affiliation(s)
- Anna E Berry
- Internal Medicine-Pediatrics Residency Program, Monroe Carell Jr. Children's Hospital and Vanderbilt University Hospital, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David W Bearl
- Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, United States
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