12/27/2022
How do I assess a patient with an LVAD?
If you encounter an LVAD patient in the wild, step 1 is to call the LVAD coordinator (the number on the device), even if they’re going in for a complaint unrelated to the device. Next, as always we’re going to look at the patient. Are they alert and oriented? How does the skin and capillary refill look? When you auscultate the chest, you should hear what sounds like a washing machine in the patients chest. This is normal functioning of the pump and is a good sign. Also take a peek at the patient’s batteries. There are two of them, ensure a good charge on each of them.
Remember, you can’t get a normal NIBP on these patients because they have minimal pulse pressure due to the continuous flow. The only reliable way to check a BP in the field is to attach a manual BP cuff, find the brachial pulse with a doppler, and inflate the cuff until you lose the signal. As you release air from the cuff, you’ll hear the brachial signal return. The pressure at which you hear the signal is the patient’s MAP. These patients are afterload sensitive and preload dependent. They like a MAP of 70-80, and REQUIRE adequate CVP (preload) and right heart function to feed the pump. Signs of right sided congestion like pedal edema and JVD should be taken seriously.
In the same vein, it’s also very difficult to get a reliable SpO2. As a result, you’ll have to assess the patient and make a judgment call to apply oxygen/PEEP/pressure support as you see fit. Capnography is a great tool in these patients as a measure of both respiratory and perfusion status. There isn’t one isolated metric for deciding when to apply oxygen etc, but this is the one time I’ll say it’s ok to empirically apply some oxygen if you think it’s appropriate. Next up: assessing and troubleshooting the device itself. Special thanks to for the VADer idea!
