A guest post by Rory Spiegel (@CaptainBasilEM) who blogs on nihilism and the art of doing nothing at emnerd.com.
Do not perform chest compressions on an LVAD patient in arrest is a pseudoaxiom for the 21st century. The concern is the force of the compressions will dislodge the cannula, turning a critically ill patient into a critically ill patient with an LVAD-sized hole in their left ventricle. The manufacturers staunchly warn against performing compressions at the risk of causing the sky to fall, our patient’s chest to explode, and an incredibly enraged cardiothoracic surgeon to magically appear at bedside spewing hellfire and brimstone.
Authors of this recent retrospective case series attempt to disprove this modern day axiom. This series describes 8 LVAD patients who presented to their facility, Sharp Memorial Medical Center, in arrest over a 4 year span, all of whom received external chest compression as part of the resuscitative efforts. They assessed device integrity post-arrest in two fashions, either by blood flow data from the LVAD control monitor or examination of the device itself on autopsy (a poor prognostic indicator for the patient). 7/8 patients had flow data post-arrest recorded, all of which indicated a functionally intact VAD. 3/8 had an autopsy performed, including the patient with missing flow data. All confirmed an anatomically intact VAD. The authors conclude that at least in this small case series no VADs were harmed during chest compressions. Whether they were helped is another question all together. These are complex patients with multiple variables including the function of both the VAD and the patient’s intrinsic heart. In this series, 5 out of 8 patients arrested due to pump malfunction, 4 of which were due to accidental disconnection (yikes!). Even in this cohort of a seemingly correctable malady (just plug the thing back in), only one patient had return of neurological function.
A case series of 8 patients is clearly not a large enough n to prove chest compressions are safe in the LVAD patient. What can be said for sure is the sky did not fall and no angry cardiothoracic surgeons materialized from thin air spewing fire and brimstone. Well, at least a half a psuedoaxiom disproven…
“Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs).” www.ncbi.nlm.nih.gov/pubmed/24472494
I would imagine doing nothing will result in death anyway so hopefully enough said.
I would imagine doing nothing will result in death anyway so hopefully enough said.