| Abstract | Srčano zatajivanje jedan je od najvažnijih uzroka mortaliteta i morbiditeta u cjelokupnoj populaciji. Mehanička potpora lijevom srcu (LVAD - “left ventricular assist device”) jedna je od naprednih mogućnosti liječenja uznapredovalog srčanog zatajivanja refrakternog na medikamentnu terapiju. Radi se o intrakorporalnoj pumpi koja potpomaže rad srca povećanjem srčanog minutnog volumena te može poslužiti kao privremena („most do transplantacije”) i kao trajna terapija (“destination therapy”). LVAD terapija povezana je s više različitih komplikacija kao što su krvarenje, periferne tromboembolije, aritmije, sepsa, hemoliza, psihosocijalni i neurološki poremećaji itd. Jedna od učestalijih komplikacija koja bitno utječe na ishode liječenja je infekcija izlaznog mjesta („driveline“) pumpe koja se vrlo teško liječi te često prelazi u kroničnu infekciju.
Cilj je ovog diplomskog rada opisati sustavne i lokalne infekcije povezane s izlaznim mjestom („drivelineom“) nakon ugradnje mehaničke potpore lijevom srcu.
Kod lokalnih infekcija najviše se pojavljuju upalne promjene oko perkutanog kabela mehaničke pumpe koje rezultiraju oteklinom, bolnošću, crvenilom i sekrecijom izlazišnog mjesta. Osim toga mogu se javiti i infekcije ležišta uređaja. Sistemske su infekcije teži oblik i u njih ubrajamo: infekcije krvotoka, sustavne infekcije povezane s VAD-om i centralnim venskim kateterom te one koje nisu povezane s VAD-om. U svrhu sprječavanja razvoja mogućih infekcija koristi se antibiotska profilaksa.
U radu prikazujemo slučaj muškarca u dobi od 38 godina opterećenog mmnogostrukim komorbiditetima, kojem je 18.03.2014. u sklopu terminalne ishemijske bolesti srca učinjena ugradnja LVAD-a. Nakon ugradnje dolazi do lokalne infekcije ishodišta („drivelinea“) koja napreduje u sustavnu infekciju te bolesnik razvija sepsu. Iz brisa rane izolirani su sljedeći mikroorganizmi: meticilin-rezistentni Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, Enterobacter spp., Anaerococcus vaginalis, a iz hemokultura izoliran je Staphylococcus epidermidis. Infekcija je djelomično kontrolirana intravenskim antibioticima i antifungicima (potonje u smislu prevencije): piperacilinom, linezolidom, klindamicinom, vorikonazolom te flukonazolom. Dugotrajna infekcija i sustavna upala podižu rizik od tromboze uređaja. Osim toga, višestruka antimikrobna terapija otežava vođenje antikoagulacije antagonistima vitamina K koji su esencijalni kod nosilaca LVAD-a. Iz navedenih razloga kod bolesnika dolazi do disfunkcije LVAD-a (pad protoka pumpe) uzrokovanog suspektnom trombozom uređaja.
Tijek i ishod liječenja kao i sestrinski postupci i zadaci prilikom praćenja statusa bolesnika opisani su u ovom radu. Doprinos ovog rada sastoji se od analize rada mehaničke srčane pumpe i njenih specifičnosti te opisa sestrinskih postupaka i vezanih intervencija u svrhu profilakse i liječenja infekcije izlaznog mjesta perkutanog kabela LVAD-a. |
| Abstract (english) | Heart failure is one of the most important causes of mortality and morbidity population-wise. Mechanical left ventricular assist device (LVAD) is one of the advanced treatment options for terminal heart failure refractory to drug therapy. It is an intracorporeal pump that supports the heart function by increasing the cardiac output and can serve as a temporary ("bridge to transplant") or as a permanent heart failure solution ("destination therapy"). LVAD therapy is associated with a number of different serious complications such as bleeding, peripheral thromboembolism, arrhythmias, sepsis, haemolysis, psychosocial and neurological disorders, etc. One of the most common complications that significantly affects treatment outcomes is driveline (i.e., percutaneous cable that servers for power supply and pump control) infection, which is very difficult to treat and often progresses to a chronic form.
The aim of this thesis is to describe systemic and local infections associated with the device driveline after the LVAD implantation. Considering local infections, most often changes occur around the percutaneous cable of the mechanical pump, resulting in swelling, soreness, redness, and secretion on the exit site. In addition, infections of the device pocket can occur. Systemic infections are more severe and include circulatory infections, systemic infections associated with LVAD and central venous catheters, and those not associated with VAD. In order to prevent the development of possible infections, antibiotic prophylaxis is used.
This thesis presents a case of a 38-year-old man burdened with multiple comorbidities, who underwent LVAD implantation in March 2014 due to terminal ischemic heart disease. After implantation, a local “driveline” infection developed which progressed to a systemic infection and sepsis. The following microorganisms were isolated from the wound swab: methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, Enterobacter spp., Anaerococcus vaginalis, while Staphylococcus epidermidis was isolated from blood cultures. The infection was partially controlled by intravenous antibiotics and antifungals: piperacillin/tazobactam, linezolid, clindamycin, voriconazole and fluconazole. Prolonged infection and systemic inflammation raises the risk of device thrombosis. In addition, multiple antimicrobial agents complicated vitamin K antagonist titration that is essential in LVAD carriers. Therefore, patient developed LVAD dysfunction (drop in pump flow) caused by probable device thrombosis. The course and outcome of the treatment as well as nursing procedures and tasks in monitoring patient status are described in this thesis. The main contribution of this tjesos consists of the analysis of mechanical heart pump function and its specifics, as well as a description of nursing procedures and related interventions for the purpose of treatment and prophylaxis of LVAD percutaneous driveline infection. |
