Task Force 4: Inpatient Management of Patients with MCSD - The ...

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after cardiac transplantation. 29 It should be noted that patients with MCS were not specifically addressed in this consensus statement. Since the burden of developing bacteremia is high in patients with MCS, secondary prophylaxis is reasonable and remains at the discretion of the physician. Driveline Care. Drivelines and external cannulas are usually covered with Dacron-velour which stimulates subcutaneous growth and sealing of the skin. 8 Due to concerns that the velour may promote settling of bacteria at the skin incision and result in infection, some surgeons have elected to bury the velour beneath the skin and bring the silastic coated part of the driveline through the incision.. It is important for the wound around the driveline to heal without gaps so pathogens cannot penetrate. The purse string suture around the driveline should be left in place for up to 30 days. Most driveline infections start with local trauma that disrupts the integrity between the driveline and surrounding skin, usually by accidental pulling of the driveline. 30 Patients have to be educated to care for their drivelines and avoid trauma. Immobilization of the driveline is important, and in case of local trauma, the VADcoordinator has to be notified so infection prevention measures can be taken. 30 In some centers, immobilization of drivelines is performed immediately after the device is placed and before the patient leaves the operating room. 31 A Foley catheter anchor may be used to secure the driveline, and often two anchors are applied to minimize movement at the exit site. The driveline site should be covered during bathing or showering until the wound is completely healed; 8 some advocate no showering for 30 days after surgery or until the driveline site is completely healed. 32 When there is formation of a gap between the driveline and surrounding tissue, it will not form new epithelium and healing would be impossible unless the tissue is debrided. 30 Protocols for the Care of the Driveline Exit Site. There are no universally accepted protocols that address wound care of the driveline exit site. Dressing changes should be done daily or every other day, and the site should be monitored carefully for any sign of infection. 32 Most commonly, cleaning is done with chlorhexidine and gauze is placed to cover the exit site. 33 For patients sensitive to chlorhexidine, hydrogen peroxide may be substituted. At the University of Pittsburgh Medical Center, a protocol for dressing changes was adapted from management of long-term hemodialysis 10
catheter care. 34 The same technique is used daily by nurses for median sternotomy, chest tubes, drivelines, and abdominal pocket wounds. Nurses apply hat, mask, sterile gloves and gown, and while the dressing change is in progress, noone is allowed to enter the room. The dressing change protocol includes 4 steps: 1) gauze soaked with anti-septic solution is used to cleanse the exit site and surrounding skin; 2) The area is rinsed with gauze soaked with sterile water; 3) The area is dried with gauze; 4) 2 x 2 gauze is applied and then covered by transparent occlusive dressing. 34 At some centers, antiseptics or antibiotics are applied around the driveline site such as povidoneiodine, silver sulfadiazine, and chlorhexidine to inhibit growth of colonizing bacteria. 8 Treatment of Device-Related Infections. Most device-related infections occur in the later phase of MCSD therapy, and management of these is reviewed elsewhere in these guidelines. However, early occurrence is possible. The general measures outlined in this section, such as appropriate management of lines and tubes, careful stabilization of the driveline, and judicious care of the driveline exit site serve to reduce early risk of infection. Recommendations for Infection Prevention Post MCS Therapy: Class I: 1. The driveline should be stabilized immediately after the device is placed, and throughout the hospital stay. Level of Evidence: C. 2. A dressing change protocol should be immediately initiated post operatively. Level of Evidence: C. 3. Secondary antibiotic prophylaxis for prevention of endocarditis has not been studied in the MCS population, but it would be considered reasonable due to the risk of bacteremia in this group. Level of Evidence: C. Nutrition The main goals of a post-operative nutritional plan are to promote surgical wound healing, optimize immune function, and improve the macro- and micronutrient substrate 11
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Page 3 and 4: additive benefits on mean pulmonary
Page 5 and 6: Recommendations for Neurohormonal B
Page 7 and 8: in Task Force 3. Some surgeons elec
Page 9: MCSD surgery is advised. 19 Preoper
Page 13 and 14: 3. Pre-albumin and C-reactive prote
Page 15 and 16: those patients with learning disabi
Page 17 and 18: may also be related to the type of
Page 19 and 20: appointments after discharge from M
Page 21 and 22: domains of HRQOL (e.g., depression,
Page 23 and 24: For patients who present with gastr
Page 25 and 26: amenable to endoscopic or surgical
Page 27 and 28: INTERMACS also mandates administrat
Page 29 and 30: 6. Discontinuation or reversal of a
Page 31 and 32: Infectious Issues The classificatio
Page 33 and 34: Level of Evidence: B. 3. A possible
Page 35 and 36: Recommendations for Inpatient Treat
Page 37 and 38: could be actuated with a hand pump
Page 39 and 40: heparin, or a heparin-alternative,
Page 41 and 42: Level of Evidence: C. Class II: 1.
Page 43 and 44: 19. Holman WL, Rayburn BK, McGiffin
Page 45 and 46: 60. McGrady A, McGinnis R, Badenhop
Page 47 and 48: 98. Cadeiras M, Nagaraj H, Kirklin
Page 49 and 50: Table 1. Causes of Deviation from N
Page 51 and 52: Table 3. Determination of MCSD Infe
Page 53: B. Deep MCSD-specific Percutaneous

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