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

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conditions. 35 A formal nutritional consultation should be completed for all patients undergoing MCS with establishment of goals for those diagnosed with nutritional deficits. Pre-operative parameters should be obtained including pre-albumin, C-reactive protein, lipid profile, thyroid profile, serum iron, transferrin, folate, B12 and trace elements. Pre-albumin and C-reactive protein can be monitored on a weekly basis postoperatively. 36 Trace elements such as zinc, manganese, selenium and copper can be checked every three months as needed. A goal of 20-25 kcals/kg/d with 1.2-1.5 g/kg/day protein should be targeted for critically ill patients. Calorie intakes should be advanced gradually based on medical status. 37. Ambulatory and non-critically ill patients need 30 to 35 kcals/kg/day to meet energy needs. 36 Ideally, feeding should begin within the first post-operative hours, enterally if possible. Enteral nutrition supports gut integrity, modulates the immune system, and is associated with a lower risk for infection than parenteral nutrition. 38 Early versus late enteral nutrition is associated with a decreased risk for mortality in ventilated patients with unstable hemodynamic conditions and on vasopressors. 39 Placement of a nasoenteric tube should be considered to improve enteral nutrition tolerance and decrease the risk for aspiration. 36 Enteral nutrition formulas should be adjusted based on tolerance. 36 Parenteral nutrition should be reserved for patients who are unable to tolerate enteral nutrition adequately due to the high risk for fungal infection. 40 Recommendations for Optimization of Nutritional Status: Class I: 1. Consultation with nutritional services should be obtained at the time of implantation with ongoing follow up post-operatively to ensure nutrition goals are being met. Level of Evidence: C. 2. Post-operatively, feeding should be started early and preferably through an enteral feeding tube. Parenteral nutrition should be started if enteral nutrition cannot be supported. Level of Evidence: C. 12
3. Pre-albumin and C-reactive protein can be monitored weekly to track the nutritional status of the post-operative patient. As nutrition improves, pre-albumin should rise and C-reactive protein should decrease. Level of Evidence: C. Device Related Education Health Care Provider Education. MCS education is an essential component of a MCS program. To safely manage MCS patients, a broad range of in-hospital health care professionals need to be educated including physicians, nurses, and other multidisciplinary team members (e.g., physical therapy and occupational therapy). A plan for comprehensive training of the majority of nurses in the hospital areas involved in the care of MCS patients will ensure that there are enough competent nurses to care for these patients. Orientation to MCS should incorporate both theory and practical sessions with the use of a training simulator, allowing the staff to have hands on experience with the equipment. Education regarding acute management should address the indications for MCS implantation, components of the device(s), post-operative hemodynamics and daily management (including driveline exit site dressing changes), recognition and management of MCSD alarms, emergency responses, medications, and MCS adverse events. 41 Providing literature on new devices will help to prepare nurses to care for patients with these devices. 42 After orientation to MCS, many institutions provide refresher courses and require semi-annual or annual assessment of MCS competencies. Regular competency assessment may help to maintain the nurse’s confidence and knowledge in the care of MCS patients. 41-43 Learning styles of staff members need to be considered in the education program. 44 Ensuring nursing accessibility to guidelines and protocols promotes consistent and safe management when caring for MCS patients. A device checklist or flow sheet, based on guidelines for monitoring MCS and providing care, facilitates guideline adherence. Patient Education. A collaborative multi-disciplinary approach to education of the patient, family, and friends is essential to the safe discharge of a MCS patient. An explanation of the surgical implant, post operative course (including recovery, 13
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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 and 10: MCSD surgery is advised. 19 Preoper
Page 11: catheter care. 34 The same techniqu
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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