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

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staff with triggers for notification of the physician. While there are considerations unique to each device, commonly displayed parameters with continuous flow devices include speed (revolutions of the impeller per minute or RPM), flow (liters/minute), and power (Watts). Pulsatility, which is the size of the flow pulse generated by the pump is also displayed either numerically or visually. Table 1 summarizes causes of deviation from “normal” device conditions. Alarms are device specific, and the user’s manual should be referenced for explanation of these. Recommendations for Device Monitoring: Class I: 1. Normal values for device parameters should be established and recorded in the medical record with triggers for physician notification. Level of Evidence: C. 2. The patient and family members should be taught to track their device parameters and alert staff when changes are observed. Level of evidence: C. 3. Changes in parameters outside of normal ranges should be thoroughly evaluated and treated appropriately. Level of evidence: C. Psychological and Psychosocial Considerations Post operative management of MCS patients should include addressing psychosocial issues by social work, psychology, and psychiatry. MCS patients may have difficulty adjusting to MCS early after surgery. Adjustment issues may differ for patients with chronic advanced heart failure versus those whose heart failure occurred subsequent to a more recent, acute, catastrophic event. 51 Additionally, patients may suffer mental status changes (e.g., delirium, mood changes, and cognitive dysfunction including memory deficits) related to pre-implant catastrophic events, surgery, or early post implant adverse events (e.g., stroke). 51 Furthermore, the occurrence of early adjustment disorders may be related to implant strategy, (i.e., destination therapy) as patients learn to live with MCS for the rest of their natural lives. Adjustment disorders 16
may also be related to the type of MCS device. For example, BiVADs may affect independence from a “lifestyle” perspective, as patients are tethered to a machine or must use a driver on a wheeled cart. As a result, these patients are less able to function independently. In contrast, patients with LVADs who are discharged with a “wearable system” carry the external components in a fanny pack. 52 Finally, psychosocial support may be indicated for patients and families while learning to manage and troubleshoot the MCSD, if they have concerns about their knowledge of MCS, lack confidence in MCSD management, or become overwhelmed. 51 There is also evidence in the literature regarding psychological sequelae early after MCS implantation. Anxiety, lack of control over one’s life, and depression have been reported in hospitalized patients after MCS implantation. 53-55 Patients have also reported moderate levels of stress related to having advanced heart failure, being hospitalized and away from family, the need for MCS, and post-operative pain. 54 Uncertainty may also be an important factor causing stress, especially for “bridge to candidacy” patients. Furthermore, family distress also requires monitoring and intervention. Psychiatric symptoms may predict nonadherence to the medical regimen, unhealthy lifestyle (including substance abuse), poor medical outcomes, and poor health related quality of life after discharge. 51 Despite the stress associated with hospitalization for MCS, patients have also generally reported that they were coping fairly well, although not as well as their selfreport of overall coping prior to surgery. 54 At 2 weeks after MCS (while still hospitalized), patients used more positive coping styles (e.g., optimistic, self-reliant, and supportant) than negative coping styles (e.g., fatalistic, evasive, and emotive), and positive coping was more effective than negative coping. 54 Importantly, psychological assessment and intervention is needed for patients who use negative coping strategies. Interestingly, at both 2 weeks and 1 month after surgery (while still hospitalized), the vast majority of BTT patients reported no regret regarding having undergone MCS implantation, citing that the MCS saved their lives. 54,55 This “honeymoon phase” may be related to relief regarding surviving surgery, denial, and not considering the demands of self-care, prognosis (especially for DT patients), and the possible complications of MCS (e.g., stroke) on lifestyle and long-term quality of life. 51,54,55 It is important to note that 17
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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 and 12: catheter care. 34 The same techniqu
Page 13 and 14: 3. Pre-albumin and C-reactive prote
Page 15: those patients with learning disabi
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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