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

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Postoperative pharmacologic therapy is an essential adjunct to device therapy. Prolonged ( >14 days) use of inotropes may be necessary to support RV function following MCSD implantation, or to enhance LV function if device speeds are temporarily set lower to prevent septal shift. Milrinone is an important inotrope for perioperative myocardial support. It enhances contractility as well as vasodilation, particularly of the pulmonary bed, which can reduce RV afterload. Dobutamine can also be used in the telemetry unit with minimal monitoring to provide beta agonist support and enhance contractility. Weaning of inotropic support should be initiated once the patient is euvolemic and is clinically guided by the physical examination with close monitoring of device parameters. Ideally, this is accomplished by initiating oral heart failure therapies with up-titration as tolerated before the inotrope weaning process. Diuretics and/or mechanical volume removal may be necessary to achieve optimal volume status. As inotropes are weaned, the clinician should evaluate for evidence of RV dysfunction including: - Increasing edema - Elevation of jugular venous pressure (JVP) or CVP as monitored by a central venous catheter. CVP should be maintained
additive benefits on mean pulmonary artery pressure and PVR without systemic hypotension and ventilation/perfusion mismatch. 2 Afterload reducing vasodilators including ACE inhibitors, angiotensin receptor blockers (ARBs), nitrates, and hydralazine are the cornerstone of treatment of heart failure patients, but their role is less well defined in the patient on MCS. Generally, resumption of afterload reduction with ACE-inhibitor or ARB is recommended in the post-operative period for the goals of treating hypertension, optimizing RV function, averting the development of aortic insufficiency (a long-term complication), preventing other vascular complications, affording renal protection, and maximizing the potential for LV myocardial recovery. Hypertension for a continuous flow VAD, typically defined as a MAP >90mmHg, is essential to treat for optimal device performance. Once pressors are weaned, an ACE-inhibitor or ARB may be initiated at low doses and slowly increased in a step-wise fashion. Hydralazine and nitrates may be introduced thereafter as second line agents if blood pressure targets have not been met, although nitrates should not be given if the patient is already being treated with a PDE-5 inhibitor. If there is right heart dysfunction or chronotropic incompetence, beta blocker use may be limited. Permanent pacing may be necessary to remedy heart rate issues. After stabilization of blood pressure, heart rate, and volume status, beta blockers may be initiated either in the hospital or early in the outpatient setting. Once again, there are insufficient data to support evidence-based recommendations for the resumption of beta blockers post MCS, but the rationale for starting them is similar to that for ACE-inhibitors and ARBs. Beta-blockers may also be helpful in the treatment of arrhythmias. Cardiac glycosides and mineralocorticoid receptor antagonists (MRA) may be resumed to help support right ventricular function and attenuate myocardial fibrosis. Hypotension may recur in the post ICU setting, due to either device related or non- device related causes. An algorithm to assess hypotension post MCSD implant is presented in Figure 1. Tamponade is a real, although unlikely, cause of hypotension once patients are stable and out of the ICU. It should always be considered as the treatment is emergent and invasive. Although tamponade is covered in Task Force 3, it is worth reiterating that echocardiography is not always reliable in the diagnosis of 3
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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 and 16: those patients with learning disabi
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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
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Page 49 and 50: Table 1. Causes of Deviation from N
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B. Deep MCSD-specific Percutaneous
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