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

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All patients who note the development of a new neurologic deficit should be quickly assessed by the MCS team in conjunction with neurologists or the acute stroke team as soon as possible. In the intra-operative or early peri-operative period, delays in detecting neurologic events can result, as they may not be evident until sedation is weaned. Thus, it is critical to assess patients’ mental status early after arrival in the intensive care unit and periodically thereafter until the patient is no longer sedated. The assessment should include appropriate imaging as directed by the neurological team, most often a CT scan of the head. In the setting of an embolic event that is diagnosed shortly after the onset of presenting symptoms, angiography or vascular intervention may be possible. The safety of thrombolytic therapy has not been established in the MCS population, but it may be risk prohibitive in the peri-operative setting. An assessment of the current INR as well as recent INR should also be performed. For those with extracorporeal devices, the pump housing, the degree of emptying, and the cannula should be inspected for clot formation. For those with continuous flow pumps, the pump parameters should be reviewed for sign of pump malfunction or thrombus. Recommendations for the Acute Management of Patients who Present with a New Neurological Deficit: Class I: 1. Assessment of current INR and review of recent INR is recommended. Level of Evidence: B. 2. Prompt neurological consultation is recommended. Level of Evidence: B. 3. Computed tomography and angiography of the head and neck is recommended. Level of Evidence: B. 4. Review of pump parameters for signs of device thrombosis or malfunction is recommended. Level of Evidence: C. 5. Inspection of pump housing for clots in extracorporeal pumps is recommended. Level of Evidence: C. 28
6. Discontinuation or reversal of anticoagulation in the setting of hemorrhagic stroke is recommended. Level of Evidence: B. Class IIa: 1. Assessing for source of thrombus in the setting of an embolic stroke should be considered. Level of Evidence: B. Class IIb: 1. Selective use of interventional radiologic approach to thrombotic strokes may be considered. Level of Evidence: C. 2. Selective use of thrombolytics in the setting of thrombotic stroke without hemorrhage on head CT scanning may be considered. Level of Evidence: C. Class III: 1. Routine use of interventional radiologic approach to thrombotic strokes is not recommended. Level of Evidence: C. 2. Routine use of thrombolytics in the setting of thrombotic stroke without hemorrhage on head CT scanning is not recommended. Level of Evidence: C. Recommendations for the Chronic Management of Patients after Presentation with a New Neurological Deficit: Class I: 1. Formal stroke rehabilitation in consultation with neurology is recommended. Level of Evidence: B. 29
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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 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: INTERMACS also mandates administrat
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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