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

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Level of Evidence: C 4. Patients with a functioning pump, but with alarms or changes in parameters that cannot be resolved as an outpatient may need to be admitted to the hospital for observation and close monitoring. Level of Evidence: C. Non cardiac procedures While on MCS, patients may face medical problems requiring surgical intervention. These interventions may be emergent or non-emergent, with varying degrees of risk to the patient and mortality outcomes. Several series have been published reporting outcomes in patient with MCS undergoing non-cardiac procedures (NCP) with 30 mortality ranging from 9 to 25%. 100-107 However, in one study, despite a 30 day mortality of 42% after emergent NCP and 18% after non-urgent NCP, overall mortality was no different for MCSD patients who underwent NCP versus those who did not. 100 Procedures generally associated with worse outcomes included laparotomy, fasciotomy, and ventriculostomy when performed for emergent indications. In contrast, procedures such as open cholecystectomy, pericardiocentesis, urologic procedures, video assisted thoracoscopic surgery (VATS), and tunneled catheter placement were performed safely. 100 When a MCS patient presents for NCP, the two main perioperative challenges include appropriate hemodynamic monitoring and anticoagulation management. If possible, the patient should undergo their NCP at the implanting medical center or a center with infrastructure and personnel to support the MCS patient. Caring for the patient should be a joint effort between the MCS team and the non-cardiac surgical team. Ideally, the physician performing the NCP should have some experience and knowledge of this patient population, which may be the case at an established MCS center. For an elective NCP, the physicians involved in the patient’s care (including the MCS physicians) should decide whether antiplatelet and/or anticoagulation with warfarin should be stopped. Sometimes, it is possible to perform procedures with low bleeding risk without interruption of therapy. In cases when warfarin therapy needs to be stopped, patients may be bridged with low molecular weight heparin, intravenous 38
heparin, or a heparin-alternative, with discontinuation prior to the elective procedure and resumption within a suitable time frame after the procedure. Alternatively, warfarin may be held for a few days without bridging if it is felt there is an increased bleeding risk with heparin or a heparin alternative. The patient should be made aware that anytime there is a discontinuation of warfarin and anti-platelet therapy there is always a risk of a thromboembolic event. Therefore, they should report any concerning symptoms promptly. For emergent procedures, anticoagulation with warfarin may need to be reversed rapidly which can be done with administration of fresh frozen plasma (FFP) or prothrombin protein concentrate (PCC). Vitamin K may be administered either orally or intravenously, but the onset of action is slower. The degree of reversal and target INR must be determined by the clinical presentation of the patient and the risk of bleeding during the NCP. At that point in time, the risk of thromboembolic events may be far outweighed by the imminent risks of bleeding. Once the emergent procedure has been completed and the post-operative risk of bleeding has abated, bridging with heparin or a heparin-alternative may be considered. Non-invasive blood pressure monitoring with Doppler may be appropriate for minor procedures. However, during any procedure where there is a risk of hypotension or non-invasive blood pressure cannot be reliably obtained, an arterial line should be placed. Placement of a central-venous catheter allows for monitoring of central-venous pressure and volume status during procedures that may result in fluid shifts, such as intra-abdominal operations. Central venous access also facilitates administration of vasoactive medications during hemodynamic instability. During any procedure, MCSD parameters should be continuously monitored by expert personnel such as an MCS nurse or perfusionist. A cardiovascular surgeon should be in the operating room or immediately available in cases where the NCP may come in proximity to the MCSD, such as during abdominal surgery. Recommendations for Management of the MCS Patient during Non-Cardiac Procedures: Class I: 39
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Page 3 and 4: additive benefits on mean pulmonary
Page 5 and 6: Recommendations for Neurohormonal B
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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
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
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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: could be actuated with a hand pump
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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