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

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Figure 1. Algorithm for Assessment of Hypotension Post-Implant Hypotension defined as MAP < 60 mmHg for continuous flow device Low VAD flows; consider hypovolemia, cardiac, obstructive High VAD flows; consider vasodilatation as cause Low JVP; decreased pulsatility or suction events High JVP No fever Fever, leukocy Low hematocrit Bleeding Bolus fluids, transfuse, hold or reverse anticoagulation, identify and treat bleeding source Adequate hematocrit Hypovolemia Bolus fluids RV dysfunction on echo with high CVP and low PCWP RV dysfunction Perform echocardiogram and consider PA catheter placement Tamponade Pulmonary embolus Pneumothorax No RV dysfunction on echo with high PCWP Vasodilating medications; hold vasodilators and initiate pressors Inadequate unloading by LVAD Adjust pump speed Sepsis; look for source, start br spectrum antib initiate pressor Assess cannula position 48
Table 1. Causes of Deviation from Normal Device Conditions Device condition Causes Interventions High flows Vasodilation Sepsis Reduce or hold vasodilators Add pressor support Look for underlying source of sepsis and treat Low flows Hypovolemia Bleeding Arrhythmias appropriately Bolus fluids Transfuse and address source of bleeding Treat arrhythmias High powers Pump thrombosis Add additional anti-platelet and anti-coagulants Consider thrombolytic Emergent pump exchange if needed High pulsatility index (PI) Low PI Suction event (“suckdown” or “PI event”): Collapse of ventricular cavity around device inflow Usually due to under filled ventricle May manifest as low flows, low PI, or alarms Recovery of LV function Percutaneous lead damage Hypovolemia Very poor native ventricular function Excessive pump speed Hypovolemia Excessive unloading of ventricle by device Arrhythmias Look for evidence of recovery Assess VAD components as appropriate Bolus fluids Add inotropic support Adjust pump speed Bolus fluids Lower pump speed Treat arrhythmias 49
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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 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: 98. Cadeiras M, Nagaraj H, Kirklin
Page 51 and 52: Table 3. Determination of MCSD Infe
Page 53: B. Deep MCSD-specific Percutaneous

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

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