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

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2. Bleeding in the early post-operative period during the index hospitalization should be urgently evaluated with lowering, discontinuation, and/or reversal of anticoagulation and antiplatelet medications. Level of Evidence: C. Infection Control. Infections in the MCSD recipient are divided into three categories: a) MCSD-specific including pump and/or cannula, pocket, and percutaneous infections; b) MCSD-related, including infective endocarditis, bloodstream, and mediastinitis; c) non-MCSD-related. 7 Patients undergoing MCS surgery are often debilitated with co-morbid conditions including diabetes, renal insufficiency, and malnutrition secondary to a long history of heart failure. 8,9 Immunological deficiencies related to T-cell response and cytokine imbalances may also be present in the population, both of which increase patients’ susceptibility to infection. 10 The most common pathogens causing infection in the MCSD recipient include Staphylococcus sp., Pseudomonas and Enterococcus. Candida is the most common etiology of fungal infections. These isolates can adhere to foreign device material and form biofilm, and therefore evade the immunological system, thereby becoming very hard to eradicate. 11-13 Candida fungemia has been associated with very high mortality in MCSD recipients. 9,14 These organisms are the major ones involved in MCSD-specific and MCSD-related infections and should be taken into consideration when perioperative antimicrobial prophylaxis is evaluated. MCSD recipients have many lines and drains, including central lines and chest tubes, and therefore their risk of infection in the immediate post-operative course is substantial. 8 They also have fresh wounds, and at times their mediastinum remains temporarily open because of edema and bleeding. It should therefore be intuitive that the need to practice meticulous line and wound care is crucial in order to prevent infection. 15-18 Infection Control Measures Before and After MCS. The wound after MCSD placement is classified as clean (Class I). Guidelines for prevention of surgical site infection were published by The Hospital Infection Control Practices Advisory Committee, and the rules should be followed in MCSD implantation operations. 18 Most patients were inpatients for some duration prior to MCS; hence, their skin is colonized with hospital organisms. Simple washing of the skin with antimicrobial soap before 8
MCSD surgery is advised. 19 Preoperative skin cleansing with chlorhexidine-alcohol is superior to povidone-iodine in clean-contaminated operations for prevention of superficial and deep wound infections. 20 During surgical creation of the pocket (if needed) and placement of a MCSD, organisms may be inoculated and later cause infection. Therefore, it is crucial to follow meticulous antiseptic techniques in the operating room. HEPA filters and laminar air flow in the operating room is suggested to maximize sterile ventilation. 21 Movement of personnel should be restricted, and people present in the operating room should use double gloving and headgear to completely cover their hair. 21 Antibiotic-soaked pads should cover the pump and cannulas, and the pump should be extracted from its sterile packing shortly before its placement in the pocket, 21 in order to minimize potential contamination. Adequate hemostasis is important since hematomas may serve as culture media for bacteria. Irrigation of the mediastinum with antibiotic solutions (vancomycin and gentamicin) is performed before wound closure. 21 Post-Operative Routine Prophylaxis. Antibiotic prophylaxis beyond 48 hours after surgery is generally unnecessary. 22 Some centers continue prophylaxis until chest tubes are removed, or in the setting of delayed chest closure. Prolonged use of vancomycin in high-risk general cardiac surgery patients was not beneficial in reducing infection. 23 Also, in a retrospective study, decreasing the duration of vancomycin prophylaxis by more than half was not associated with an increase in infection rate after MCSD placement. 24 The use of nasal mupirocin to reduce MRSA colonization and secondarily reduce staphylococcus infection is practiced by many centers. 25,26 The optimal regimen for antibiotic prophylaxis in patients undergoing MCSD placement is not known, but many centers use a combination of intravenous vancomycin, rifampin, levofloxacin, and fluconazole as recommended in the REMATCH trial. 27,28 An important consideration to take into account is the antibiotic resistance-profile of organisms in the medical center performing the MCSD implant . Secondary prophylaxis given for procedures (dental, respiratory, genitourinary, gastrointestinal) have not been studied in MCSD recipients. In general, prophylaxis has not been recommended for cardiac patients except in certain high risk groups such as those with prosthetic valves, forms of congenital heart disease, and with valvulopathy 9
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Page 3 and 4: additive benefits on mean pulmonary
Page 5 and 6: Recommendations for Neurohormonal B
Page 7: in Task Force 3. Some surgeons elec
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 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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