Mechanical circulatory support guidelines issued

Recommendations for optimal nutritional status include consultation with nutritional services at the time of implantation with ongoing follow-up post operatively to ensure nutrition goals are being met. For those unable to meet nutritional goals orally, feeding should be started early and preferably through an enteral feeding tube. Parenteral nutrition should only be started if enteral nutrition is not possible and under the guidance of nutritional consultation.

Prealbumin and C-reactive protein levels can be monitored weekly to track the nutritional status of the postoperative patient. As nutrition improves, prealbumin should rise and C-reactive protein should decrease.

Patient and caregiver education should be initiated shortly after surgery and reinforced by the nursing staff. Educational strategies should use written, verbal, and practical methods.

MCS parameters should be written in the medical record at regular intervals with established criteria for parameters that require physician notification.

The patient and family members should be taught to track their device parameters and alert staff when changes are observed. Changes in parameters outside of normal ranges should be thoroughly evaluated and treated appropriately.

Routine support should be available from social workers, psychologists, or psychiatrists as patients and families adjust to life changes after MCS. Routine surveillance for psychiatric symptoms should be performed. If symptoms develop, consultation with specialists (including social work, psychology, and/or psychiatry) for diagnosis, treatment, and follow-up is recommended.

Assessment of specific problems that are related to domains of health-related quality of life (depression, anxiety, or pain) based on symptoms should help guide an action plan for these patients.

Successful discharge should include patient, caregiver and community provider education with written discharge instructions and preemptive home preparation regarding the safe management of the device and the MCS patient.

Recommendations for management of anticoagulation and antiplatelet therapy for patients who present with gastrointestinal bleeding include holding back anticoagulation and antiplatelet therapy in the setting of clinically significant bleeding and reversing anticoagulation in the setting of an elevated INR and clinically significant bleeding.

Anticoagulation and antiplatelet therapy should continue to be held until clinically significant bleeding resolves in the absence of evidence of pump dysfunction. The patient, device parameters, and the pump housing (if applicable) should be carefully monitored while anticoagulation and antiplatelet therapy is being withheld or the dose reduced.

Patients who present with a first episode of gastrointestinal bleeding should be managed in consultation with gastroenterology. Patients should at least have a colonoscopy and/or upper endoscopic evaluation. If the results are negative, evaluation of the small bowel, particularly in those with continuous-flow devices, should be considered.

In patients with persistent bleeding and a negative endoscopic evaluation, a tagged red blood scan or angiography should be considered.

Once the gastrointestinal bleeding has resolved, anticoagulation and antiplatelet therapy can be reintroduced with careful monitoring.

For patients with recurrent episodes of gastrointestinal bleeding, repeated endoscopic evaluation should take place in conjunction with gastroenterology consultation. When no source of bleeding can be detected or the source is not amenable to therapy, the type and intensity or even the use of antiplatelet therapy should be reevaluated in the context of the bleeding severity and pump type. Further, the goal INR or even the continued use of warfarin should be reevaluated in the context of the bleeding severity and pump type.

The patient and device parameters should be carefully monitored when anticoagulation and antiplatelet therapy have been reduced or discontinued because of recurrent gastrointestinal bleeding.

Reducing the pump speed for continuous-flow pumps in the setting of recurrent gastrointestinal bleeding due to arteriovenous malformations may be considered.

When patients present with a new neurologic deficit, assess the current INR and review the recent INR. Prompt consultation with neurology is recommended, as is CT and angiography of the head and neck.

Review the pump parameters for signs of device thrombosis or malfunction, and inspect the pump housing for clots in extracorporeal pumps. Discontinuation or reversal of anticoagulation in the setting of hemorrhagic stroke is recommended.

Assessing for the source of the thrombus should be considered in embolic stroke patients. Selective use of an interventional radiologic approach to thrombotic strokes or selective use of thrombolytic agents in the setting of thrombotic stroke without CT scan evidence of hemorrhage may be considered.

Chronic management of patients after presentation with a new neurologic deficit may include formal stroke rehabilitation in consultation with neurology, close monitoring of anticoagulation in the setting of an embolic event to ensure adequate levels of anticoagulation, long-term control of blood pressure, administration of the National Institutes of Health (NIH) stroke scale at 30 and 60 days, and resumption of anticoagulation in consultation with neurology or neurosurgery in the setting of hemorrhagic stroke.