Improving Nutrition Practices for Critically Ill Postoperative Heart Transplant and Ventricular Assist Device Implant Patients

Purpose Patients undergoing orthotropic heart transplantation (OHT) and left ventricular assist device (LVAD) implantation may be challenging to feed postoperatively in the setting of cardiac dysfunction requiring high-dose vasoactive support. Variability in enteral nutrition (EN) practices in this setting is associated with onset of malnutrition and severe gastrointestinal (GI) complications such as bowel ischemia. Currently, there is limited guidance for nutrition in postoperative cardiothoracic surgery patients with significant hemodynamic compromise. To address the need for optimizing nutrition in this patient population, we created High Risk Enteral Nutrition Guidelines (HRENG) to provide postoperative nutritional guidance regarding EN route, timing, formula, feeding rate/progression, monitoring, and energy targets for EN and TPN in hemodynamically unstable OHT and LVAD patients. Methods HRENG were utilized in critically ill postoperative OHT and VAD implant patients that met at least two of the following criteria: cardiogenic shock, ECMO cannulation, low cardiac output on high dose vasopressor support, open chest, intubation >48 hours and signs of end organ dysfunction. Retrospective chart review was conducted on eligible OHT and LVAD patients for the 15 months prior to and following the implementation of HRENG at our institution. Data was collected regarding adherence to the guidelines and incidence of bowel ischemia. Results There were 26 eligible patients who underwent OHT and LVAD prior to initiating HRENG. Analysis of these revealed inconsistent postoperative feeding practices and 5 cases (19.2%) of bowel ischemia. After implementing HRENG, 28 patients OHT (n=11) and LVAD (n=17) met inclusion criteria. The mean age was 57.1 years, 38% ischemic, 38% women. 3/17 of LVAD patients had HM3; 14/17 had HVAD. Adherence to HRENG was achieved in 25/28 (89.2%) of patients. Of the 25 patients with adherence to HRENG, there were no cases (0%) of bowel ischemia. Of the 3 patients with nonadherence to these guidelines, 2 (66.67%) developed bowel ischemia. Conclusion Implementation of postoperative nutrition guidelines targeted for hemodynamically unstable OHT and VAD implantation patients may align feeding practices and reduce the incidence of ischemic GI complications. Patients undergoing orthotropic heart transplantation (OHT) and left ventricular assist device (LVAD) implantation may be challenging to feed postoperatively in the setting of cardiac dysfunction requiring high-dose vasoactive support. Variability in enteral nutrition (EN) practices in this setting is associated with onset of malnutrition and severe gastrointestinal (GI) complications such as bowel ischemia. Currently, there is limited guidance for nutrition in postoperative cardiothoracic surgery patients with significant hemodynamic compromise. To address the need for optimizing nutrition in this patient population, we created High Risk Enteral Nutrition Guidelines (HRENG) to provide postoperative nutritional guidance regarding EN route, timing, formula, feeding rate/progression, monitoring, and energy targets for EN and TPN in hemodynamically unstable OHT and LVAD patients. HRENG were utilized in critically ill postoperative OHT and VAD implant patients that met at least two of the following criteria: cardiogenic shock, ECMO cannulation, low cardiac output on high dose vasopressor support, open chest, intubation >48 hours and signs of end organ dysfunction. Retrospective chart review was conducted on eligible OHT and LVAD patients for the 15 months prior to and following the implementation of HRENG at our institution. Data was collected regarding adherence to the guidelines and incidence of bowel ischemia. There were 26 eligible patients who underwent OHT and LVAD prior to initiating HRENG. Analysis of these revealed inconsistent postoperative feeding practices and 5 cases (19.2%) of bowel ischemia. After implementing HRENG, 28 patients OHT (n=11) and LVAD (n=17) met inclusion criteria. The mean age was 57.1 years, 38% ischemic, 38% women. 3/17 of LVAD patients had HM3; 14/17 had HVAD. Adherence to HRENG was achieved in 25/28 (89.2%) of patients. Of the 25 patients with adherence to HRENG, there were no cases (0%) of bowel ischemia. Of the 3 patients with nonadherence to these guidelines, 2 (66.67%) developed bowel ischemia. Implementation of postoperative nutrition guidelines targeted for hemodynamically unstable OHT and VAD implantation patients may align feeding practices and reduce the incidence of ischemic GI complications.