Recommendations for postoperative management in the intensive care unit

Recommendation	Class	Level	References
Monitoring
In postoperative patients with mechanical circulatory support, continuous electrocardiography, pulse oximetry, central venous pressure and invasive arterial blood pressure monitoring are recommended.	I	C
Miniaturized transoesophageal echocardiographic probes that can be maintained in the oesophagus in situ for up to 72 h may be considered to assist in the management of fluid resuscitation and to diagnose complications.	IIb	C	[317]
A pulmonary artery catheter should be considered to assist in the management of fluid resuscitation and to diagnose complications in patients receiving an LVAD and at risk of postoperative RV failure.	IIa	C	[71, 318]
Transpulmonary thermodilution and pulse contour-derived measurement of cardiac output are inadequate in continuous-flow ventricular assist device and biventricular assist device settings and are therefore not recommended.	III	C
Postoperative laboratory monitoring, including daily measurement of plasma free haemoglobin and lactate dehydrogenase, is recommended.	I	C
Right ventricular failure in patients with a left ventricular assist device
Regular echocardiographic scans should be considered to monitor RV function in patients supported by an LVAD.	IIa	C	[317, 319, 320]
Echocardiography is recommended to guide weaning from temporary RV support.	I	B	[321, 322]
Inhaled NO, epoprostenol (or prostacyclin) and phosphodiesterase 5 inhibitors may be considered to reduce right heart failure after LVAD implantation.	IIb	C	[323–327]
Inotrope and vasopressor support
Norepinephrine should be considered as a first-line vasopressor in case of postoperative hypotension or shock.	IIa	B	[9, 328, 329]
Dopamine may be considered in case of postoperative hypotension or shock.	IIb	B	[9, 328, 329]
The combination of norepinephrine and dobutamine should be considered instead of epinephrine in case of postoperative hypotension and low cardiac output syndrome with RV failure.	IIa	C	[9, 71, 330, 331]
Epinephrine may be considered in case of postoperative hypotension and low cardiac output syndrome with RV failure.	IIb	C
Phosphodiesterase 3 inhibitors may be considered in patients with long-term mechanical circulatory support with postoperative low cardiac output syndrome and RV failure.	IIb	C	[332, 333]
The use of levosimendan in case of postoperative low cardiac output syndrome may be considered.	IIb	A	[334, 335]
Postoperative mechanical ventilation
Avoidance of hypercarbia that increases pulmonary artery pressure and RV afterload is recommended.	I	C
Bleeding and transfusion management
If mediastinal drainage exceeds 150–200 ml/h in the early postoperative phase, surgical re-exploration should be considered.	IIa	C
Activated recombinant factor VII may be considered as a salvage therapy for intractable haemorrhage after correction of bleeding risk factors and after exclusion of a surgically treatable cause of bleeding.	IIb	C	[336, 337]

LVAD: left ventricular assist device; NO: nitric oxide RV: right ventricular.