The PCI procedure of the LAD SVG was then started. Optimizing the spatial relationship between the catheter and adjacent intracardiac structures is necessary to minimize device-related complications. Notably, low native heart pulsatility may similarly trigger either the Impella Position Wrong or the Impella Position Unknown alarm, as the software cannot interpret the dampened amplitude of the placement signal and motor current (Figure 3E). 2021 Mar 26;100(12):e25159. Train a core group of critical care nurses to care for the patient, monitor the device, change tubings, and troubleshoot alarms. After making note of the catheter depth from the vascular access site, the nonimager should then loosen the vascular access site Tuohy-Borst lock (Figure 5) and rotate, advance, or withdraw the catheter as appropriate to optimize its position. 0000003906 00000 n The Impella RP is a right ventricular (RV) support system that is percutaneously positioned in the pulmonary artery via the femoral vein under fluoroscopy. An enlarged uvula is often caused by infection, an allergic reaction, or irritation from chemicals or medical procedures. Notably, the device manufacturer suggests measuring catheter depth from the aortic annulus to the middle of the echolucent inlet area, (i.e., 0.5 cm more than the distances stated above). A multidisciplinary approach to establishing a program for the Impella is useful in ensuring competency and good outcomes for patients. A low purge pressure alarm indicates that the purge pressure to the Impella motor has decreased below 300 mm Hg. An official website of the United States government. That waveform depicts the pressure gradient across the intra- and extraluminal surface of the cannula, and when the device is correctly positioned, the intra- and extraluminal pressures reflect the pressure within LV and aortic root, respectively. Infusion of purge solution alone infrequently results in the desired therapeutic systemic anticoagulation and an additional infusion of parenteral heparin is often required. Single Access Technique. Nursing care is directed toward support of critically ill patients, including frequent hemodynamic assessment, titration of vasoactive medications as indicated, Impella console troubleshooting, and monitoring for potential complications. MeSH In our facility, we often use transthoracic echocardiography to aid in the assessment of our patients. Transthoracic echocardiography showed increased contractility, and the ejection fraction was 40%. The proximal port of this lumen is red. Immediately before removal of the device, decrease the performance level to P0. Correct placement across the aortic valve is critical to avoid complications including hemolysis, suction episodes and inadequate hemodynamic support. Bivalirudin was administered for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. Optimal imaging often requires off-axis parasternal long-axis views obtained by fanning and rotating the probe until the entire length of the cannula and the aortic annulus are seen. Additionally, a gross assessment of cannula depth can be inferred by contrasting the placement signal and LV pressure waveforms on SmartAssist capable devices (see controller alarm section.). The purpose of this review is to describe how to manage, reposition, and wean patients from the Impella catheter. Partner with industry. We have extensive experience with the IABP and with surgically placed VADs, including the Abiomed AB5000, Thoratec CentriMag, XVE, and HeartMate II. The 13F arterial sheath was sutured in placed for removal 2 hours later, after the patient had returned to the CICU. In our facility, physicians who can place this device are those who have interventional cardiology and/or cardiac surgery privileges. Console and infusion pump setup requires 2 to 3 minutes to complete. Placement monitoring screen display shows that pump position is wrong. Once the imager has a nonforeshortened image of the catheter in the parasternal long-axis view, the Impella motor speed should be temporarily set to power level P2, which reduced the risk of damaging the submitral apparatus during the catheter manipulation. Esposito ML, Morine KJ, Annamalai SK, et al. Low purge pressures require immediate intervention by a critical care nurse. In one trial5 in which an IABP was compared with an Impella in cardiogenic shock patients, after 30 minutes of therapy, the cardiac index (calculated as cardiac output in liters per minute divided by body surface area in square meters) increased by 0.5 in the patients with the Impella compared with 0.1 in the patients with an IABP. Crowley J, Cronin B, Essandoh M, DAlessandro D, Shelton K, Dalia AA: Transesophageal echocardiography for, 2. You can get a swollen uvula from infections including the flu, mononucleosis, croup, and strep throat. A low purge pressure can allow blood to enter the motor and damage the motor, rendering the device inoperable. doi: 10.1097/MD.0000000000025159. 8600 Rockville Pike Unloading using Impella CP during profound cardiogenic - SpringerOpen Quick Reference and Troubleshooting Guide Impella Heart Cardiogenic shock (CS) is a life-threatening condition associated with significant morbidity and mortality. Curr Cardiol Rep. 2018 Jan 19;20(1):2. doi: 10.1007/s11886-018-0946-2. Some patients on Impella support may be intubated and receiving mechanical ventilation. Toddler On Board Car Sign, Suction Cup Baby On Board Sign, Child - eBay Detailed view of distal end of Impella 2.5. Our facility has a high-volume interventional cardiology program as well as a busy adult and pediatric cardiovascular surgery service. The patients hemodynamic status is assessed after every decrease in performance level. In our facility, this role is filled by the interventional cardiology clinical nurse specialist. Device profile of the Impella 5.0 and 5.5 system for mechanical circulatory support for patients with cardiogenic shock: overview of its safety and efficacy. Sheaths were placed in the right femoral vein, the right femoral artery, and the left femoral artery. The motor current will be flattened. Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD: Venoarterial extracorporeal membrane oxygenation for, 7. An additional method to ensure proper depth is to interrogate the aortic root with color Doppler from the parasternal long-axis view. 3. placement monitoring is suspended or disabled. Get new journal Tables of Contents sent right to your email inbox, Impella Management for the Cardiac Intensivist, Articles in PubMed by Alexander I. Papolos, Articles in Google Scholar by Alexander I. Papolos, Other articles in this journal by Alexander I. Papolos, A Narrative Review of Nutrition Therapy in Patients Receiving Extracorporeal Membrane Oxygenation, Use of Impella in Patients Listed for Heart Transplantation, Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis, Thrombosis in Extracorporeal Membrane Oxygenation (ECMO) Circuits, Heparin Versus Bivalirudin for Anticoagulation in Adult Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis, Privacy Policy (Updated December 15, 2022). The structural design of each of these LV support catheters is grossly similar (Figure 2). Frontiers | Central Venous Pressure and Clinical Outcomes During Left Distal pulses of the affected leg should be assessed at least hourly. After advancement, always remove any slack by slowly pulling back on the catheter until cannula movement is observed. In general, if the patient subsequently develops oliguria, tachycardia, lactate >2 mg/dL, or a cardiac index <2.0 L/min/m2 we will resume the prior level of cardiac support provided by the Impella. Catheters with SmartAssist, however, will more specifically identify the nature of the mispositioning and can distinguish between the ventricular and aortic placement of the inlet and outlet areas (Figure 3C and 3D). Support with Impella versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A protocol for systematic review and meta-analysis. He had a long history of diabetes and had undergone coronary artery bypass surgery 20 years prior. Train a core group of nurses and cardiovascular technologists from the catheterization laboratory for initial setup of the console, catheter preparation, and assisting with placement of the device. Purge Screen Displays purge system information displayed as a function of time. The second lumen ends near the motor above the level of the aortic valve and is used to monitor aortic pressure. 597 17 The necessary images may be particularly difficult to obtain if the Impella device is medially or laterally oriented. In this article, I discuss the Impella 2.5, review indications and contraindications for its use, delineate potential complications of the Impella 2.5, and discuss implications for nursing care for patients receiving extended support from an Impella 2.5. It should not be used in patients with moderate to severe aortic insufficiency; it may worsen the degree of insufficiency because the aortic valve cannot close completely with the device in place. Diastolic LV numbers are also very negative and the Max and Min flows displayed on the console are lower than expected. Hemolysis can occur in patients who are on the Impella 2.5. Our practice of monitoring and managing RV function relies heavily on invasive hemodynamics and ultrasound imaging. When the activated clotting time was higher than 250 seconds, the Impella 2.5 was advanced into position via the left common femoral artery and placed across the aortic valve into the left ventricle. In these illustrations, the Impella Catheter is positioned correctly. In our facility, we have a trained CICU nurse managing the Impella while the patient is in the cardiovascular operating room. Before Optimal hemodynamic effect from the IABP is dependent on several factors, including the balloons position in the aorta, the blood displacement volume, the balloon diameter in relation to aortic diameter, the timing of balloon inflation in diastole and deflation in systole, and the patients own blood pressure and vascular resistance.3,4, The Impella 2.5 (Figure 1) aspirates up to 2.5 L/min of blood from the left ventricle and displaces it into the ascending aorta, rapidly unloading the left ventricle and increasing forward flow.
