signs of suction in impella

A 74-year-old man was transferred to our facility after sustaining a nonST-segment elevation myocardial infarction. The second lumen of the Impella 2.5 is flushed with heparinized saline (500 mL normal saline with 1000 units heparin) by using regular (not infusion pump) intravenous tubing. Regular documentation is essential, and review of trends is useful when troubleshooting. The placement signal will show depressed cardiac function, evidenced by a damped appearing waveform. Hear the stories of patients and explore the latest innovations in Impella technology. Rotation can often be difficult and applying more than a full 360 degrees of torque is often necessary. As the performance level increases, the flow rate and number of revolutions per minute increase. Abiomed provides strong clinical support as well as excellent print and Web-based educational materials. We developed preprinted orders for physicians to use for patients remaining on support to ensure consistency in care (Table 8). The console can run on a fully charged battery for up to 1 hour. The Impella (Abiomed Inc.) is an axial flow pump on a pigtail catheter that is placed across the aortic valve to unload the left ventricle by delivering non-pulsatile blood flow to the ascending aorta. a1 Infusion of purge solution alone infrequently results in the desired therapeutic systemic anticoagulation and an additional infusion of parenteral heparin is often required. 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. In cases of RV failure, Impella flows can be limited by poor RV output as well as by RV distention that shifts the interventricular septum toward the LV, which can precipitate suction events. bXSG. 2. position is wrong. The Impella 2.5 should not be used in patients with aortic valve disease or known left ventricular thrombus. E-mail: [emailprotected]; Twitter: @AlexPapolos. In Europe, the Impella 2.5 has been in wide use for several years.8,9 In the United States, several small trials5,6,912 have been completed or are underway to evaluate the Impella 2.5. Frequent hemodynamic evaluation is needed. The components required to run the device are assembled on a rolling cart (Figure 6) and include the power source, the Braun Vista infusion pump, and the Impella console (Figure 7). In these illustrations, the Impella Catheter is positioned correctly. Parameters to assess regularly include placement signal, placement monitoring (pump position), dual signal, purge pressure, motor current, and speed (Table 6). 597 0 obj <> endobj xref 2020 Jan 22;2(1):23-44. doi: 10.36628/ijhf.2019.0015. / Ongoing practice is essential to develop and maintain competency. Cardiogenic shock (CS) is a life-threatening condition associated with significant morbidity and mortality. Please try after some time. Some facilities may use what is referred to as a preclose method while the patient is still in the catheterization laboratory; that technique uses 2 8F Perclose suture-mediated closure devices (Abbott Laboratories, Abbott Park, Illinois). Staff received 1-to-1 mentoring from the Impella coordinator. For this reason, we recommend a conservative approach to catheter manipulation with a the enemy of good is perfect philosophy. The second lumen ends near the motor above the level of the aortic valve and is used to monitor aortic pressure. 3. placement monitoring is suspended or disabled. This should prompt urgent ultrasound assessment as the device may need to be either retracted or advanced. Abiomed also provides assistance with troubleshooting via 24-hour-a-day, 7-day-a-week telephone support. To understand the hemodynamics of a patient in cardiogenic shock receiving Impella support, a pulmonary arterial catheter is recommended.5 The overall weaning strategy is to achieve adequate organ perfusion at the lowest device power setting to minimize device-related complications and to determine candidacy for device removal. A 63-year-old woman was admitted to our facility with an acute anteroseptal myocardial infarction. Weaning from the partial circulatory support provided by the Impella 2.5 can be approached in different ways. None of the patients had hemodynamic instability develop during the procedure. His left ventricular end-diastolic pressure was markedly elevated at 40 mm Hg (normal, 512 mm Hg), and his cardiac index was reduced at 1.98. The aortic valve symbols will not be seen on the placement monitoring diagram. The motor current signal will be flattened. The Impella RP is a right ventricular (RV) support system that is percutaneously positioned in the pulmonary artery via the femoral vein under fluoroscopy. The necessary images may be particularly difficult to obtain if the Impella device is medially or laterally oriented. to maintaining your privacy and will not share your personal information without Jo Kajewski, Advanced Impella Trainer, gives an in-depth look at managing Impella positioning using imaging. 2021 Feb 26;16(2):e0247667. The most common include suction, low purge pressure, and high purge pressure alarms. cardiac intensive care unit; cardiogenic shock; Impella; mechanical circulatory support. In order for the interrogator to connect with the permanent pacemaker or implantable cardioverter defibrillator, the Impella console must be turned off for a few seconds while the signal is established. It is used for high-risk percutaneous coronary intervention and CS. 2). Cardiogenic shock was defined as a (1) systolic blood pressure 90 mm Hg or need for inotropes or vasopressors to maintain systolic blood pressures 90 mm Hg, (2) signs of peripheral hypoperfusion, and (3) cardiac index <2.2 L/min/m 2 and pulmonary capillary wedge pressure 15 mm Hg. 2021 Mar 26;100(12):e25159. As soon as the signal has been established, Impella support is immediately restarted. The Impella 2.5 catheter (Figure 2) contains a nonpulsatile microaxial continuous flow blood pump (Figure 3) that pulls blood from the left ventricle to the ascending aorta, creating increased forward flow and increased cardiac output. Keyword Highlighting your express consent. 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. Sheaths were placed in the right femoral vein, the right femoral artery, and the left femoral artery. The total duration of Impella support was slightly less than 2 hours. The Impella (Abiomed, Danvers, MA) mechanical circulatory support (MCS) system is a catheter-based continuous flow pump that is typically placed percutaneously or by surgical cutdown into the femoral or subclavian artery. 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. While the inability to provide anticoagulation is a contraindication, there is ongoing research into nonanticoagulant purge solution alternatives. PMC The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Free shipping for many products! Partner with industry. 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). Signs of pulmonary congestion should be monitored, as, at least in theory, high Impella RP support with reduced LV function could cause overflow and pulmonary congestion. Diagnostic cardiac catheterization and coronary angiography performed at the referring facility showed severe triple vessel coronary disease and high-grade lesions in 2 SVGs. The PROTECT I study was done to assess the safety and efficacy of device placement in patients undergoing high-risk PCI.10 Twenty patients were enrolled in that prospective, multicenter study. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. You may be trying to access this site from a secured browser on the server. P9 can be activated only for 5-minute intervals when the Impella 2.5 is in use. The patient was transferred to the CICU for continued monitoring. Just visit www.ccnonline.org and click Respond to This Article in either the full-text or PDF view of the article. Brenda McCulloch is a member of the Abiomed Administrative Advisory Board. 0000004641 00000 n %PDF-1.4 % Implementation of the ventilator bundle is required for these patients, including elevation of the head of the bed to decrease the risk of ventilator-associated pneumonia, as well as deep venous thrombosis and peptic ulcer prophylaxis. She had no further chest pain during her hospitalization and was discharged home in stable condition 3 days later. A high purge pressure alarm indicates that the purge pressure is greater than 700 mm Hg and generally indicates a kink in the tubing or catheter. The Impella coordinator is present for implants to assist the catheterization laboratory staff as needed. The motor current will be flattened. The purpose of this review is to describe how to manage, reposition, and wean patients from the Impella catheter. The patient was brought to the catheterization laboratory and prepared for the procedure. High-risk PCI - Impella 2.5, CP - < 6 hours (temporary) VAD for use during high-risk percutaneous coronary intervention (prevent hemodynamic instability) 2. Review of patient care management strategies, console troubleshooting, and fluid/tubing setup has also been added to our annual VAD skills fair (Table 9). If the patients ventricular function is very poor, a positioning alarm can occur. Our training for our cardiac intensive care unit (CICU) nurses consisted of a series of three 1-hour sessions, encompassing a review of pertinent physiology and hemodynamics, Impella console management and troubleshooting, and tubing changes with hands-on practice and documentation practice. 0000003312 00000 n It is used for high-risk percutaneous coronary intervention and CS. If the catheter pigtail is hooked on the mitral apparatus and/or papillary muscle, it may be necessary to first advance the catheter deeper into the ventricle and then rotate the catheter to disengage it from the valvular structures. The Impella coordinator is present to assist with tubing changes as needed by the nursing staff. The Impella 2.5 instructions for use recommend a 40-minute manual hold to achieve hemostasis at the arterial access site. The most commonly reported complications of Impella 2.5 placement and support include limb ischemia, vascular injury, and bleeding requiring blood transfusion.6,9 Hemolysis has been reported.5,10 Other potential complications include aortic valve damage, displacement of the distal tip of the device into the aorta, infection, and sepsis. It is a single tubing system that bifurcates and connects to each port of the catheter. A console simulator is available that can be used to practice troubleshooting. All had poor ventricular function (ejection fraction =35%) and had PCI on an unprotected left main coronary artery or the last remaining patent coronary artery or graft. She was taken to the catheterization laboratory, where she was found to have a significant obstruction of the left main coronary artery complicated by plaque rupture. It is important to note that this derived ventricular pressure is not an accurate measure of the true LV pressure and thus may not directly replace the value of monitoring the pulmonary arterial capillary wedge pressure via a pulmonary artery catheter. The ISAR-SHOCK trial was done to evaluate the safety and efficacy of the Impella 2.5 versus the IAPB in patients with cardiogenic shock due to acute myocardial infarction.5 Patients were randomized to support from an IABP (n=13) or an Impella (n=12). Some were designed to support future versions of Impella catheters. Epub 2020 Dec 28. Find many great new & used options and get the best deals for Grandchild On Board Car Sign, Suction Cup Baby On Board Sign in Yellow and Black at the best online prices at eBay! The patients diastolic pressure increased significantly more with Impella support than with IABP support (P=.002). The PCI procedure of the LAD SVG was then started. The Impella TM Device.