signs of suction in impella

a1 Patel SM, Lipinski J, Al-Kindi SG, et al. In cases of heparin-induced thrombocytopenia, use of argatroban or bivalirudin in place of heparin in the purge solution has been reported to be safe and effective.2,3 Notably, a rising purge pressure may reflect thrombus formation in or around the motor. The device may cause calcium to break off of the aortic valve and embolize, causing stroke. The Impella MCS system is a relatively new technology that has become widely used for the treatment of cardiogenic shock in medical and surgical cardiac intensive care units. The alarm will read pump position unknown due to low pulsatility. The Impella console is not able to determine the pump position because the patients systolic and diastolic pressures are not very different. Data is temporarily unavailable. When hemolysis occurs, hemoglobin level and hematocrit decrease, haptoglobin level decreases, and plasma levels of free hemoglobin increase. It cannot be used in patients with documented left ventricular thrombus. With the physician at the bedside, transthoracic echocardiography is performed and the pumps performance level is decreased. Keywords: The cannula appears as two bright echogenic, parallel lines, sometimes referred to as the railroad tracks, which ends at the inlet area. On the placement signal screen, the waveform will show a ventricular, rather than an aortic, pressure waveform. 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. Some patients on Impella support may be intubated and receiving mechanical ventilation. Some were designed to support future versions of Impella catheters. The purpose of this review is to comprehensively describe our strategy for managing, repositioning, and weaning the Impella catheter. An audible alarm also will sound. He was experiencing progression of his anginal symptoms, and his functional capacity was poor. There is currently no consensus on best practice regarding its use in these two distinct indications. sharing sensitive information, make sure youre on a federal The heparinized saline is placed in a pressure bag that is inflated to 300 mm Hg. The purpose of the bend is to orient the catheter toward the apical anteroseptal portion of the LV and away from the posterolateral wall, papillary muscles, and mitral apparatus. 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. The placement signal will show a normal appearing aortic waveform with systolic and diastolic pressures similar to those shown by the patients arterial catheter. It is useful in patients undergoing high-risk PCIs. 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. The aortic valve symbols will not be seen on the placement monitoring diagram. Bookshelf As with all forms of MCS, device-related complications remain a major concern, the incidence of which can be mitigated by adhering to a few fundamental concepts in device management. The second lumen ends near the motor above the level of the aortic valve and is used to monitor aortic pressure. The pharmacy prepares the heparinized 20% glucose purge solution and sends it to the unit before our standard change time of 3 pm daily. After any adjustment, return the power level back to the desired setting and then reassess catheter depth, orientation, and mitral valve function before tightening the Tuohy-Borst lock and making note of the final vascular access site depth. SmartAssist technology on the Impella CP or Impella 5.5 devices can help with this as well. The smaller diameter Impella 2.5 and CP are typically inserted percutaneously under fluoroscopic guidance in the cardiac catheterization laboratory; however, transesophageal echocardiography (TEE) guided placement is also possible.1 The larger diameter Impella 5.0 and 5.5 are typically inserted by surgical cutdown via a prosthetic graft sewn onto the subclavian artery and are positioned under fluoroscopy or by TEE. 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). The necessary images may be particularly difficult to obtain if the Impella device is medially or laterally oriented. Ongoing practice is essential to develop and maintain competency. The placement signal will show depressed cardiac function, evidenced by a damped appearing waveform. The placement signal will display either an aortic pressure waveform (correct position) or ventricular pressure waveform (incorrect position) depending on the position of the fiber-optic sensor. Inotropic agents, such as dobutamine and milrinone, and vasopressors, such as dopamine and norepinephrine, may still be needed after the Impella 2.5 is placed to maintain a cardiac index of at least 2 and systolic blood pressure at 90 mm Hg or higher. Garan AR, Kanwar M, Thayer KL, et al. For this reason, we recommend a conservative approach to catheter manipulation with a the enemy of good is perfect philosophy. 0000004020 00000 n The nursing care of patients remaining on Impella 2.5 support requires astute assessment and expert nursing care (Table 4). doi: 10.1371/journal.pone.0247667. $L"$ The motor current signal will be flattened. 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. Sheaths were placed in the right femoral vein, the right femoral artery, and the left femoral artery. 2020 Jan 22;2(1):23-44. doi: 10.36628/ijhf.2019.0015. Please enable it to take advantage of the complete set of features! official website and that any information you provide is encrypted Review of patient care management strategies, console troubleshooting, and fluid/tubing setup has also been added to our annual VAD skills fair (Table 9). The Impella RP can be used in tandem with a left-sided Impella device. 0000004641 00000 n After advancement, always remove any slack by slowly pulling back on the catheter until cannula movement is observed. Suction alarms can occur if the performance level is too high for the patient; for example, in a patient who is hypovolemic or if the device is emptying the ventricle. Context 1. . The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Notably, catheter position is best assessed ultrasonographically, as radiography does not accurately identify the cannula position relative to cardiac anatomic structures. Reports of longer duration of therapy in both the United States and Europe have been published.8,9, The Impella 2.5 has been used for hemodynamic support during high-risk PCI and for hemodynamic support of patients with myocardial infarction complicated by cardiogenic shock or ventricular septal defect, cardiomyopathy with acute decompensation, postcardiotomy shock, off-pump coronary artery bypass grafting surgery, or heart transplant rejection and as a bridge to the next decision.9. 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. If the device advances too far and both the inflow and outflow areas are fully in the left ventricle, the pump position wrong alarm will occur. 0000000016 00000 n Function keys that are used with the Impella 2.5 include the P-PERF, MENU, SIGNAL, SCALE, and the ON keys. 0000000636 00000 n Include the cardiovascular surgery staff and perfusion staff in the initial training. : Complete hemodynamic profiling with pulmonary artery catheters in, 6. As the Impella RP is not widely used, this review will focus only on the left-sided catheters; however, many of the concepts discussed are transitive. A broad mosaic color Doppler pattern caused by artifact from the motor will be seen, which should be limited to the aortic side of the valve. 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. As the performance level increases, the flow rate and number of revolutions per minute increase. 0000001527 00000 n v67z]FcUe7sne[l}g&_}V^7vk~7S/o}AoepY5OTYe>acQ*|o? \-yVJUrM^2E~,d3EN9--u1C~A+ / The use of anticoagulation is required, and bleeding may develop in some patients. With respect to weaning order of operations, we generally favor first weaning and decannulation from VA-ECMO (if possible from a pulmonary support perspective), which is based on the higher MCS complication rates and patient immobility associated with VA-ECMO cannulation. MeSH A patient experiencing continuous suction may show systolic LV numbers, shown in white, that are uncoupled from the aortic numbers shown in red. Diagnostic cardiac catheterization and coronary angiography performed at the referring facility showed severe triple vessel coronary disease and high-grade lesions in 2 SVGs. During stent deployment, the patient had severe chest pain and showed ST-segment elevation in the anterior leads. Train a core group of critical care nurses to care for the patient, monitor the device, change tubings, and troubleshoot alarms. Catheters with SmartAssist have an upgraded optical pressure sensor that directly measures aortic pressure and uses changes in motor current to infer an estimated LV pressure waveform. The most reliable and accurate transthoracic acoustic widow to assess catheter position is the parasternal long-axis window because it will provide a view of the catheter from an orthogonal angle of insonation (Figure 4). No sound other than alarms is audible during Impella support, unlike the sound heard with an IABP. The power connections for the pump motor and sensors are . The following 3 case studies demonstrate the successful use of Impella 2.5 support during high-risk PCIs at our facility. Identification of Cardiogenic Shock Correspondence: Alexander Papolos, MD, Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, 110 Irving St., NW, Rm A127, Washington, DC, 20010. With correct positioning and function, the placement signal and motor current are pulsatile, reflecting the dynamic pressure gradient between the aorta and LV, as well as the cyclical variation in energy required to maintain the desired motor speed over the cardiac cycle (Figure 3A). He had a history of coronary artery bypass grafting surgery several years prior as well as heart failure. A low purge pressure alarm indicates that the purge pressure to the Impella motor has decreased below 300 mm Hg. If both the placement signal and motor current waveforms have minimal variability, the Impella Position Wrong alarm will display, indicating that both the inlet and outlet areas may be on the same side of the aortic valve (Figure 3B). Sheaths were placed in the right femoral vein, the right femoral artery, and the left femoral artery. Cardiogenic shock; Impella; Mechanical support devices; intra-aortic balloon pump; mechanical circulatory support; percutaneous ventricular assist device. National Library of Medicine The aortic annulus and the ventricular end of the cannula must be well visualized in a single image to make an accurate measurement. The cannula portion of the catheter is built with a 30 bend (except for the Impella LD, which has a straight design). Troubleshooting tips. Catheter position should be assessed daily and in response to unexpected clinical changes or specific device alarms. The question that then arises is when to favor escalating inotropes to assist in device weaning. 0000002856 00000 n Abdullah KQA, Roedler JV, Vom Dahl J, Szendey I, Haake H, Eckardt L, Topf A, Ohnewein B, Jirak P, Motloch LJ, Wernly B, Larbig R. PLoS One. Pahuja M, Hernandez-Montfort J, Whitehead EH, Kawabori M, Kapur NK. Papolos, Alexander I. Methods Cardiogenic shock was induced by injecting microspheres in the left main coronary artery in 18 adult Danish Landrace pigs. The size and function of the left and right ventricles as well as interventricular septal position should also be assessed, as low flow and suction alarms can be caused by over-decompression of the LV, RV failure, and/or obstructive physiology. The physician can evaluate left ventricular size and function and can quickly assess how well the patient tolerates decreases in the performance level. Our practice is to integrate clinical factors, such as mean arterial pressure, heart rate, and urine output with invasive hemodynamics, and lab dataspecifically, serum lactate and pulmonary arterial oxygen saturation every 6 hours. The Impella 2.5 should not be used in patients with aortic valve disease or known left ventricular thrombus. LV Aortic valve Mitral valve Impella 2.5 outlet area Impella 2.5 . 2 main types of pumps currently used: Heparin 9000 units was administered intravenously for anticoagulation, and the Impella 2.5 was advanced into position in the left femoral artery. Free shipping for many products! If you have a swollen uvula, you may also be experiencing a sore throat, trouble swallowing, and maybe even a fever. The patients diastolic pressure increased significantly more with Impella support than with IABP support (P=.002). We found performing such changes at a consistent time to be very helpful. Retract the device until diastolic pressures normalizes. This arrangement allowed ample time for setting up the console and infusion pump before the Impella was placed. The patient was brought to the catheterization laboratory and prepared for the procedure. Conversely, lack of expected pulsatility in the placement signal and/or in the motor current signal may reflect a problem. All patients with this device are observed by this clinical nurse specialist during their hospital stay. POTENTIAL ADVERSE EVENTS Acute renal dysfunction, Aortic valve injury, Bleeding, Cardiogenic shock, Cerebral vascular accident/Stroke, Death, Hemolysis, Limb ischemia, Myocardial infarction, Renal failure, Thrombocytopenia and Vascular injury In addition to the risks above, there are other WARNINGS and PRECAUTIONS associated with Impella devices. Cardiogenic shock - Impella 2.5, CP, 5.0, LD - Temporary VAD for less than or equal to 4 days: 2.5, CP - Temporary VAD for less than or equal to 14 dyas: 5.0, LD Limit the physicians who can place and manage the device and have them proctor one another. Utilization of the Impella for hemodynamic support during percutaneous intervention and cardiogenic shock: an insight. The patients remaining hospital course was uneventful and he was discharged 2 days later taking appropriate medications for after PCI and to treat heart failure. A newer option that is now available for select patients is the Impella 2.5, a short-term partial circulatory support device or percutaneous ventricular assist device (VAD). It is used for high-risk percutaneous coronary intervention and CS. Coordination with the perfusionist is essential when patients are being placed on cardiopulmonary bypass. Fluoroscopic guidance in the catheterization laboratory or operating room is required. The device received 510(k) clearance from the Food and Drug Administration in June 2008 for providing up to 6 hours of partial circulatory support. You can get a swollen uvula from infections including the flu, mononucleosis, croup, and strep throat. Abiomed has sponsored several of these trials, including PROTECT I, PROTECT II, RECOVER I, RECOVER II, and ISAR-SHOCK. A 74-year-old man was transferred to our facility after sustaining a nonST-segment elevation myocardial infarction. Disclosure: The authors have no funding or conflicts of interest to report. In our facility, physicians who can place this device are those who have interventional cardiology and/or cardiac surgery privileges. The coronary guidewire was advanced through the LIMA graft to the distal LAD. A low purge pressure alarm indicates that the purge pressure to the Impella motor has decreased below 300 mm Hg. Nalluri N, Patel N, Saouma S, Anugu VR, Anugula D, Asti D, Mehta V, Kumar V, Atti V, Edla S, Grewal RK, Khan HM, Kanotra R, Maniatis G, Kandov R, Lafferty JC, Dyal M, Alfonso CE, Cohen MG. The use of continuous cardiac output monitoring may be useful for patients with cardiogenic shock. Our typical hemodynamic targets are a mean arterial pressure of 6070 mm Hg, a right atrial pressure of 812 mm Hg, a pulmonary arterial wedge pressure <15 mm Hg, and a cardiac index >2.0 L/min/m2. Shearing of red blood cells is a common and clinically relevant problem with the Impella catheter. The entire LV placement signal waveform shifts downward. 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 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. We recommend the following steps to optimize imaging: minimize the depth and narrow the sector width to the target field of view, angle the ultrasound probe to achieve a horizontally oriented view of the cannula, and adjust the gain to best highlight the target structures. 4, 5 Right ventricular failure occurs in 25% of patients after left ventricular assist device insertion, thus the advent of Impella RP. Support with Impella versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A protocol for systematic review and meta-analysis. Heparin 7000 units was administered intravenously for anticoagulation. 2021 Feb;19(2):151-164. doi: 10.1080/14779072.2021.1863147. Expert Rev Med Devices. At maximum performance (P9), the pump rotates at 50000 revolutions per minute and delivers a flow rate of 2.1 to 2.6 L/min. Before The pigtail attaches to a radiopaque/echogenic structure termed the teardrop which is contiguous with the inlet area, through which blood enters the ventricular end of the catheters cannula. There is a pressure sensor built into the aortic end of the cannula that is used to produce a placement signal waveform tracing (Figure 3A). (NOTE: While the illustrations in this document depict the Impella 2.5 Catheter, the information presented also applies to the Impella 5.0 Catheter and Impella LD Catheter.) 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. This should prompt urgent ultrasound assessment as the device may need to be either retracted or advanced. Accurate Impella placement is essential during all phases of Impella support but it is particularly important for long term support. Just before the patients return to the CICU, the pulmonary artery pressure decreased to 70/4148 mm Hg and the cardiac index was 2.69. 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). A 63-year-old woman was admitted to our facility with an acute anteroseptal myocardial infarction. The Impella coordinator is present to assist with tubing changes as needed by the nursing staff. 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. She returned to the catheterization laboratory 3 days later for high-risk PCI of the left main coronary artery. At first, an effort should be made to identify and treat these conditions (Fig. While a small amount of hemolysis is unavoidable, significant hemolysis can quickly cause pigment nephropathy and further complicate the management of an already critically ill patient. Based on our experiences, we share the following recommendations. P2 is the lowest performance level that can be used while the distal end of the Impella 2.5 is in the left ventricle. Areas covered: Repositioning is best performed under fluoroscopic guidance, whenever possible. The 13F arterial sheath was sutured in placed for removal 2 hours later, after the patient had returned to the CICU. Acute renal dysfunction, Aortic valve injury, Bleeding, Cardiogenic shock, Cerebral vascular accident/Stroke, Death, Hemolysis, Limb ischemia, Myocardial infarction, Renal failure, Thrombocytopenia and Vascular injury In addition to the risks above, there are other WARNINGS and PRECAUTIONS associated with Impella devices.

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