7.19Impella ® System for Use During Cardiogenic ShockIf the Impella® 2.5 or Impella CP ® Catheter has sudden low flows or suction at startup:1. Remove the catheter from the patient and ensure that ACT is 250 seconds or above.2. Closely inspect the inlet and outlet areas and remove any thrombus or other foreignmaterials.3. If materials have been removed, run the Impella® at P-8 or AUTO in a basin.4. If flows are still above 2.2 L/min, reinsert the Impella® Catheter into the patient.5. If no material is visible or if the flows are still low, there could be a clot inside thedevice. An assessment (fluoroscopic or echocardiography) of the left ventricle isrecommended to rule out left ventricular thrombus before inserting another device.SUCTION WITH THE IMPELLA® 5.0 OR LD CATHETERIf the “Suction” alarm occurs during support with the Impella® 5.0 or LD Catheter, follow therecommended actions:1. Reduce P-level by 1 or 2 levels to reduce the effects of suction.2. Check the Impella® Catheter for correct positioning using imaging. Reposition thecatheter by rotating or moving it into or out of the ventricle slightly. Either or both ofthese actions could help move the inlet of the Impella® Catheter away from the interiorventricular wall.3. Assess patient’s fluid intake and output to confirm adequate volume status.4. Confirm right ventricular function by assessing CVP or right side function withechocardiography. If CVP is not an option, check the pulmonary artery diastolicpressure to assess the patient volume status.5. Return the P-level to pre-alarm setting.HEMOLYSISWhen blood is pumped, it is subjected to mechanical forces. Depending on the strength of theblood cells and the amount of force applied, the cells may be damaged, allowing hemoglobin toenter the plasma. Pumping forces can be generated by a variety of medical procedures includingheart lung bypass, hemodialysis, or ventricular assist device (VAD) support. Patient conditions—including catheter position, pre-existing medical conditions, and small left ventricular volumes—may also play a role in patient susceptibility to hemolysis.Hemolysis should be monitored during support. Patients who develop high levels of hemolysismay show signs of decreased hemoglobin levels, dark or blood-colored urine, and in some cases,acute renal failure. Plasma-free hemoglobin (PfHgb) is the best indicator to confirm whether apatient is exposed to an unacceptable level of hemolysis.Management technique may differ depending on the underlying cause of hemolysis. Table 7.1provides guidance for various circumstances.7 PATIENT MANAGEMENT TOPICS
