This is my first of many posts on the Impella system by Abiomed. It is going to be part of my “Cardiogenic Shock: Rise of the Machines” lecture for Portland in August 2020.
I am planning on covering LVADs, RVADs, ECMO, TandemHeart, etc. in the upcoming months but one does not need to work at an ECMO or transplant hospital to see an Impella. This post is targeted for the clinician or nurse who is caring for the patient and is curious as to what’s the next step. Not intended for repositioning the device or criteria for installing it. I’ll get there. Give me time. Besides, I took a break from the Ketamine for this today.
When managing a patient on the Impella, whichever of their devices, a question always comes up when the patient becomes hypotensive. Do they need vasopressors or ionotropes? This algorithm from the Detroit Cardiogenic Shock Initiative is a helpful guide, definitely not an end-all-be-all but it’s better than flying without any instruments. Every patient with an Impella NEEDS a swan. You need to be able to measure the right heart pressures appropriately. You also need to be able to have an idea of what your SVR is. Without these parameters handy, you’re in the blind and clueless. Honestly, you should consider transferring the patient out to another shop before they get too sick to salvage.
Calculating the CPO and PAPI is something that nurses do and let the physicians know when things are going south. My favorite is to get the call followed by a suggestion to start a new med. that shows they’re vested and I love that.
Even though I do not run ECMO or have an LVAD program at my shop, I’m fortunate that I have colleagues at nearby hospitals who respond to my texts promptly and are around to help. It’s a blessing. My fellowship training provided me with a great amount of experience to where I do what I know how to do and when I need to make that call, I make it. No shame. Patients come over ego.
-EJ
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