PLACE LABEL HERE

IMPELLA POSTINSERTION

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Follow the Catheterization Post-Procedure orders (form # 13217) or CVC Post-op orders (form # 40026) with the following additions/exceptions:

IMPELLA CATHETER TYPE: 2.5CP

VITAL SIGNS:

  1. Vital signsq 15 min x 4; q 30 min x 2; q 1 hr and PRN
  2. Neurovascular checks q15min x 4; q 30min x 2; then q1hr and PRN

3. Initiate Impella flowsheet (form # 32749) document q1hr and PRN

DIAGNOSTICS AND TESTING:

4. On Admission: 12 Lead ECG, Reason:_____Read by:______

PCXR. Reason:______

5. Daily in AM: BMPPT/INR Anti Xa (Heparin Level)

 PCXR daily while Impella catheter in place, Reason:______

OTHER ORDERS:

6. Indwelling catheter to urometer for strict I&O. Document urine output hourly

7. Immobilize affected extremity to stabilize insertion site and order knee immobilizer if needed

8. Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058) if not done already

9. Pressure relief boots to both feet while device in place

ACTIVITY:

10. Strict bedrest

11. Maintain HOB flat with affected extremity straight. May use Reverse Trendelenburg up to 30o

12. May turn side to side q 2 hrs as tolerated

IMPELLA MANGEMENT:

13. Change purge cassette and tubing q 72 hrs

14. Connect 0.9% NaCl to the Impella red pressure port via straight IV tubing and pressure bag with 300-350 mmHg pressure. Flush q2hrs by squeezing together the white pressure valve on Impella pressure line

15. Monitor catheter placement using dual waveforms of motor current and placement signal

16. For CPR change flow from AUTO to MANUAL and decrease level to P-2

17. Never reduce flow level below P-2 unless removing catheter

18. If catheter displaced, or unknown placement:

Reduce flow level to P-2

Notify managing Physician STAT

Order STAT bedside echocardiogram to assist managing Physician in repositioning catheter

19. Notify Managing Physician (Cardiology or CV Surgery) for:

Purge infusion rate <4mL/hr or > 25mL/hr

Catheter removal or displacement

Flow less then 1L/min

20. D5W 500 ml with Heparin 25,000 units (50 units/ml) for Impella Purge Fluid, titrate 5-25 ml/hr based on Impella machine. Change bag q24hrs.

Copy to pharmacyOrder writer’s initials______

*3-33584* FORM 3-33584 REV. 10/2016 Page 1 of 2

PLACE LABEL HERE

IMPELLA POSTINSERTION

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

21. Anticoagulation:

 Heparin Impella ACT Nomogram

A.ACT on arrival to unit

B.Begin Heparin IV infusion: 25,000 unit/500 ml diluent (50 units/ml)

at 12 units/kg/hr, max initial rate is 1,000 units/hr

Check ACT 2 hrs after starting infusion and titrate according to Heparin Impella ACT Nomogram (see below)

 CVOR Patient: start Heparin infusion 8 hrs post-operatively

or

Continue Heparin IV infusion: 25,000 unit/500 ml diluent premix (50 units/ml)

and titrate according to Heparin Impella ACT Nomogram below

Heparin Impella ACT Nomogram
ACT Result / Heparin Infusion Adjustment: / Repeat
ACT in:
< 140 / Increase infusion rate by 2 unit/kg/hr / 1 hr
141-159 / Increase infusion rate by 1 unit/kg/hr / 1 hr
160-180 / Target Range, no change / 4 hours
Once two consecutive ACT in range repeat qAM
181-200 / Decrease infusion rate by 1 unit/kg/hr / 1 hr
> 200 / Hold infusion for 1 hour then decrease infusion rate by 2 units/kg/hr / 1 hr
  1. Notify physician if 2 consecutive ACTs greater than 200 or less than 140 seconds or for signs of bleeding

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-33584 REV. 10/2016 Page 1 of 2

PLACE LABEL HERE

HEPARIN IMPELLA ACT NOMOGRAM

FLOWSHEET

ACT Result / Rate Change / Repeat ACT in:
< 140 / Increase infusion rate by 2 units/kg/hr / 1 hr
Notify physician if 2 consecutive ACTs < 140
141-159 / Increase infusion rate by 1 unit/kg/hr / 1 hr
160-180 / Target Range, no change / 4 hours
Once two consecutive ACT in range repeat q AM
181-200 / Decrease infusion rate by 1 unit/kg/hr / 1 hr
> 200 / Hold infusion for 1 hours then decrease infusion rate by 2 units/kg/hr / 1 hr
Notify physician if 2 consecutive ACTs > 200 and observe for signs of bleeding.

DO NOT ADJUST WEIGHT AFTER INITIATION OF INFUSION

A double check signature indicates that the following items have been verified by

both staff members (RN to RN): drug, dose, and/or dose adjustment, and

pump setting (drug, dosing weight, and infusion dose).

IV Pump Dosing Weight ______kg (max 85 kg)
Date / Initials / New Bag (time) / ACT Result / Hold Time On Off / Kg weight on pump / Heparin Infusion Rate / Next Heparin Level
Date / AUD#
Time / Time
Baseline______/ __12__ units/kg/hr
______units/kg/hr
______units/kg/hr
______units/kg/hr
______units/kg/hr
______units/kg/hr
______units/kg/hr
______units/kg/hr
______units/kg/hr
Initial / Full Signature / Initial / Full Signature / Initial / Full Signature

*1-43257* FORM 1-43257 INITIATED 10/2017 Page 1 of 1