We have been seeing an increase in Impella transfers lately so I figured I would throw something together and share some info on them. Just like how IABPs have proliferated Impella’s are now becoming more popular due to their relative ease of insertion and ability to stabilize patients in extremis. However many facilities that have the ability to place Imeplla’s in the Cath Lab do not have the necessary ICU/CCU support to manage them or the CT surgery to bride to another device which necessitates transfer to tertiary facilities. First thing I would recommend is to download the Impella app by Abiomed. Tons of great info. Impella is an Axial Flow Percutaneous Left Ventricular Assist Device (PLVAD) and more recently a Percutaneous Right Ventricular Assist Device (PRVAD). The LVAD comes in a few different models with varying range of flow rates and sheath sizes. The 2.5 (2.5L Flow) and CP (3.5L Flow) are the most common as they only require 6-9fr sheaths which can be placed peripherally in the femoral artery. The 5.0 (5.0L flow) and LD (5.0+L flow) are inserted via 21fr sheaths and are usually inserted via an Axillary Artery Cutdown or centrally via a sternotomy. Transport of a 5.0/CP should be rare since most hospital which placed them are tertiary facilities however if they need to transplant they may be transported to a transplant center. The Imeplla RP is inserted via the Femoral Vein and provides up to 4.5L of flow. It is possible to have both an Impella RVAD and LVAD simultaneously for biventricular support. Indications: 1) Cardiogenic Shock (Temporary or Bridge to LVAD/ECMO) 2) Cardiac support during high risk PCI 3) Adjunct to VA ECMO to vent the LV and prevent LV distention/Thrombus Contradictions: 1) Aortic disease 2) Aortic Valve disease 3) LA/LV thrombus 4) Severe bleeding or sepsis Complications: 1) Limb ischemia 2) Aortic valve damage 3) Hemolysis/bleeding 4) Vessel damage Impella vs IABP. Impella is true mechanical circulatory support but does not increase coronary perfusion where as an IABP increases coronary perfusion but does relatively little for circulatory support. Studies show little difference in mortality in Acute MI. Impella is better suited for cardiogenic shock without current ischemia (Post PCI, Non-ischemic CHF, etc) however for patients whom still have ischemia (Still need CABG, Poor flow after PCI) an IABP may be better. If you are transporting these patients I am assuming you have done the Impella training online so I will not go into the various placement and motor current signals however just remember that the 2.5/CP and 5.0/LD have different ways of detecting placement, Open pressure port vs differential pressure. Again, reference the Impella App for examples. Patient management: Same as any other device make sure you document insertion depth and assessment of insertion site. Make sure there are no hematomas or active bleed. Make sure the catheter is secured. Assess peripheral pulses as limb ischemia is a big concern. Keep head of bed the same since flexion/extension of the upper body may cause the catheter to dislodge. The device should have a pressure bag for the arterial line and a bag of purge fluid that is Dextrose (D5-D20) with Heparin. Like any other LVAD the Impella relies on preload so make sure fluid status is adequate. If patient is in RV failure you may need to aggressively treat with Inotropes or pacing if fluid bolus are not enough to maintain preload. If they have a Swan I would have a NS drip with pressure bag placed to the Cordis or RV/Pacer port (Orange) so you can bolus if needed. Titrate pressor to maintain perfusion however remember SBP = SVR so don’t go crazy. Patients who have poor native heart function may go non-pulsatile at times. Assess placement signals, Flow, and motor current and make sure the Impella is not out of position. The motor current and flow should stay normal. Assess for shock, get a MAP. Remember that normal Cardiac Output is 4-8L whereas the Impella is only providing 2.5L without native function. Treat ventricular arrhythmias if needed. If Impella alarms suction event then reduce power level and give fluid. If it alarms placement signal then reduce power level to P2 and treat patient medically. They actually dislodge fairly easily (out of the ventricle, not the patient) Call receiving and let them know they will need to reposition on arrival. If it alarms about purge flow make sure the purge line is not kinked or has air bubbles. Re-prime if needed. That is pretty much the basics. Feel free to add your experiences or ask questions.