Transport Considerations: BiPella and Impella^TM with ECMO

In this critical care transport webinar, Jena Billig, BSN, RN, CCRN, CFRCN, from the Patient Outcomes and Education team, discusses important concepts for transporting patients supported with both left- and right-sided Impella devices (BiPella patients) and patients supported with extracorporeal membrane oxygenation (ECMO) and an Impella device.

With regard to BiPella support, the objectives of this call are to understand how to assess BiPella patients for changes in condition and intevene appropriately, as well as to understand the importance of Impella support in relation to native heart function. Jenna explains that BiPella support typically involves left-side support with an Impella CP^TM with SmartAssist^TM or Impella 5.5^TMwith SmartAssist^TM device and right-sided support with an Impella RP^TM Flex with SmartAssist^TM in patients experiencing biventricular failure. She states, “It’s important to note that our cardiovascular system is a closed loop circuit, so what comes out the left is going to go out to the body, come back to the right.” She also emphasizes that it is important to consider Impella function as well as the native heart contribution when establishing and managing flow. In addition, Jena discusses BiPella anticoagulation considerations. She also discusses how to handle scenarios that may occur during transport in which either the left or right ventricle is overloaded or underfilled.

The goals of this call with regard to patients supported with Impella and ECMO are to understand the benefit and assess for the need to utilize Impella to unload the left ventricle during ECMO, and to acknowledge risks for differential hypoxia and how it relates to Impella with ECMO support. To address these goals, Jena briefly explains the components of the ECMO circuit and the effects of peripheral veno-arterial ECMO (VA ECMO), explaining how VA ECMO can overload the left ventricle (LV) and how an Impella device helps unload the LV. She highlights the importance of ongoing assessment of left ventricular distension and emphasizes that ECMO is the primary support for these patients and that ECMO and Impella should have a symbiotic, not competitive, relationship.

Jena also briefly discusses the simultaneous use of Impella and an intra-aortic balloon pump (IABP). Although this combination is not recommended, she briefly reviews the effects when IABP and Impella are used concurrently.