Unique Plan Description: Cards Impella Post op
Plan Selection Display: Cards Impella Post op
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2019-05-02 08:33:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-06-22 08:43:01
Available at all facilities: Yes

Cards Impella Post op
Vital Signs
	Vital Signs
		T;N, Q15min x 4, then Q30min x 2, then hourly
	Notify MD
		For SBP <____or >_____
Activity
	Bedrest
		T;N
			Comment: with head of bed elevated less than 30 degrees if groin insertion site is stable. Log roll to turn. Keep leg of pump insertion site straight.
	Immobilizer, Knee - Apply
		T;N, May use knee immobilizer as needed to prevent leg flexion on side of the device insertion.
Laboratory
STAT Lab
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	CBC with Diff
		T;N, Stat, spec type = Blood
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
	Plasma Hemoglobin (HGB)
		T;N, Stat, spec type = Blood
	Ionized Calcium
		T;N, Stat, spec type = Blood
	Magnesium Level
		T;N, Stat, spec type = Blood
	Phosphorus
		T;N, Stat, spec type = Blood
	Glucose POC - RN
		T;N, Q2H-Sch
			Comment: Q2H if diabetic, ok to modify order to Q4H if no history of diabetes. Notify MD if blood sugar >200 x 2 consecutive, and initiate CT Surg Regular Insulin Drip.
	Heparin Anti-Xa Heparin
		Stat, spec type = Blood
			Comment: Comment: Heparin Impella Protocol - On arrival to unit draw STAT heparin antiXa level, If heparin antiXa level <=0.7units/ml Initiate Heparin Impella protocol, if heparin antiXa level >0.7units/ml draw heparin antiXa level in 1H
		T;N+360, Timed, Q6H, spec type = Blood
Tomorrow's Lab
	Comprehensive Metabolic Panel
		T+1;0400, Routine, Q24H, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, Q24H, spec type = Blood
	PTT - MH/WH/JE
		T+1;0400, Routine, Q24H, spec type = Blood
	hs Troponin T - MH/WH/JE
		T+1;0400, Routine, Q24H, spec type = Blood
	hs Troponin I - FH
		T+1;0400, Routine, Q24H, spec type = Blood
	Plasma Hemoglobin (HGB)
		T+1;0400, Routine, spec type = Blood
	Order Lab
		T+2;0400, Order Plasma Hemoglobin every day
Diagnostic Tests

	Chest 1 View
		T;N, Stat, Post Op F/U
			Comment: on arrival to ICU
		T+1;0600, Routine, Post Op F/U, DAILY
			Comment: Post Impella Placement
	Echo Limited
		T;N, Stat, Indication: Congestive heart failure
			Comment: Post op Followup
	ECG
		T+1, Stat, Indication: Post Cardiac Procedure, DAILY
			Comment: in the am
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV
			Comment: Conc: 100 units/mL. Heparin Impella ProtocolTitration as follows ONLY while patient on Impella device (heparin antiXa level  to be checked every 6 hours):  START Initial infusion rate once heparin antiXa level <=0.7units/ml: 12units/kg/hr (Maximum weight for dosing 110kg. MAXIMUM INITIAL RATE=1000units/hr); titrate as follows:1) anti-factor Xa UFH <than 0.2 units/mL, bolus 60 units/kg & increase rate by 4 units/kg/hr.2) anti-factor Xa UFH = 0.2-0.29 units/mL, bolus 30 units/kg & increase rate by 2 units/kg/hr. 3) anti-factor Xa UFH = 0.3-0.7 units/mL, (therapeutic range) Do not give bolus & do not change rate. 4) anti-factor Xa UFH = 0.71-0.95 units/mL, do not bolus. Decrease rate by 2 units/kg/hr.  5) anti-factor Xa UFH = 0.96 units/mL or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr. Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 12 unit/kg/hr
	Dextrose 5% in Water IVPB
		250 mL, Catheter, Once, STAT, 250 ml/hr
			Comment: To be used as purge solution in the cath lab. To be changed to Sodium Bicarb upon arrival to CVICU
	sodium bicarbonate 25mEq/D5W 1000mL soln
		1,000 mL, Solution, Catheter, Q24H, PRN for see comment, STAT, 5 ml/hr
			Comment: sodium bicarbonate 25meq/D5W 1000mL. Connect to the Impella Device as purge solution in place of D5W if Impella device is to continue upon transfer to CVICU. NOT TO BE INFUSED Intravenously.
Medications
	HEParin 1000 units/mL injectable soln
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg bolus.  Anti-factor Xa UFH level < 0.2 units/mL, Patient on Heparin Impella Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 6600 units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg bolus.  Anti-factor Xa UFH level between 0.2-0.29 units/mL.  Patient on Heparin Impella Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 3300 units)
Patient Care
	Resuscitation Status
		Full Code
		No Code
	Monitor Central Venous Pressure (CVP)
		T;N, with each vital signs, notify MD if CVP <12.
	Foley Catheter
		T;N, Insert, Critically ill requiring accurate output, with urometer
	No IM Injections
		T;N, Avoid Intramuscular injections while on heparin infusion
	Vascular Assessment-Focused
		T;N
			Comment: Assess condition of arterial site and Doppler distal pulses with each vital signs
	Notify MD
		T;N, If dressing becomes saturated or non occlusive
	Impella Monitoring and Care
		T;N
			Comment:  Mark and document placement (cm marker on the Impella catheter closes to the sheath)( for the Impella device upon arrival to ICU and with each shift assessment and evaluate position hourly. Insure the Impella catheter has been secured to inner aspect of the patient leg by Cath Lab. Monitor patient, Impella and infusion. Record required information hourly. Change FLUSH tubing every 96 hours. Change PURGE solution every 24 hours. Change PURGE cassette every 5 days.
		T;N, Notify MD if change in Impella flow/waveform, unresolved high or low purge pressure, mal-positioned pump.
		T;N
			Comment: Emergency; CPR/Defibrillation: DO NOT unplug or stop the Impella device if CPR or Defibrillation is required. 1. Reduce Impella flow to P-2 at start of chest compressions. 2. NO change is needed for defibrillation. 3. Confirm Impella placement post CPR and/or defibrillation using placement signal waveform and return to previous level of support, unless otherwise ordered by physician.
	Impella Settings
		Performance level at P2
		Performance level at P3
		Performance level at P4
		Performance level at P5
		Performance level at P6
		Performance level at P7
		Performance level at P8
		Performance level at P9
		Maintain pump performance level to keep flow___ L/min
	Impella Weaning
		T;N
			Comment: Impella Weaning is per individual MD order only.  If hypotension (SBP or MAP outside of specified parameters) occurs or the Impella is not able to run at the desired flow rate, return patient to prior P level setting and notify physician. Once patient has maintained hemodynamics on P-2 stop peripheral Heparin Infusion. Check heparin antiXa level hourly until heparin antiXa level is <0.2units/ml. Notify physician of heparin antiXa level results.
	Impella Removal
		T;N
			Comment: Only an Impella trained physician may remove the Impella Catheter. With physician at bedside, reduce flow to P-1, physician will pull the Impella Catheter back across the patient's aortic valve. THEN: reduce flow to P-0, the physician will then explant the Impella catheter and repositioning sheath together. Physician is responsible for manual hold of pressure to Impella insertion site (typically about 45 min, or about 20 min followed by application of FemStop) to achieve hemostasis.
	Notify MD
		T;N, If bleeding or hematoma at insertion site
		T;N, If signs of limb ischemia to include: change in limb color, change in limb temperature, change in or loss of distal pulses
		T;N, If significant change in VS, EKG or hemodynamics
		T;N, If reduced urine output or tea colored urine (may indicate hemolysis)
	Intake and Output
		Q1H
			Comment: Notify MD if urine output < 30ml/hr x 2.
	Discontinue Medication
		Discontinue any previous heparin orders
Consults/Follow-up
	Pharmacy Consult
		Discontinue any previous heparin orders

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase