Optimizing anticoagulation for patients receiving Impella support.

Anticoagulation of patients treated with the Impella percutaneous mechanical circulatory support (MCS) devices is complex and lacks consistency across centers, potentially increasing the risk of complications. In order to optimize safety and efficacy, an expert committee synthesized all available evidence evaluating anticoagulation for patients receiving Impella support in order to provide consensus recommendations for the management of anticoagulation with these devices. The evidence synthesis led to the creation of 42 recommendations to improve anticoagulation management related to the use of the Impella devices. Recommendations address purge solution management, intravenous anticoagulation, monitoring, evaluation and management of heparin-induced thrombocytopenia (HIT), and management during combination MCS support. The use of a heparinized, dextrose-containing purge solution is critical for optimal device function, and a bicarbonate-based purge solution may be an alternative in certain situations. Likewise, intravenous (ie, systemic) anticoagulation with heparin is often necessary, although evidence supporting the optimal assay and target range for monitoring the level of anticoagulation is generally lacking. Patients treated with an Impella MCS device may develop HIT, which is more difficult to evaluate and treat in this setting. Lastly, the use of Impella with extracorporeal membrane oxygenation or for biventricular support creates additional anticoagulation challenges.

Survey of Anticoagulation Practices with the Impella Percutaneous Ventricular Assist Device at High-Volume Centers.

OBJECTIVES: To characterize anticoagulation practices with the Impella percutaneous ventricular assist device (pVAD). BACKGROUND: Managing anticoagulation in patients being supported by the Impella pVAD is made challenging by several unique features of the device. These include the release of a dextrose-based purge solution containing unfractionated heparin (UFH), the need to concurrently administer systemic anticoagulation with intravenous UFH, and the lack of an alternative strategy in patients with contraindications to UFH. METHODS: To characterize anticoagulation practices with the Impella pVAD, we conducted a survey of centers in the United States performing a high volume of Impella cases, which we defined as > 1 per month. Centers were contacted via email or phone and individuals who agreed to participate were provided with a link to complete the survey online. The primary measures of interest were variations in practice across centers and variations from the manufacturer's recommendations. RESULTS: Practices varied considerably among respondents (65 of 182 centers, or 35.7%) and often diverged from manufacturer recommendations. Approximately half of centers (52.4%) reported using a UFH concentration of 50 units/mL in the purge solution, whereas most of the remaining centers (41.3%) reported using lower concentrations. Strategies for the initiation and adjustment of systemic therapy also varied, as did practices for routinely monitoring for hemolysis. Nearly one-fifth of centers (16.7%) had not developed an alternative strategy for the purge solution in patients with contraindications to UFH. Most centers (58.4%) reported using argatroban or bivalirudin in this scenario, a strategy that diverges from the manufacturer's recommendations. CONCLUSIONS: Given these findings, studies to determine a systematic approach to anticoagulation with the Impella device are warranted.

Cisatracurium dosing in a patient with hyperthermia.

PURPOSE: A case report involving varying cisatracurium dosing requirements in a hyperthermic patient undergoing prone ventilation who subsequently received active cooling as part of targeted temperature management is presented. SUMMARY: Cisatracurium is known to be primarily metabolized via pH- and temperature-dependent Hofmann elimination. Previous reports in the literature described cases of decreased dosing requirements for both cisatracurium and its parent compound, atracurium, for patients in hypothermic states. While augmented atracurium dosing requirements in hyperthermic states have been reported, a literature search found no such reports concerning cisatracurium administration. In the case described here, a patient was initiated on cisatracurium for treatment of symptoms suggestive of acute respiratory distress syndrome (ARDS) and septic shock. An initial dosing requirement of 12 µg/kg/min (adjusted to a goal of 2-4 twitches per train-of-four monitoring) was needed to achieve adequate paralysis while the patient remained hyperthermic (a bladder temperature of 40.1°C). This cisatracurium infusion rate exceeded maximum reported and maximum institutional infusion rates (10 µg/kg/min). After initiation of cooling and lowering of the bladder temperature to 37.8°C, the cisatracurium rate requirement decreased to 5 µg/kg/min. CONCLUSION: A hyperthermic patient thought to have ARDS and septic shock required a high rate of cisatracurium infusion for adequate paralysis during mechanical ventilation. The cisatracurium did not appear to cause prolonged neuromuscular blockade.

Organisational learning in hospitals: A concept analysis.

AIM: To provide a clear definition and description of organisational learning in hospitals. BACKGROUND: Organisational learning is a promising strategy nurse managers, and leaders can use to improve organisational performance. A clear definition and description of organisational learning is necessary to advance theory, research and practice in this field. METHODS: Walker & Avant's method was used to conduct a concept analysis of organisational learning in hospitals. Data sources included 147 empirical studies, 16 review articles, three dictionary entries and three book chapters. RESULTS: Organisational learning occurs when experiences are translated into positive changes in the organisation's collective knowledge, cognition and actions. Organisational context plays a key role in the learning process. Other manifestations of the concept are identified. CONCLUSIONS: This concept analysis provides a clear definition of organisational learning and a description of its defining attributes, antecedents, empirical referents and consequences. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers and leaders can improve patient and organisational outcomes by creating an environment conducive to translating experiences into organisational learning. Further research is needed to continue advancing the science of organisational learning in hospitals.