Nautilus Delta Instructions for Use updated July 2015

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Nautilus Delta Instructions for Use 1. DEVICE DESCRIPTION ... 3 1.1 Intended Use ... 3 1.2 Indications for Use ... 3 1.3 Description of Nautilus Delta ... 3 1.4 How Nautilus Delta works ... 4 2. CONTRAINDICATIONS ... 6 3. WARNINGS ... 6 4. PRECAUTIONS ... 8 5. OPERATOR’S MANUAL ... 10 5.1 Nautilus Delta Patient Module ... 10 5.2 Nautilus Delta Operator Module ... 11 5.3 The Graphical User Interface ... 13 5.4 Procedure workflow ... 17 5.4.1 Nautilus Delta System Setup ... 17 5.4.2 Patient preparation ... 17 5.4.3 Assess catheter tip position ... 18 5.4.4 Document the procedure ... 19 5.5 Error Messages and Troubleshooting ... 19 5.6 Cleaning and Disinfection... 20 5.7 Warranty ... 20 5.8 Service and Repair ... 21 5.9 Technical Specifications ... 21 5.10 Disposal Information ... 22 6. CONTACT INFORMATION ... 22 7. MANUFACTURER’S DECLARATION ... 22

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1. DEVICE DESCRIPTION 1.1 Intended Use The intended use of the Nautilus Delta system is to support central venous catheter navigation and tip positioning. Nautilus Delta can be used as an alternative method to fluoroscopy and chest X-ray for central venous catheter tip placement confirmation. 1.2 Indications for Use Nautilus Delta is indicated for navigation and positioning of central venous catheters such as PICCs, CVCs, implantable ports, brachial ports, and hemodialysis catheters. Nautilus Delta provides real-time catheter tip location information by using the patient’s cardiac electrical activity. Nautilus Delta is indicated for use as an alternative method to chest X-ray and fluoroscopy for central venous catheter tip placement confirmation. Limiting but not contraindicated situations for this technique are in patients where alterations of cardiac rhythm change the presentation of the P wave as in atrial fibrillation, atrial flutter, severe tachycardia, and pacemaker driven rhythm. In such patients, who are easily identifiable prior to central venous catheter insertion, the use of an additional method is required to confirm catheter tip location. 1.3 Description of Nautilus Delta Nautilus Delta can be used in the following indoor environments: - Physician private office - Nursing homes use intended for professional use only - Home use intended for professional use only - Bedside, operating rooms, radiology suites, dedicated suites for placement of central venous catheters Figure 1 shows the Nautilus Delta device, which consists of the following components: a) Single use sterile ECG extension cable b) Non-sterile ECG cable c) Patient Module (ECG data acquisition and processing and integrated remote control) d) Operator Module (Mobile medical application (e) running on any mobile platform, e.g., tablet or smartphone, complying with the specified minimum requirements) The Nautilus Delta single use sterile ECG extension cable also known as Nautilus Adaptor can be connected to any commercially available central venous catheters as well to any stylets, guidewires or syringe needles used for the placement of central venous catheters. ECG signals are transmitted through the ECG cable from the patient and the catheter to the Patient Module, where these signals are converted into digital data and processed. The information is then sent via Bluetooth to the mobile medical application (app) running on the mobile platform. The Nautilus Delta app displays the following relevant information screen:  Intravascular ECG waveforms in real time at the tip of the catheter  Computed navigation signal in real time (optional)  External (skin) ECG waveforms in real time  Heart rate in real time 3 [11.2.3.5.1] [IFU Nautilus Delta UE en.pdf] [Page 3 of 25]

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  

Frozen (reference) intravascular ECG waveforms or navigation signal on demand Red marks on the R peak of the QRS complex Status of power of the Patient Module battery d b e

c b

a

a

Figure 1: Nautilus Delta Note: For users adopting IEC color coding for ECG cable leadwires

Also, if required, the frozen waveforms can be printed on labels by an optional label printer which communicates via Bluetooth with the tablet. The following commands:  increase the amplitude of the intravascular ECG waveform or of the navigation signal,  decrease the amplitude of the intravascular ECG waveform or of the navigation signal,  freeze the intravascular ECG waveform or of the navigation signal on the screen,  print and archive the frozen image are available by pressing dedicated control buttons available on the Patient Module or by touching the corresponding buttons displayed on the touchscreen. The graphical user interface also allows for patient data management: patient data input, saving data, and play back recorded data. 1.4 How Nautilus Delta works In order to obtain electrical signals form the tip of the central venous catheter, Nautilus Delta uses the catheter as an intravascular electrode in two different techniques: metal guidewire and column of saline. In the metal guidewire technique, a metal guidewire inserted inside the catheter is used as an intravascular electrode, whereas, in the column saline technique, the column of physiological saline solution contained in the catheter is used. Both these techniques are currently accepted and used by the medical community as demonstrated by a large knowledge base. Additional electrodes are placed on the patient’s skin as illustrated in Figures 2a and 2b. For users adopting IEC color coding for ECG cable leadwires, a reference electrode (green) is placed on the patient’s skin on the lower left abdomen and an additional electrode (black) is placed on the patient’s skin on the lower right abdomen in order to improve signal quality and reduce noise (Figure 2a). For users adopting AHA color coding for ECG cable leadwires, a 4 [11.2.3.5.1] [IFU Nautilus Delta UE en.pdf] [Page 4 of 25]

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reference electrode ( red) is placed on the patient’s skin on the lower left abdomen and an additional electrode (green) is placed on the patient’s skin on the lower right abdomen in order to improve signal quality and reduce noise (Figure 2b). A control electrode (blue) is placed on the patient’s skin right below the jugular notch on the manubrium of the sternum. The ECG signal measured at the control electrode, also called surface (or skin) ECG, is used as a baseline, to estimate the patient’s heart rate and to detect the R-peak of the QRS complex of the ECG waveform.

Figure 2a: Navigation signal computed by Nautilus Delta at different locations in the venous system: A – brachial or basilic vein; B – innominate vein; C – internal jugular vein; D – subclavian vein; 1 – superior vena cava; 2 – cavo-atrial junction; 3 – right atrium (For users adopting IEC color coding for ECG cable leadwires)

Figure 2b: Navigation signal computed by Nautilus Delta at different locations in the venous system: A – brachial or basilic vein; B – innominate vein; C – internal jugular vein; D – subclavian vein; 1 – superior vena cava; 2 – cavo-atrial junction; 3 – right atrium (For users adopting AHA color coding for ECG cable leadwires)

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For catheter guidance and positioning, Nautilus Delta displays by default the intravascular ECG at the tip of the catheter. The intravascular ECG at the tip of the catheter allows for positioning the catheter tip at or around the CAJ. Alternatively, the user can select to use Nautilus Delta in Navigation Mode by checking the appropriate box on the graphical user interface. In Navigation Mode, Nautilus Delta computes a navigation signal using the intravascular ECG signal obtained from the tip of the catheter and the skin ECG signal obtained from the control electrode. Figures 2a and 2b shows the navigation signal computed by Nautilus Delta at different locations in the venous system related to central venous access and central venous catheter placement. The red marker indicates the position of the R-peak of the QRS complex of the ECG waveform. The changes in the amplitude of the navigation signal aligned with the P-wave of the ECG waveform, allow the user to estimate whether the tip of the catheter is approaching or moving away from the CAJ. The changes in the amplitude of the navigation signal aligned with the Rpeak of the ECG waveform, allow the user to estimate whether the tip of the catheter is approaching or moving away from the control electrode. 2. CONTRAINDICATIONS There are no contraindications specific to Nautilus Delta. There are no complications specific to Nautilus Delta. 3. WARNINGS Warning Warning

Warning

Warning

Warning

Warning

Before using the Nautilus Delta System for the first time, be sure to read and understand all of the information in the Instructions for Use. This device should only be operated by qualified medical personnel trained in central venous catheter placement procedures and in assessing the ECG information provided by the Nautilus Delta system. In patients where alterations of cardiac rhythm significantly change the presentation of the P wave ( e.g., P wave not present, P wave not identifiable, P wave intermittent) as in atrial fibrillation, atrial flutter, severe tachycardia, and pacemaker driven rhythm, the use of an additional method, according to your institutional guidelines, is required to confirm catheter tip location. In any situation in which you cannot unambiguously identify the specific ECG waveforms for different locations in the vasculature as described in the Instructions for Use, the use of an additional method, according to your institutional guidelines is required to confirm catheter tip location. Unstable ECG waveforms may be detected because of patient’s movements or manipulation by the user. In such a situation the use of an additional method, according to your institutional guidelines is required to confirm catheter tip location. Nautilus Delta device can interfere with pacemaker device. If you have a pacemaker or other electrical medical devices, you should consult your physician before using the product. 6

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Warning Warning

Warning Warning Warning Warning Warning Warning

Warning

Warning

Warning

Warning

Warning

Do not power the Nautilus Delta in the presence of flammable anesthetics or gases. Explosion may result. If the Nautilus Delta is visibly damaged or warmer than the ambient temperature, discontinue use immediately. Use of damaged device may result in injury or equipment damage. Read and follow the Instructions for Use provided with the Nautilus Adaptor when using it with the Nautilus Delta System. Nautilus Delta is not intended to diagnose or treat disease. Nautilus Delta is not intended to be used as monitoring equipment. Nautilus Delta is not intended to be used as life-supporting equipment. The Nautilus Delta only works for a sinus rhythm of the heart. If no ECG waveforms are detected, verify the connection between the patient’s skin and the electrodes, between the electrodes and the ECG cable, and between the Nautilus Electrical Adaptor and the ECG cable, as it may be caused by an impedance mismatch between the patient and the ECG electrodes. If the problem persists, the use of an additional method for catheter tip location confirmation, according to your institutional guidelines is required to confirm catheter tip location. In certain patients, unstable ECG waveforms may be detected because of the manipulation of the Nautilus Adaptor by the operator. Verify that the connection between the Nautilus Adaptor and the central venous catheter and the connection between the Nautilus Adaptor and the ECG cable are free from contact with any other material and do not touch the adaptor and any of its connections. If the problem persists, the use of an additional method for catheter tip location confirmation, according to your institutional guidelines is required to confirm catheter tip location. When using the saline technique, ensure that the catheter lumen is constantly filled with saline, such that electrical conductivity trough the catheter is ensured from the proximal to the distal end of the vascular access device. Place skin electrodes carefully at locations indicated by the Instructions for Use and ensure good skin-electrode contact. Use commercially available skin electrodes/pads with snap buttons according to the manufacturer’s instructions for use. Failure to do so may cause unstable ECG waveforms and/or ECG waveforms which are not described in the Instructions for Use. In such a case, the use of an additional method, according to your institutional guidelines is required to confirm catheter tip location. To avoid the risk of confusing or misinterpreting patient data when transmitting data via Bluetooth, verify that the Operator Module is paired with the appropriate Patient Module. Do not place and/or use the Nautilus Delta in the presence of strong magnetic fields such as Magnetic Resonance Imaging (MRI) devices. The high magnetic fields created by an MRI device will attract the equipment with a force sufficient to cause death or serious personal injury to persons between the equipment and the MRI device. This magnetic attraction may also damage the equipment. The 7

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Warning Warning Warning Warning

magnetic and the RF fields associated with the MRI environment may interfere with the display of ECG waveforms. Consult the MRI manufacturer for more information. Nautilus Delta must only be charged with the power supply and USB cable provided with the Nautilus Delta system. Do not use the system with other ECG cable than the ECG cable provided with Nautilus Delta. Do not charge the Nautilus Delta while using the device in a medical procedure. When the battery icon of the Patient Module displayed on the screen is empty with a red liner, there are 5 minutes more of normal operation prior to automatic power down. End the procedure and power up the Patient Module.

Warning

Do not modify Nautilus Delta without authorization of the manufacturer.

Warning

Field repair of this device is not possible. Do not attempt to open the case, repair or replace components of Nautilus Delta. Opening the case may damage the device and void the warranty. Only Romedex International qualified personnel should be opening, replacing batteries or servicing the system. Do not remove system labels. Ensure all connecting cables and connections are electrically insulated and do not come into contact with other electrical cables or metal surfaces Do not submerge any of the Nautilus Delta components or accessories or allow fluid to enter any of the connectors. Use of incorrect cleaners can result in optical impairment of the LCD and/or damage to the mobile platform. Always refer to the cleaner manufacturer's guidelines and material safety data sheets for proper handling and use of the products. Always switch off the Patient Module before transporting and/or packaging it. Wait until no LEDs are illuminated. Dispose of the product according to local standards and regulations for electronic devices. The battery used in this product may present a risk of fire or chemical burn if damaged or not handled properly.

Warning Warning Warning Warning

Warning Warning Warning

4. PRECAUTIONS Caution Caution

Federal (USA) law restricts this device to sale by or on the order of a physician. Nautilus Delta complies with International IEC 60601-1-2:2007 for electromagnetic compatibility (EMC) for medical electrical equipment. This standard is designed to provide reasonable protection against harmful interference in a typical medical installation. However, because of the proliferation of radiofrequency transmitting equipment and other sources of electrical noise in healthcare and other environments, it is possible that high levels of such interference due to close proximity or strength of a source might disrupt the performance of this device. Medical electrical equipment needs special precautions regarding EMC, and all equipment must be installed and put into service according to the EMC information specified in the Instructions for Use. 8

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Caution

Caution

Caution

Caution

Caution

Caution

Nautilus Delta may interfere with wireless devices working in 2.4 GHz radiofrequency bandwidth, if not installed and used in accordance with the instructions for use. However, there is no guarantee that interference will not occur in a particular installation. Active electric motor driven equipment, such as pumps, may interfere with the display of the ECG waveforms by Nautilus Delta. In any situation in which you cannot unambiguously identify the specific ECG waveforms for different locations in the vasculature as described in the Instructions for Use, the use of an additional method, according to your institutional guidelines is required to confirm catheter tip location. Equipment such as CT scanners, X-rays and fluoroscopy systems, cauterizers and diathermy equipment, operating in close proximity may emit strong electromagnetic or radio frequency interference (RFI) which could interfere with the display of ECG waveforms by Nautilus Delta. In any situation in which you cannot unambiguously identify the specific ECG waveforms for different locations in the vasculature as described in the Instructions for Use, the use of an additional method, according to your institutional guidelines is required to confirm catheter tip location. Electric equipment which requires direct contact with the patient may interfere with the display of ECG waveforms by Nautilus Delta. Do not use electric cauterization, electric scalpels, and ablation equipment while using the device. In any situation in which you cannot unambiguously identify the specific ECG waveforms for different locations in the vasculature as described in the Instructions for Use, the use of an additional method, according to your institutional guidelines is required to confirm catheter tip location. Portable and mobile RF communications equipment may interfere with the display of ECG waveforms by Nautilus Delta. In any situation in which you cannot unambiguously identify the specific ECG waveforms for different locations in the vasculature as described in the Instructions for Use, the use of an additional method, according to your institutional guidelines is required to confirm catheter tip location. It is possible that high levels of radiated or conducted radio-frequency electromagnetic interference (EMI) from portable and mobile RF communications equipment or other strong or nearby radio-frequency sources, could result in performance disruption of the device. Evidence of disruption may include image degradation or distortion, equipment ceasing to operate, or other incorrect functioning. If this occurs, survey the site to determine the source of disruption, and take the following actions to eliminate the source(s): - Turn equipment in the vicinity off and on to isolate disruptive equipment. - Relocate or re-orient interfering equipment. - Increase distance between interfering equipment and Nautilus Delta. - Remove devices that are highly susceptible to EMI. - Restrict use of personal communicators (cell phones, computers) in areas with devices susceptible to EMI. 9

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-

Caution Caution Caution Caution

Share relevant EMI information with others, particularly when evaluating new equipment purchases which may generate EMI. - Purchase medical devices that comply with IEC 60601-1-2 Standards - Contact Romedex International or its representative Use Nautilus Delta within its designated range of approximately 10 meters. Moving outside this range may cause missing or lost data. The full performance of a new battery is achieved only after two or three complete charge and discharge cycles. Do not leave a fully charged battery connected to a charger, since overcharging may shorten its lifetime. If left unused, a fully charged battery will lose its charge over time.

5. OPERATOR’S MANUAL 5.1

Nautilus Delta Patient Module

The Nautilus Delta Patient Module (Figure 3) is supplied with an ECG cable (Figure 1-b) and a Li-Po battery charger. The main functions of the Patient Module are: a) Data acquisition and processing of intravascular and skin ECG signals b) Integrated remote control c) Bluetooth communication with the Operator Module d) Detecting the R-peak of the QRS complex of the ECG waveform e) Computing the patient’s heart rate f) Computing a navigation signal. The Patient Module provides for a simplified user interface as shown in Figure 3: a) “+/-“ buttons to increment/decrement the amplitude of the ECG signal b) “Freeze” button to freeze an image on the reference screen c) “Print” button to document the procedure by printing and saving case information d) “On/off” button to turn the Patient Module on and off e) “Bluetooth” light – to indicate the status of the Bluetooth connection. f) “On/off” light – to indicate if the Patient Module is on or off. g) “Battery” light – to indicate if the battery’s status is critical. The Patient Module can be inserted in a commercially available sterile bag in order to allow a sterile operator to use the functions available on the Patient Module user interface from the sterile field (Figure 5). Telescopically folded sterile off the shelf polyethylene covers for use in vascular access procedures may be used. Standard dimensions as 15.2x147 cm or larger are convenient. For example the iVAS Transducer Cover from Civco is recommended. The ECG cable provided with Nautilus Delta is connected to the Patient Module. The ECG cable leads (IEC color codes) are connected as illustrated in Figure 4a: a) Black: on the lower right abdomen b) Green: on the lower left abdomen c) Blue: below the jugular notch on the manubrium of the sternum d) Red: to be connected to the banana plug of the Nautilus adaptor.

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The ECG cable leads (AHA color codes) are connected as illustrated in Figure 4b: a) Green: on the lower right abdomen b) Red: on the lower left abdomen c) Blue: below the jugular notch on the manubrium of the sternum d) White: to be connected to the banana plug of the Nautilus adaptor. 5.2

Nautilus Delta Operator Module

The Nautilus Delta Operator Module consists of a mobile medical application running on a mobile platform. Examples of these mobiles platforms include mobile computers such as Android phones, tablet computers, or other computers that are typically used as smart phones or personal digital assistants. Figure 6 illustrates a mobile platform (tablet computer) with a 7” touchscreen running the Android operating system and the Nautilus Delta mobile medical applications.

Fig. 3: Patient Module Nautilus Delta

Fig. 5: Patient Module in a sterile bag

Figure 4a: Nautilus Delta ECG cable for IEC color codes Figure 4b: Nautilus Delta ECG cable for AHA color codes

The minimum requirements for a legally marketed mobile platform to be able to run the Nautilus Delta mobile medical application are: a) Processor: single core at 1.6 GHz or dual core at 1 GHz b) Display: 5” c) Touch screen d) Internal memory: 8 GB e) Bluetooth 2.1 + EDR f) Android 4.0 g) 4 hours battery autonomy

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Figure 6: Operator Module

Figure 7 shows the Nautilus Delta mobile platform in a clinical setting on a cart next to the patient’s bed. A commercially available mobile platform stand like the one in Figure 8 can be used.

Figure 7: Nautilus Delta Mobile Platform in Clinical Setting

Figure 8: Stand for mobile platform

The use of the mobile platform stand is indicated for a better stability of the mobile platform, it allows a better visibility of the device screen and offers versatility of its orientation (Landscape versus Portrait). Recommended stands are those supplied by AIDATA ex: Mini Retina Display Stand or the Universal Tablet Station.

Figure 9: Label printer

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An optional printer can be connected via Bluetooth to the mobile platform in order to document the catheter placement procedure. Labels are recommended in order to document the procedure results in the patient’s file. A recommended printer for documenting purpose is MLP-2 (mobile, thermal printer). Nautilus Delta Medical Application can be downloaded from Google Play or from www.romedex.com website. To install the Nautilus Delta Mobile Medical Application on the mobile platform using the website one may follow the next steps: 1. Using the Chrome internet browser on the mobile platform, go to http://romedex.com and select Products menu, then select Nautilus Delta. 2. On the Nautilus Delta page, select Software and then select Android application link (the Software button is in the Downloads area). 3. When selecting Android application link, the following message will come up: This type of file can harm your device. Do you want to keep Delta.apk anyway? Select OK and the download will start automatically and the file will be saved on your mobile platform. 4. Go to your favourite File Manager and select Download file. If your tablet is not set up to allow the instalation from an unknown source, the following message will come up: For security, your tablet is set to block installation of apps obtained from unknown sources.Select Settings and then Security. 5. Click to enable Unknown sources. The following message will come up: Your tablet and personal data are more vulnerable to attack by apps from unknown sources. You agree that you are solely responsible for any damage to your tablet or loss of data that may result from using these apps. Choose Ok. 6. Go to Downloads area and select Delta.apk and click Next and then Install. The Nautilus Delta icon will be added to the application list of the mobile platform. 7. For your convenience, create a shortcut of the Nautilus Delta app to the main screen of the mobile platform.

Note: Before starting to install a new version of Nautilus Delta app from www.romedex.com, you have to uninstall the Nautilus Delta app previously installed on your tablet if any.

5.3

The Graphical User Interface

The main screen of the graphical user interface of Nautilus Delta is shown in Figure 10:

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Figure 10: Nautilus Delta graphical user interface

a. b. c. d. e. f. g. h.

External (skin) ECG waveform in real time (1) Intravascular ECG waveform or navigation signal in real time (2) Frozen intravascular ECG waveforms at a desired moment as reference (3) Red mark for each R peak (6) Heart rate in real time in beats per minute (7) Patient Module Battery status (8) Menu bar with three icons: Patient, Print and Settings (9) Nautilus Delta logo

As the screen is touch sensitive, using the Touch Screen Controls detailed bellow, specific functions are available. The following functions can be performed using the tablet touchscreen interface: a. To freeze the ECG signal, tap once in the window of the screen displaying the intravascular ECG waveform or navigation signal (2). The waveform will be copied and displayed in the reference window of the screen (3). This allows a particular waveform to be studied, compared, captured or printed b. To empty the reference window, double tap in the reference window. c. To enlarge/decrease the ECG signal, use the fingerzoom in/out function on the intravascular ECG waveform or navigation signal window and the signal amplitude will be increased/decreased. d. To scroll up/down the baseline of the ECG signal, drag the ECG waveform up and down in the corresponding window with one finger. e. To access the Patient screen, tap once on the Patient icon will open.

and the Patient Info screen

f. To document the procedure, tap once on the Print icon . The case data will be saved in a file. The default name of this file is the patient identification and the date and time when started the recorded sequence. A png image file will be saved as well. It contains Patient information, the frozen intravascular ECG waveform or navigation signal and the corresponding skin ECG waveform. If an optional printer is connected to the Operator Module, the png file will also be printed out. g. To access the Settings screen, tap once on the Settings Icon and the Settings screen will open. 14 [11.2.3.5.1] [IFU Nautilus Delta UE en.pdf] [Page 14 of 25]

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The battery status of the Patient Module (8) is represented using a battery icon which is gradually green (full), (75%), and (50%) or gradually red indicating different degrees of warning for the low level of the battery: (25%) and (10%). The 10% battery level ensures at least 5 minutes of normal operation according to the specifications prior to automatic power down. Figure 11a shows the Patient Information screen with the following fields: a. Patient b. Institution c. Device Type d. Inserted Length e. Notes The operator can introduce the patient information selecting the corresponding fields and using the touchscreen keyboard. The information introduced in the fields a, b, c, and d will be shown on each printed label. The Patient Information screen has a menu bar with the following items: Folder, Settings and New Patient.

Figure 11a: Nautilus Delta Patient Information Screen

Tapping the Folder icon opens a dialog box which allows for the selection of one of the following two options, Figure 11b: a. Play Back: ECG data of any of the recorded cases can be played back. b. Open Image: Saved printouts in png format can be reviewed.

Figure 11b: Nautilus Delta Patient Information Screen

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Tapping the New Patient icon 11c).

clears all fields of the Patient Information screen (Figure

Figure 11c: Nautilus Delta Patient Information Screen

Tapping the Settings Icon Settings screen.

opens the System Settings screen. Figure 12 shows the System

Figure 12: Nautilus Delta Settings user interface

The System Settings screen displays: 1. The Bluetooth window displays and refreshes information about the Bluetooth connection and the devices discovered and allows for pairing (connecting) the Operator Module with the Patient Module. 2. The Settings window contains ECG sampling rate, intravascular and control electrode gains, filter and scale settings; for all these settings, Factory Default function is available. Touching the Factory Default button restores the factory defaults: ECG Rate = 250 samples/sec; IV Gain = 6; CE Gain = 8; Filter = 50 Hz (on). 3. Checking the box R-Peak View enables the display of a red marker to identify the R peak of the QRS complex of the ECG waveform. The box R-peak view is checked by default. 4. Checking the box NaviView allows for displaying navigation information. The box NaviView is not checked by default. 5. The Operator Module is set for automatically pairing with the last known Delta Patient Module. 6. The skin ECG signal and the heart rate in real time 7. Menu bar with

Patient and

Print/Save icons. 16

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5.4

The Procedure Workflow

5.4.1 Nautilus Delta system setup 1. Ensure that the Patient Module and Operator Module are charged. 2. Turn on the mobile platform. Press and hold the On/Off button. 3. Turn on the Nautilus Delta Patient Module. Press and hold the On/Off button for more than 10 seconds until the Power Indicator glows white. Than release the button. Wait until the Bluetooth Indicator is blinking white. 4. Turn on the MLP2 Bluetooth printer if available. Press and hold the power button. The Power Indicator glows green, a blank label is released and the mini screen displays the message: Labels. 5. On the mobile platform tap Settings/Bluetooth and after Scanning (Search for devices), the available devices are listed. Select the Delta Patient Module and the MLP 2 printer you may want to pair with (you will find the Bluetooth IDs on the label on the back of the devices). The pairing will be done automatically. 6. Go to the mobile platform screen and tap the Nautilus Delta icon to launch the Nautilus Delta application. 7. If the mobile platform has been previously connected to the same Patient Module, the the two devices will communicate and the waveforms will be automatically displayed on the Main interface. If not, enter in the Settings screen. The app will automatically start discovery of the DELTA devices in the proximity. The user has to select the name of the device to which connection is required. A green check mark identifies the selected device. Tapping on Connect button, the two components of the system will be paired and automatically the Main graphical interface will be displayed. The Bluetooth icon glows indicating that the connection between the Patient Module and the tablet is established. 8. If the mobile platform has been previously connected to the same printer, and the “Auto Connect” option on the printer’s settings window is selected, the next connection will be automatically realized. 9. If the devices: Delta Patient Module, mobile platform and printer are Bluetooth paired, the following messages are displayed: Delta Connected! PRINTER Connected! 10. Signals start to be displayed in the two real time windows of the screen. The data start to be recorded. 11. The system is ready for the procedure. 12. Place the mobile platform in a location such as to be visible to the operator when performing the placement procedure. 13. Place the Patient Module to allow for connection of the ECG cable to the patient and for operation by the sterile operator when performing the placement procedure. 5.4.2 Patient preparation 1. Enter Patient information as needed on the Patient screen of the Operator Module 2. Connect the ECG cable to the patient: Before preparing the sterile field, take the ECG cable supplied with the Nautilus Delta System and wipe the cable down according to hospital’s guideline. Locate three new off-the-shelf ECG snap electrode patches and place one on the patient’s skin below the jugular notch over the manubrium of the sternum, one on the patient’s lower left abdomen, and one on the patient’s lower right abdomen For users adopting IEC color codes for ECG cable:  Connect the green clip connector of the provided ECG cable to the electrode snap on the patient’s lower left abdomen. 17 [11.2.3.5.1] [IFU Nautilus Delta UE en.pdf] [Page 17 of 25]

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

Connect the black clip connector of the provided ECG cable to the electrode snap on the patient’s lower right abdomen.  Connect the blue clip connector of the provided ECG cable to the electrode snap on the patient’s skin below the jugular notch over the manubrium of the sternum.  Leave the red clip connector of the provided ECG cable in a reachable location for the connection with the sterile adaptor during the procedure. For users adopting AHA color codes for ECG cable:  Connect the red clip connector of the provided ECG cable to the electrode snap on the patient’s lower left abdomen.  Connect the green clip connector of the provided ECG cable to the electrode snap on the patient’s lower right abdomen.  Connect the blue clip connector of the provided ECG cable to the electrode snap on the patient’s skin below the jugular notch over the manubrium of the sternum.  Leave the white clip connector of the provided ECG cable in a reachable location for the connection with the sterile adaptor during the procedure. 3. Connect the ECG cable to the Patient Module. 4. Prepare the sterile field for the procedure. 5. Wrap the Patient Module in a sterile cover and place it in the sterile field. 6. Evaluate the skin ECG waveform, Figure 10, display window (1). The skin ECG waveform should be at this time visible and stable. It should be possible to unambiguously identify the ECG waveform elements, e.g., the P-wave and the R-wave, as represented in the Instructions for Use. If this is not the case, do not attempt to use Nautilus Delta system for catheter navigation and positioning and use another method for catheter tip location verification as indicated by the institutional guidelines, e.g., chest Xray or fluoroscopy. 7. Prepare the patient for and perform for central venous catheterization per institution’s guidelines. 8. Connect the Nautilus Adaptor to the catheter according to the Instructions for Use of the Nautilus Adaptor used for the procedure. 9. Connect the Nautilus Adaptor banana plug to the Nautilus Delta ECG cable. 10. If needed, read the patient’s heart rate on the Nautilus Delta screen. 5.4.3 Assessment of catheter tip position Use the navigation map in Figures 2a or 2b to assess the catheter tip location as a function of the navigation signal or the intravascular ECG signal. Place the catheter tip at the desired location according to the institution’s guidelines. If you cannot identify the waveforms illustrated in Figures 2a and 2b, do not attempt to use Nautilus Delta system for catheter navigation and positioning and use another method for catheter tip location verification as indicated by the institutional guidelines, e.g., chest X-ray or fluoroscopy. A) The navigation signal at the level of the introducer at the access point in the brachial or basilic vein has a large negative amplitude aligned with the R-peak of the ECG waveform identified by a red marker. B) In the innominate vein beneath the control electrode, the navigation signal has a small biphasic amplitude aligned with the R-peak of the ECG waveform identified by a red marker. 18 [11.2.3.5.1] [IFU Nautilus Delta UE en.pdf] [Page 18 of 25]

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C) If the catheter goes accidentally in the internal jugular vein, the navigation signal will have a negative amplitude aligned with the R-peak of the ECG waveform identified by a red marker. This amplitude will be smaller than the one at the access point (A) but larger than the one in the innominate vein (B). The further away the tip of the catheter is form the heart, the larger the negative amplitude of the navigation signal aligned with the Rpeak. D) If the catheter goes accidentally in the contra-lateral subclavian vein, the navigation signal will have a negative amplitude aligned with the R-peak of the ECG waveform identified by a red marker. This amplitude will be smaller than the one at the access point (A) but larger than the one in the innominate vein (B). The further away the tip of the catheter is form the heart, the larger the negative amplitude of the navigation signal aligned with the R-peak. 1) In the superior vena cava, the navigation signal has a positive amplitude aligned with the R-peak identified by a red marker and an increased P-wave to the left of the red marker. 2) At the cavo-atrial junction, the navigation signal has a positive amplitude aligned with the R-peak identified by a red marker and a maximal P-wave to the left of the red marker. 3) In the right atrium, the navigation signal has a positive amplitude aligned with the R-peak identified by a red marker and a biphasic P-wave to the left of the red marker. 5.4.4 Documenting the procedure When the desired catheter tip location has been reached, press the Freeze button on the Patient Module (Figure 3) or tap on the touchscreen of the Operator Module in display window (2), Figure 10 to copy the target ECG waveform onto the reference display window (3), Figure 10. To document the procedure press the Print button on the Patient Module (Figure 3) or tap the Print icon on the touchscreen of the graphical user interface of the Operator Module. The case data will be saved in a file. The default name of this file is the patient identification and the date and time when started the recorded sequence. A png image file will be saved as well. It contains Patient information, the frozen intravascular ECG waveform or navigation signal and the corresponding skin ECG waveform. If an optional printer is connected to the Operator Module, the png file will also be printed out. 5.5

Error Messages and Troubleshooting

1. Cannot connect to Patient Module. This error messages is generated when the Operator Module cannot establish Bluetooth communication with the Patient Module. In such a case, ensure that the Patient Module is turned on and within a radius of 10 m. Try reconnecting manually by taping the “Refresh” and then the “Connect” buttons on the Bluetooth window (Figure 12). 2. Battery level low for the Patient Module. This message is display as an LED message on the Patient Module (Figure 3), the battery icon on the Patient Module keyboard is blinking. This message is also displayed on the Operator Module (Figure 10), a red battery icon in the up right corner of the screen. In such a situation, recharge the Patient Module. 3. Nautilus Delta stopped working. Under certain conditions, for example when you try to open a file in Playback mode, which you may have not properly saved, the Nautilus Delta applications may stop working and it will generate the message “Nautilus Delta stopped 19 [11.2.3.5.1] [IFU Nautilus Delta UE en.pdf] [Page 19 of 25]

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working” message before closing. In such a situation, restart the application by tapping on the Nautilus Delta icon on the Operator Module. 4. If you have connected the ECG cable to the patient but do not see the skin ECG waveform in display window (1), Figure 10, check the skin electrodes placement and connection and check the connection of the ECG cable to the Patient Module. 5. If you have connected the Nautilus Adaptor to a catheter and to the ECG cable but do not see the intravascular ECG or the navigation signal in display window (2), Figure 10, wait 2-3 seconds without touching the adaptor in order to allow the ECG signal to stabilize. If you are using the saline column technique, ensure that your catheter is flushed and filled with saline. 6. Refer to the instructions for use for the printer from the printer manufacturer for error message and troubleshooting of the printer. 5.6

Cleaning and Disinfection

To clean the Nautilus Delta, the mobile platform and the optional accessories: 1. Turn off the Patient Module, the Operator Module and the printer 2. Disconnect the power supply from the Patient Module/Operator Module/Printer if connected 3. Disconnect the power supply from the wall socket if connected 4. Remove the ECG cable from the Patient Module if connected 5. Remove the USB power cable if connected 6. Dampen a nonabrasive cloth with either mild soap or detergent cleaning solution 7. Clean external surfaces of all components using the dampened cloth to remove dirt or body fluids. 8. Wipe with water-dampened cloth, then wipe with a dry cloth. 9. Towel dry with a clean cloth. For a list of disinfectants approved for use for the Patient Module, ECG cable, Operator Module, Power supply, USB power cable and optional accessories contact Romedex International [email protected]. 5.7

Warranty

Romedex International warrants that the hardware products it manufactures will be free from defects in materials and workmanship for the warranty period. During the warranty period, Romedex International agrees to repair or, at Romedex International discretion, replace, free of charge, any defective unit that is returned to Romedex International facility. The warranty on the repaired or replaced unit continues from the purchase date of the original unit. If warranty service is required, the Client must ship the products back to Romedex International in their original or equivalent packaging, prepay shipping charges, and insure the shipment or accept the risk of loss or damage during shipment. Romedex International will ship the repaired

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