Transcript Intra-aortic Balloon Pump Counterpulsation and Mechanical

Aidah Abu Elsoud Alkaissi
RN, BSN, MSN, PhD
Intra-aortic Balloon Pump
Counterpulsation
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Journal of Cardiothoracic and Vascular Anesthesia, Vol
17, No 6 (December), 2003: pp 736-739
Intraoperative Transesophageal Echocardiographic Imaging of an
Intra-aortic Balloon Pump Placed via the Ascending Aorta
Kent H. Rehfeldt, MD,* and Roger L. Click, MD†
THE USE OF A perioperative intra-aortic balloon pump(IABP) in cardiac surgical
patients is relatively common,
occurring in 2% to 12% of cases.1 Although a femoral arteryinsertion site is typically
used, the failure rate for IABP insertion
via the femoral artery has been reported to be around 5%.2,3In patients in whom
the IABP cannot be inserted from a
femoral approach, placement via the ascending aorta may bepossible. When this
transthoracic approach is used, intraoperative
transesophageal echocardiography (TEE) is especiallyuseful in confirming correct
position of the IABP in the thoracic
aorta, as described in the following cases.
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From the Section of Cardiology and Cardiovascular Surgery, Norfolk General Hospital and
Eastern Virginia Medical School, Norfolk, Virginia
Prophylactic Use of Intra-aortic Balloon Pump in Aortocoronary Bypass for
Patients with Left Main Coronary Artery Disease
H. R. RAJAI, M.D., et al
Aortocoronary bypass surgery in patients with left main coronary artery disease is reported
to have an operative mortality of between 1.4 and 39%. It is generally accepted that the
operative mortality in this group of patients is considerably greater than in routine bypass
candidates, presumably due to the large amount of myocardium threatened
by a single lesion. In an effort to preserve threatened left ventricular myocardium, intraaortic balloon pumping was instituted prophylactically prior to sternotomy in 20 consecutive
patients with left main coronary artery disease (luminal narrowing greater than 50%). Sixty
per cent of these patients had New York Heart Association Class IV angina, 25% had Class III,
and 15% Class II. Fifty per cent of the patients in this group presented with unstable angina.
Operative patients requiring left ventricular aneurysmectomy and/or valve replacement,
were excluded. No operative deaths have been encountered in 20 consecutive patients
managed in this manner. One patient displayed signs of myocardial infarction in the
postoperative period.
Correctable peripheral vascular ischemic complications of pump insertion were encountered
in three patients. Preliminary results from this ongoing study support the hypothesis that
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prophylactic intra-aortic balloon pumping is a low risk procedure that should be utilized
Objectives
 Demonstrate a basic understanding of the purpose and desired
outcomes of IABP
 Identify key patient safety issues associated with the use and
monitoring of IABP
 Describe nursing interventions related to IABP use and
monitoring
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IABP PURPOSE
 Improves cardiac function during cardiogenic shock.
 26-28 cm balloon surrounds end of centrally placed catheter
(from groin)
 Placed into descending thoracic aorta
 Inflates in diastole - fills coronary arteries retrograde
 Deflates in systole - decreases LV afterload
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Indications
 1. Refractory ventricular failure
 2. Cardiogenic shock
 3. Unstable refractory angina
 4. Impending (To threaten to happen) infarction
 5. Mechanical complications due to acute myocardial
infarction
 6. Ischemia related intractable (Difficult to manage)
ventricular arrhythmias
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Indications
 7. Cardiac support for high-risk general surgical and coronary
angiography/ angioplasty patients
 8. Septic shock
 9. Weaning from cardiopulmonary bypass
 10. Support for failed angioplasty and valvuloplasty
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Contraindications
 Severe aortic insufficiency
 2. Abdominal or aortic aneurysm
 3. Severe calcific aorta-iliac disease or peripheral vascular
disease
 4. Scarring of the groin
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Contraindications
 Contraindications: Incompetent aortic valve (because
inflation increases aortic regurgitation)
 􀂄 Nursing: Head of bed must be kept 30 degrees or lower.
Must monitor for infection or bleeding
 􀂄 IABP augments cardiac output by 15% & provides total
support for the heart; which allows the heart to recover
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What is an IABP?

 The Intra-Aortic Balloon
Counterpulsation system is a
volume displacement device.
 A device used to reduce left
ventricular systolic work, left
ventricular end-diastolic
pressure, and wall tension
 Decreases oxygen consumption
 Increases cardiac output,
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perfusion, pressure and volume
to Coronary Artries 7/17/2015
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The System 97e is a
helium charged,
mobile, Intra-Aortic
Balloon Pump (IABP).
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Intra-Aortic Balloon Pump (IABP)
-.

It is inserted into the
descending aorta via the
femoral artery either
percutaneously or by surgical
cut-down.

The balloon rapidly deflates
just before ventricular systole
to reduce the impedance (A
measure of the total
opposition to current flow in
an alternating current circuit)
to left ventricular ejection
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 It consists of a catheter and a
drive console.
 The catheter has a long
balloon mounted on the end.
 It should be positioned so that
the tip is approximately 1 to 2
cm below the origin of the
left subclavian artery and
above the renal arteries.
 On chest x-ray the tip
should be visible in the
2nd or 3rd intercostal
space
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Surgical Indications
 Post Surgical Myocardial Dysfunction
 Support for weaning from Cardiopulmonary Bypass (CPB)
 Cardiac support following correction of anatomical defects
 Maintenance of graft patency post CABG
 Pulsatile flow during CPB
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Desired Outcome
 Appropriately timed blood volume displacement (30 – 50 mL) in
the aorta by the rapid shuttling of helium gas in and out of the
balloon chamber, resulting in changes in inflation and deflation
hemodynamics
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Insertion Techniques
 A percutaneous placement of the IAB via the femoral artery using
a modified Seldinger technique (a needle is used to puncture the
structure and a guide wire is threaded through the needle; when
the needle is withdrawn, a catheter is threaded over the wire; the
wire is then withdrawn, leaving the catheter in place.)
 After puncture of the femoral artery a J-shaped guide wire is
inserted to the level of the aortic arch and then the needle is
removed.
 The arterial puncture side is enlarged with the successive
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placement of an 8 to 10,5Fr dilator/sheath combination. Only the
dilator needs to be removed
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Insertion Techniques
 Continuing, the balloon is threaded over the guide wire into
the descending aorta just below the left subclavian artery.
 The sheath is gently pulled back to connect with the leak-
proof cuff on the balloon hub, ideally so that the entire sheath
is out of the arterial lumen to minimize risk of ischemic
complications to the distal extremity.
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Insertion Techniques
 There are alternative routes for balloon insertion.
 In patients with extremely severe peripheral vascular disease or in
pediatric patients the ascending aorta or the aortic arch may be
entered for balloon insertion.
 Other routes of access include subclavian, axillary or iliac arteries.
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Intra-aortic balloon catheter
 A balloon catheter comprising an outer
tube, a balloon, a tip and an inner tube,
a proximal portion of said inner tube
disposed within the outer tube and a
distal portion of said inner tube
extending beyond a distal end of the
outer tube, the tip, a distal end of the
inner tube, and a distal end of the
balloon membrane are connected,

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Arterial Pressure
Balloon Pump
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IABP
correct placement
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Inflation
 It inflates immediately
following aortic valve
closure to to augment
diastolic coronary
perfusion pressure.
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the intra-aortic balloon positioned in
the descending thoracic aorta, just
below the left subclavian artery, but
above the renal arteries.
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The principles of counterpulsation
state that the balloon should be inflated
at the start of diastole, just prior to the
Dicrotic Notch.
Aortic volume and pressure are
increased through displacement
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1.
2.
3.
4.
5.
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Increased coronary
perfusion pressure
Increased systemic
perfusion pressure
Increased O2 supply to
both the coronary and
peripheral tissue
Increased baroreceptor
response
Decreased sympathetic
stimulation causing
decreased Heart Rate,
decreased Systemic Vascular
Resistance, and increased
Left Ventricular function
Inflation of IABP Causes
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Deflation
 The balloon rapidly
deflates just before
ventricular systole to
reduce Left Ventricular
work
 Deflation creates a
"potential space" in the
aorta, reducing aortic
volume and pressure
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1.
2.
Afterload reduction and therefore a
reduction in myocardial oxygen
consumption (MVO2)
Reduction in peak systolic pressure,
therefore a reduction in LV work
Deflation of the IABP
Causes
3. Increased Cardiac Output
4. Improved ejection fraction (The
amount of blood pumped out of a
ventricle during each heart beat. The
ejection fraction evaluates how well
the heart is pumping; Normally 50 70 percent) and forward flow
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Factors Affecting Diastolic
Augmentation
 1. Patient Hemodynamics




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Heart Rate
Stroke Volume
Mean Arterial Pressure
Systemic Vascular Resistance
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Factors Affecting Diastolic
Augmentation
 2. Intra-aortic Balloon Catheter






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IAB in sheath
IAB not unfolded
IAB position
Kink in IAB catheter
IAB leak
Low Helium concentration
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Factors Affecting Diastolic
Augmentation
 3. IABP


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Timing
Position of the IAB augmentation control
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Review of Arterial Pressure
Landmarks
 AVO = Aortic valve opens,
beginning of systole
PSP = Peak systolic pressure,
65-75% of stroke volume has
been delivered
DN = Dicrotic notch,
signifies aortic valve closure
and the beginning of diastole
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AEDP = Aortic end diastolic
pressure
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The rule of inflation is: inflate just
prior to the Dicrotic Notch
 To accomplish the goals of
inflation, the balloon must be
inflated at the onset of
diastole
 The result of properly timed
inflation is a pressure rise
PDP/DA = Peak diastolic
pressure or diastolic
augmentation, this is the
pressure generated in the
aorta as the result of inflation
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Review of Arterial Pressure
Landmarks in 1:2 Assist
 PAEDP = Patient aortic end diastolic pressure,
this is the patient's unassisted diastole
PSP = Peak systolic pressure, this is the
patient's unassisted systole
PDP/DA = Peak diastolic pressure or
diastolic augmentation, this is the pressure
generated in the aorta as the result of inflation
BAEDP = Balloon aortic end diastolic
pressure, this is the lowest pressure produced
by deflation of the IAB
APSP = Assisted peak systolic pressure, this
systole follows balloon deflation and should
reflect the decrease in LV work
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Inflation Hemodynamics
 Coronary artery blood flow and pressure are increased
 Increased renal and cerebral blood flow
 Increased diastolic pressure increases perfusion to distal organs and
tissues
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Triggering
 It is necessary to establish a reliable trigger signal before
balloon pumping can begin
 The computer in the IAB console needs a stimulus to cycle
the pneumatic system, which inflates and deflates the
balloon
 The trigger signal tells the computer that another cardiac
cycle has begun
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Triggering
 In most cases it is preferable to use the R wave of the ECG as the
trigger signal
 However, there are other trigger options for instances when the
R wave cannot be used or is not appropriate
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Trigger Loss
 The console MUST see a trigger to initiate an inflate/deflate
cycle
 If no trigger is seen when the clinician attempts to start
pumping, no pumping will occur and an alarm will be
sounded
 If the trigger is lost after pumping starts, no further pumping
will occur until a trigger is re-established
 The pump will go to STANDBY and an alarm will be
sounded
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Trigger Loss
 If the current trigger is lost the clinician can choose an
alternate, available trigger to resume pumping
 For example, if the ECG lead becomes disconnected the
Arterial Pressure trigger may be selected until the ECG is reestablished
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ECG Trigger
 Since triggering on the R wave of the ECG is preferred, it
is very important to give the IABP a good quality ECG
signal and lead
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Poor ECG Choices
 Note: changing QRS morphology may
cause wandering timing
 Note: tall T waves may cause double
triggering or may alter previously set
timing points
 Note: wandering baseline may cause
skipped trigger
 Note: artifact may cause inappropriate
triggering
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ECG Gain
 In addition to selecting a lead with a QRS morphology that provides
consistent, appropriate triggering, it is important to ensure the QRS
complex has adequate amplitude
 The computer has a minimum height requirement to recognize the
initial deflection as an R wave, whether upright or negative in
configuration
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Triggering on the Arterial Pressure
Waveform
 Arterial pressure provides another signal to the IABP to
determine where the cardiac cycle begins and ends
 It is used when the ECG has too much interference from
patient movement or poor lead connection
 There are limitations to triggering on the arterial pressure
curve
 Therefore AP trigger should be considered a backup trigger and
not the one used as the primary trigger
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Valid Trigger Indications
 Accurate Heart Rate displayed on pump
 Assist marker on/under ECG in same ratio as assist ratio, e.g. if
in 1:1 there should be one assist marker per ECG complex
 Flash heart symbol next to HR on screen
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Trigger Loss
Possible Cause
ECG
1.
2.
3.
4.
5.
6.
Loose or disconnected
ECG leads
Current type of ECG
trigger is not
appropriate
ECG signal too small
Very noisy ECG
Monitor input
disconnected
Patient's cardiac
activity ceased
Operator Action
1.
2.
3.
4.
5.
6.
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Check electrodes, lead wires
and connections.
Change to alternate
appropriate ECG trigger.
Change lead selection; change
trigger source; check electrode
placement.
Increase ECG gain if
applicable.
Change to AP trigger.
Check connections from
monitor and secure.
CHECK PATIENT FOR
CARDIAC ACTIVITY
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Trigger Loss
Possible Cause
Arterial
Pressure
1.
Arterial line dampened,
disconnected or turned
OFF
2.
Heart Rate is irregular
3.
Patient's cardiac activity
ceased
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Operator Action
1.
Check arterial tracing;
flush line; check
transducer and monitor
input; change to ECG
trigger.
2.
Change to ECG trigger
3.
CHECK PATIENT FOR
CARDIAC ACTIVITY
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TIMING and WEANING
 Balloon synchronization starts usually at a beat ratio of 1:2.
 This ratio facilitates comparison between the patient’s own
ventricular beats and augmented beats to determine ideal
IABP timing.
 Errors in timing of the IABP may result in different waveform
characteristics and a various number of physiologic effects.
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TIMING and WEANING
 If the patient’s cardiac performance improves, weaning from the
IABP may begin by gradually decreasing the balloon augmentation
ratio (from 1:1 to 1:2 to 1:4 to 1:8) under control of
hemodynamic stability.
 After appropriate observation at 1:8 counterpulsation the balloon
pump is removed.
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Gas Alarms/Balloon Pressure
Waveform
 During a cycle of inflation/deflation, helium is rapidly moved in and out of the
balloon. The environment within the balloon and the surrounding forces that affect
balloon behavior all contribute to a predictable pattern of gas flow and pressure.
 The Arrow International IABP consoles have in-line transducers that relay the pattern
of gas pressure during the inflate/deflate cycle.
 The gas pressure characteristics are converted into a waveform that is reflective of the
behavior of the gas.
 This transduced waveform can tell us much about the interaction of the balloon within
the patient's aorta.
 Thorough understanding of the balloon pressure waveform is also important for
efficient troubleshooting of the console as most of the alarms are based on this gas
surveillance system.
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Normal Waveform Variations
Tachycardia
Hypertension
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Bradycardia
Hypotension
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Abnormal Waveform Variation: Wide
Inflation and/or Deflation Artifact
 Note the wide inflation and




deflation artifacts.
This is generally indicative of
something impeding the rapid
inflation and deflation of the IAB,
such as kinking of the gas lumen.
This may result in poor
augmentation and/or poor
afterload reduction.
It may also lead to helium/gas
loss alarms in higher Heart Rates
when in a 1:1 assist ratio. It may
precede high pressure/kinked line
alarms.
The goal is to eliminate the
partial obstruction, if possible, to
enable the IABP to assist the
patient better by moving the
helium more rapidly.
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Abnormal Waveform Variation: Helium Loss / Gas Loss
/ Gas Leakage Alarms
 Note the BPW baseline is
below 0.
 This indicates that a
portion of the gas that
went out to the balloon
did not return to the
pump.
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1.
Observe for blood in the gas tubing. If even a slight amount
were present, it would indicate a balloon rupture.
1.
2.
Do not resume pumping. Notify physician immediately
and prepare for IAB removal.
Check connections where gas tubing connects to IAB and to
pump.
1. Secure if loose.
3.
Check for kinks, as they may trap gas in the IAB.
1.
If water is present in the gas tubing, remove the
condensation. Pushing the helium through the water during
inflation and deflation slows down gas transition. If gas
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Abnormal Waveform Variation: High
Pressure / Kinked Line Alarm
 Note that the plateau
pressure is still greater
than 250mmHg when it is
time to deflate.
 This indicates that not all
of the gas could enter the
balloon.
 It is generally due to a kink
in the catheter, either
internal to the patient or
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external
.
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1.
Reposition patient. Keep affected leg straight. Use rolled
towel under hip to hyperextend hip.
2.
Apply slight traction to the catheter if suspect kinking at
the insertion site or in the artery.
3. Introducer sheath may be kinked which in turn is kinking
the balloon. Suspect this particularly if placement of the
sheath was difficult. Pull sheath back or rotate sheath a
partial turn.
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1.
Check placement of the balloon; it may be too high or too
low.
2.
IAB may be partially wrapped if alarm occurs shortly after
insertion. Take steps to facilitate unwrapping (consult IAB
manufacturer).
1.
The balloon may be too large for the patient. Reduce the
helium volume the balloon is inflated with. It is
recommended to not reduce the volume below 2/3 of
maximum. For example, do not decrease volume in a 40cc
IAB below 27cc.
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Abnormal Waveform Variation: High
Baseline / Fill Pressure
 Indicates too
much gas in the
system.
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1.
Check for intermittent obstruction of gas lumen.
2.
Overfill of system.
3.
This condition may occur during ascent (an upward slope)
in air transport since gas expands as you go up in altitude
(elevation).
4.
Reset the alarm and restart pumping.
5.
The volume will be adjusted automatically for current
barometric pressure.
6.
In the AutoCAT, ensure that the tubing to the condensation
bottle (located behind the helium tank) is not kinked.
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Potential Side Effects and
Complications
 Bleeding at the insertion site
 Thrombocytopenia
 Immobility of the balloon catheter
 Balloon leak
 Infection
 Compartment syndrome
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IABP COMPLICATIONS
􀂄 Aortic dissection during insertion
􀂄 Reduction of platelets, RBC destruction
􀂄 Peripheral emboli
􀂄 Balloon rupture with gas embolus
􀂄 Renal failure (balloon occlusion of renal artery)
􀂄 Vascular insufficiency of catheterized limb
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Complications of IABP
 The following patients are at the greatest risk of developing
complications associated with IABP:
 Peripheral vascular disease (PVD), female, diabetic, HTN,
smokers, obese, high SVR, shock
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Complications of IABP
 Aortic wall dissection, rupture or local vascular injury
 Care as indicated
 Emboli: thrombus, plaque or air
 Care as indicated
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Treatment of an air embolism is as
 Administer
100% oxygen and intubate for significant
follows
respiratory distress or refractory hypoxemia.
 Oxygen may reduce bubble size by increasing the gradient for
nitrogen to move out.
 Promptly place patient in Trendelenburg (head down) position
and rotate toward the left lateral decubitus position.
 This maneuver helps trap air in the apex of the ventricle,
prevents its ejection into the pulmonary arterial system, and
maintains right ventricular output.
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Complications of IABP
 IABP Rupture: Helium embolus or catheter entrapment (take
or catch as if in a snare or trap)
 COFFEE GROUNDS seen in the drive line is a precursor to
a rupture
 NOTIFY RT & PHYSICIAN!!!!!
 IF THERE IS A FLAGRANT (bad or offensive) RUPURE
OF THE IABP CLAMP THE GAS LINE!!!!!
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Complications of IABP
 Infection
 Check catheter insertion site often
 STRICT ASEPTIC TECHNIQUE
 Restrict movement while IABP in place
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Complications of IABP
 Obstruction
 Malposition
 Too high – obstruction of left subclavian, carotids
 CHECK LEFT RADIAL ARTERY PULSE
 Too low – obstruction of renal and mesenteric arteries
 MONITOR URINE OUTPUT
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Complications of IABP
 Compromised circulation due to catheter
 Ischemia
 Routine nursing care and monitoring
 Compartment syndrome
 Rare complication seen in the LE (lupus erythematosus) , usually
related to infection
 Monitor calf circumference
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Complications of IABP
 Hematologic
 ALL PATIENTS Typed & Crossmatched!!!
 Bleeding
 REMOVE THE DRESSING!!!
 PUT ON STERILE GLOVES!!!
 HOLD PRESSURE!!!
 Thrombocytopenia
 Routine monitoring
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1.
2.
3.
4.
5.
6.
7.
8.
9.
Zero Baseline (on console)
Balloon Pressure Baseline
Rapid Inflation
Peak Inflation Artifact
Balloon Pressure Plateau (IAB fully
inflated)
Rapid Deflation
Balloon Deflation Artifact
Return to Baseline (IAB fully deflated)
Duration of Balloon Cycle
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European Journal of Cardio-thoracic Surgery 11 (1997) 1176–1179
Case report
Successful surgery for perforation of the thoracic aorta caused by the
tip of an intra-aortic balloon pump
Thomas Wolff *, Peter Stulz
Klinik fu¨r Herz- und Thoraxchirurgie, Kantonsspital, Spitalstrasse 21, CH-4031 Basel,
Switzerland
We describe a case of perforation of the thoracic aorta caused by the tip of an intraaortic balloon pump. The perforation was
confirmed by computed tomography (CT) scan and immediate surgical repair was
successful. Vascular injury due to the insertion
of an intra-aortic balloon pump is quite common but is predominantly confined to
limb ischemia or injury to the femoral or iliac
artery. Iatrogenic aortic perforation leading to significant bleeding is much less
common and usually fatal. © 1997 Elsevier Science
B.V.Keywords: Aortic injury; Intra-aortic balloon pump; Complication
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Circ J 2002; 66: 423 –424
Perforation of the Descending Aorta by the Tip of an Intra-Aortic Balloon Pump
Catheter
Ryo Shiraishi, MD*; Yukio Okazaki, MD; Kozo Naito, MD; Tsuyoshi Itoh, MD
Perforation of the proximal descending aorta occurred in a patient on intra-aortic balloon
pump (IABP) supportafter emergency coronary intervention for acute myocardial infarction.
The IABP catheter was inserted under fluoroscopic guidance into the right femoral artery
without difficulty, but after 8 h on IABP support the patient
went into shock with a left hemothorax. Emergency surgery was performed with
cardiopulmonary bypass and a perforation of the proximal descending aorta with active
bleeding was found and successfully repaired. A distorted descending aorta in which the IABP
catheter was kinked, as in the aortic arch, was discovered during
surgery and confirmed postoperatively with 3-dimensional computed tomography scans,
particularly in the lateral view. Not only the antero-posterior but also the lateral fluoroscopic
view is recommended to prevent aortic perforation by a kinked IABP catheter. (Circ J 2002; 66:
423 –424)
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Heart Inst J 1995;22: 202-3J
Thrombosis of the Abdominal Aorta
Elisabeth Leude, MD et al
A Rare Complication of the lntraaortic Balloon Pumping Device
We describe a patient who died due to thrombosis of the abdominal aorta and its
branches after placement of an intraaortic balloon pumping device. This
rare complication, which occurred despite careful insertion technique, underscores the
need to select balloon
size as a function of the individual patient's morphology. (C omplication rates
associated with the use of an intraaortic balloon pump(IABP) range from 10% to 20%.'5 Trauma-related complications are themost frequent, including dissection,
perforation, and thromboembolism.We describe a patient who died of thrombosis of
the abdominal aorta and itsbranches subsequent to intraaortic balloon pumping. To
our knowledge, this complication has been reported only once before in the literature.
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Conclusions
 1.The consistent application of intra-aortic balloon pump
support of patients with coronary artery disease and its
complications has provided a therapeutic platform for direct
surgical intervention on otherwise unstable patients with
cardiac ischemia, heart failure, and shock.
 This integrated approach to the treatment of patients with
coronary artery disease has profoundly affected how this
disease process is managed throughout the world.
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 Maintain systemic arterial pressure with fluid resuscitation and
vasopressors/beta-adrenergic agents if necessary.
 Consider transfer to a hyperbaric chamber. Potential benefits
of this therapy include (1) compression of existing air bubbles,
(2) establishment of a high diffusion gradient to speed
dissolution of existing bubbles, and (3) improved oxygenation
of ischemic tissues and lowered intracranial pressure.
 Circulatory collapse should be addressed with CPR and
consideration of more invasive procedures
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Thank you
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