2820Intra-Aortic Balloon Pump Counterpulsation1I

7/27/2019 2820Intra-Aortic Balloon Pump Counterpulsation1I

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In tra-aort ic Bal loon Pump

Counterpulsat ion

10/16/20131

Aidah Abu Elsoud Alkaiss i

RN, BSN, MSN, PhD


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Intraoperative Transesophageal Echocardiographic Imaging of an

Intra-aorticBalloon 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 thistransthoracic 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.

Journal of Cardiothoracic and Vascular Anesthesia, Vol

17, No 6 (December), 2003: pp 736-739

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From the Section of Cardiology and CardiovascularSurgery, Norfolk General Hospital and

EasternVirginia 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 threatenedby a single lesion. In an effort to preserve threatened left ventricular myocardium, intra-

aortic 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

prophylactic intra-aortic balloon pumping is a low risk procedure that should be utilized10/16/2013

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Objectives

Demonstrate a basic understanding of the purposeand desired outcomes of IABP

Identify key patient safety issues associated with theuse and monitoring of IABP

Describe nursing interventions related to IABP useand monitoring

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IABP PURPOSE

Improves cardiac function during cardiogenic

shock.

26-28 cm balloon surrounds end of centrallyplaced 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 tomanage) 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 BalloonCounterpulsation system is avolume displacement device.

A device used to reduce leftventricular systolic work, leftventricular end-diastolic

pressure, and wall tension

Decreases oxygen consumption

Increases cardiac output,perfusion, pressure and volume

to Coronary Artries 10/16/201314


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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 thedescending aorta via the

femoral artery either

percutaneously or by surgical

cut-down.

The balloon rapidly deflates

just before ventricular systole

to reduce the impedance (Ameasure of the total

opposition to current flow in

an alternating current circuit)

to left ventricular ejection10/16/201317
http://classes.kumc.edu/cahe/respcared/cabgcs/cabgdis.htmlhttp://classes.kumc.edu/cahe/respcared/cabgcs/cabgdis.htmlhttp://classes.kumc.edu/cahe/respcared/cabgcs/cabgdis.htmlhttp://classes.kumc.edu/cahe/respcared/cabgcs/cabgdis.html


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It consists of a catheterand a drive console.

The catheter has a longballoon mounted on theend.

It should be positionedso that the tip isapproximately 1 to 2 cmbelow the origin of theleft subclavian arteryand above the renalarteries.

On chest x-ray the tipshould be visible in

the 2nd or 3rd 10/16/201318


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Surgical Indications

Post Surgical Myocardial Dysfunction

Support for weaning from Cardiopulmonary Bypass(CPB)

Cardiac support following correction of anatomicaldefects

Maintenance of graft patency post CABG

Pulsatile flow during CPB 10/16/201319


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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 inchanges in inflation and deflation hemodynamics

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Insertion TechniquesA percutaneous placement of the IAB via the femoral

artery using a modified Seldinger technique (aneedle 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 placement of an 8 to 10,5Fr dilator/sheath

combination. Only the dilator needs to be removed10/16/201321
http://www.biology-online.org/dictionary/Needlehttp://www.biology-online.org/dictionary/Puncturehttp://www.biology-online.org/dictionary/Structurehttp://www.biology-online.org/dictionary/Guidehttp://www.biology-online.org/dictionary/Wirehttp://www.biology-online.org/dictionary/Placehttp://www.biology-online.org/dictionary/Placehttp://www.biology-online.org/dictionary/Wirehttp://www.biology-online.org/dictionary/Guidehttp://www.biology-online.org/dictionary/Structurehttp://www.biology-online.org/dictionary/Puncturehttp://www.biology-online.org/dictionary/Needle


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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 sothat the entire sheath is out of the arterial lumen

to minimize risk of ischemic complications to the

distal extremity.10/16/201323


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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 proximalportion of said inner tube

disposed within the outer tube

and a distal portion of said

inner tube extending beyond adistal end of the outer tube, the

tip, a distal end of the inner

tube, and a distal end of the

balloon membrane are 10/16/201325


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Arterial Pressure

Balloon Pump

Console 10/16/201326


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Inflation

It inflates immediately

following aortic valve

closure to to augmentdiastolic coronary

perfusion pressure.

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the intra-aortic balloon positioned inthe descending thoracic aorta, just

below the left subclavian artery, but

above the renal arteries.

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Inflation of IABP Causes

1. Increased coronaryperfusion pressure

2. Increased systemic

perfusion pressure3. Increased O2 supply

to both the coronaryand peripheral tissue

4. Increasedbaroreceptorresponse

5. Decreasedsympatheticstimulation causingdecreased HeartRate, decreased

Systemic Vascular 10/16/201332


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Deflation

The balloon rapidlydeflates just beforeventricular systole toreduce Left Ventricularwork

Deflation creates a"potential space" in theaorta, reducing aortic

volume and pressure

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Deflation of the IABPCauses

1. Afterload reduction and

therefore a reduction in

myocardial oxygen

consumption (MVO2)

2. Reduction in peak systolic

pressure, therefore a reduction

in LV work

3. Increased Cardiac Output

4. Improved ejection fraction

(The amount of blood pumped

out of a

ventricle during each heartbeat. The ejection fraction10/16/201334

Factors Affecting Diastolic


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Factors Affecting Diastolic

Augmentation

1. Patient Hemodynamics

Heart Rate

Stroke Volume Mean Arterial Pressure

Systemic Vascular Resistance

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R i f A t i l P


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Review of Arterial Pressure

Landmarks

AVO = Aortic valveopens, beginning of

systole

PSP = Peak systolicpressure, 65-75% of

stroke volume has been

delivered

DN = Dicrotic notch,

signifies aortic valve

closure and the

be innin of diastole10/16/201338


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R i f A t i l P


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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 10/16/201340


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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 triggersignal before balloon pumping can begin

The computer in the IAB console needs astimulus to cycle the pneumatic system, which

inflates and deflates the balloon

The trigger signal tells the computer that anothercardiac cycle has begun

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Trigger Loss

The console MUST see a trigger to initiate aninflate/deflate cycle

If no trigger is seen when the clinician attempts tostart pumping, no pumping will occur and analarm 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 10/16/201344


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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 beselected until the ECG is re-established

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Poor ECG Choices

Note: changing QRSmorphology may causewandering timing

Note: tall T waves may cause

double triggering or may alterpreviously set timing points

Note: wandering baseline maycause skipped trigger

Note: artifact may causeinappropriate triggering

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Triggering on the Arterial


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Triggering on the Arterial

Pressure Waveform

Arterial pressure provides another signal to theIABP to determine where the cardiac cycle beginsand ends

It is used when the ECG has too muchinterference from patient movement or poor leadconnection

There are limitations to triggering on the arterialpressure curve Therefore AP tr igger should be con sidered a backuptr igger and no t the one used as the pr imary tr igger

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TIMING and WEANING

Balloon synchronization starts usually at a beatratio of 1:2.

This ratio facilitates comparison between thepatients own ventricular beats and augmented

beats to determine ideal IABP timing.

Errors in timing of the IABP may result in differentwaveform characteristics and a various number of

physiologic effects.

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Abnormal Waveform Variation: Wide

Inf lat ion and /or Deflat ion A rt i fact

Note the wide inf lat ion anddeflat ion art ifacts.

This is general ly ind icat iveof someth ing impeding therapid inf lat ion and deflat ionof the IAB , such as k inkingof the gas lumen.

This may resul t in pooraugmentat ion and/or poo rafter load reduct ion .

It may also lead tohel ium/gas loss alarms in

higher Heart Rates when ina 1:1 ass ist r atio. It mayprecede highpressu re/kink ed l inealarms.

The goal is to el im inate thepart ial obs truc t ion, i f

pos sible, to enable the10/16/2013 58


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Abnormal Waveform Variation: Hel ium Loss /

Gas Loss / Gas Leakage A larms

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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Potential Side Effects and


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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 limb10/16/201367


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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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Aortic wall dissection, rupture or local vascularinjury

Care as indicated

Emboli: thrombus, plaque or air

Care as indicated

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Infection

Check catheter insertion site often

STRICT ASEPTIC TECHNIQUE

Restrict movement while IABP in place

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Obstruction

Malposition

Too high obstruction of left subclavian, carotids

CHECK LEFT RADIAL ARTERY PULSE

Too low obstruction of renal and mesentericarteries

MONITOR URINE OUTPUT

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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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Hematologic

ALL PATIENTS Typed & Crossmatched!!!

Bleeding

REMOVE THE DRESSING!!!

PUT ON STERILE GLOVES!!!

HOLD PRESSURE!!!

Thrombocytopenia

Routine monitoring10/16/201375


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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 surgicalintervention 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.10/16/201380

Maintain systemic arterial pressure with fluid


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a ta syste c a te a p essu e t u d

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 invasive10/16/201381


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2820Intra-Aortic Balloon Pump Counterpulsation1I

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