Cardiology in Critical Care
Intra-aortic Balloon Pump
IABP

nursebob 9/22/2005

Principles of Intraaortic Balloon Pump Therapy.

The purpose of IABP is to increases the oxygen supply to allow the heart muscle to rest and improves perfusion to the coronary arteries. The Intraaortic balloon is placed within the descending aorta. As the IABP inflates and deflates it allows an increase in oxygen supply to the myocardium, decreases workload of the left ventricle and increases cardiac output and perfusion of the vital organs. The device is designed to inflate and deflate with each heart beat. The balloon will inflate during diastole causing blood to be forced back toward the extremities as well as into the coronary arteries and main branches of the aortic arch. Before systole the balloon will deflate resulting in decreased pressure within the aorta. This action result in less work for the left ventricle, to expel blood during contraction and

Counterindications of Intraaortic Balloon Pump Therapy

There are certain conditions when the IABP should not be used; aortic valve regurgitation, aortic aneurysm, severe peripheral vascular disease, coagulopathy, or end-stage heart disease not awaiting transplant.

Placement of the Intraaortic Balloon

The position of the intra-aortic balloon is critical to its effectiveness. It must be positioned in the descending thoracic aorta slightly distal to the subclavian artery. This position must be verified by chest xray. The tip of the balloon should be just below the level of the aortic knob, and should be in a straight line curving to the right. This would indicate the tip of the balloon has entered the aortic arch. Balloon sizes may varry but the Red 9.5 fr. and the Yellow 8.5 are the most common sizes used. Proper positioning is important to insure effectiveness in coronary and renal artery perfusion. Proper placement must be verified by initial and daily chest xray

Intraaortic Balloon Pump Timing

The balloon should inflate during the diastolic phase of the cardiac cycle. Counterpulsation should be achieved during deflation of the intraaortic balloon during the systolic phase of the cardiac cycle. The intraaortic balloon, identifies the R wave as a triggering event in most cases. Once the R wave has been identified the balloon pump inflates. Deflation will continue throughout the systolic phase of the cardiac cycle. During the diastolic phase of the cardiac cycle inflation occurs. By setting the inflation marker at the diacromatic notch, inflation will continue until the next R wave of the next QRS occurs.

Nursing Care of the Patient Undergoing Intraaortic Balloon Pump Therapy

1. Only nurses who have been trained in the timing and trouble shooting of the Intraaortic balloon pump should be caring for IABP patients. The Nurse/Patient ratio for a patient with an IABP is 1:1.
Rationale: This is to provide safe, consistent levels of nursing care for IABP patients. The nurse assigned to relieve for breaks will be approved to care for the patient on the IABP.

2. Ensure that a set of skin and external leads are connected and functional. Select the desired ECG source from waveform selector in the IABP controls.
Rationale: A back-up triggering mode must be readily available. Adjust trigger modes as required to ensure balloon pumping.

 

3. The ECG trigger will be used for most situations.  Pressure trigger is a sutable trigger if the ECG is temporarily lost or if the patient has no ECG rhythm and is receiving CPR. The pacemaker trigger should be avoided. After changing the trigger mode the assist button must be pressed to resume pumping.
Rationale: Trigger modes may require changing to ensure optimal balloon function. When using the pressure trigger during CPR or severe hypotension,  the pressure threshold can be reduced to ensure that the pump recognizes systolic events.  Adjust by using the arrows in the auxiliary trigger option. ECG trigger mode will work well for patients being paced.  The pacemaker trigger modes will only work for fixed rate pacing.  If the patient is in a pacemaker trigger mode, the pump will ignore native beats and only operate with paced impulses.

4. A previously prepared and zeroed transducer is connected to the aortic arterial line of the balloon and then to the IABP. This should be secured level with the patient’s mid-axillary line. This position should be rechecked hourly and with each patient repositioning.
Rationale: The pressure module provides an alternate blood pressure source in the event that the bedside monitor should fail. The IABP pressure should be the one that is treated.

5. The pressures are to be recorded on the flow sheet every hour. These include Ba. Assisted Peak Pressure. (APSP), Ba. Assisted Aortic End Diastolic Pressure (BaEDP), Diastolic Augmentation (DA), and Unassisted Aortic End diastolic pressure (EDP). The pressures from the IABP are the ones that should be treated. Unless it can be determined that the IABP is giving an inaccurate reading. Vasoactive drugs should be titrated according to the mean blood pressure (MAP) from the IABP console. The BP from the IABP console should be used when calculating hemodynamics.
Rationale: When the IABP is timed adequately the diastolic blood pressure (DBP) is augmented to be higher than the systolic blood pressure (SBP). The SBP will be the highest pressured on the bedside monitor. If the balloon is successful at augmenting the DBP above the SBP, the SBP displayed by the bedside monitor will actually be the augmented DBP

If augmentation is sub optimal, the augmented pressure may not exceed the SBP...in this case, the SBP will remain the highest pressure and will be displayed by the bedside monitor appropriately. The IABP console differentiates between the SBP, augmented pressure and end diastolic pressure.   It will also display assisted and unassisted systole and diastole if the pump is placed in 1:2 or 1:3.
Aortic and peripheral systolic and diastolic pressures are not necessarily the same; peripheral arterial lines often amplify the SBP.  Mean BP will usually correlate much more closely and is a better indicator of BP. Aortic pressure represents the central or core BP.  It is a better indicator of BP than a peripheral arterial line, as long as the aortic line is patent and displaying accurate values. Pressure trends and consistency among pressure measurements are the most important findings.

 

6. Evaluate Cardiac Output within 1 hour of any change in the assist interval.
Rationale: To assess whether the change is tolerated.

 

7. Obtain an arterial timing strip and balloon waveform q.12.h. And PRN.  Evaluate the timing and attach the tracing to the IABP record. 
Rationale: To evaluate timing and provide a record for future reference.

 

8. If the augmentation volume is reduced for the purpose of weaning, return the pump to full augmentation volume at a ratio of 1:1 for 5 minutes each hour.

Do not increase the augmentation volume if the balloon volume has been reduced due to aortic size.

Rationale: To reduce risk of platelet aggregation. Balloons that do not fully inflate are prone to vertical folds which can predispose the balloon to rupture.

Ideally, appropriately size balloons are inserted that permit full inflation.  Occasionally, patients can be temporarily vasoconstricted, necessitating balloon volume reduction.  Balloon volume increases may be possible as the patient's condition improves.

 

9. Assess capillary refill and pedal pulses q1h. Assess capillary refill and left radial pulse at the start of each shift and q1h.  Notify the physician of any change from the previous hour. Document on flow sheet and nursing note.

Rationale: The balloon catheter or thrombus can obstruct flow to the distal extremities.  If the balloon migrates too high, it can obstruct flow to the left subclavian artery.

10. Change site site dressing per CVL dressing procedure and policy for your instution.

Observe site and report any signs of infection to the physician.
Rationale: To minimize risk of infection.

 

11. The patient will have a daily chest x- ray.

Rationale: To assess position of the IAB and to assess for sign of pulmonary complications

 

12. Maintain HOB 300. Avoid hip flexion. Log roll or straight lift  for CXR.
Rationale: Hip flexion can put strain on the insertion site and cause vascular trauma. Raising the head of the bed can shorten the aorta and permit migration of the IABP catheter. Ideally, keep the HOB elevated versus supine, to reduce risk for aspiration.

 

13. Provide chest vibration to promote secretion clearance q4h - 6h and prn

Rationale: Immobility and sternal pain predispose patient to secretions and atelectasis.

 

14. Measure urinary output q1h.

Rationale: Decreased urine production can occur as a result of low cardiac output, balloon placement that is too low, prerenal failure from a thrombus, or hypotensive shock.

 

15. Perform a neurologic assessment, using the Glasgow Coma, q1h if unconscious or q. shift if the patient is awake.

Rationale: Decrease C.O., cerebral embolus or migration of IAB may impair cerebral function. ICU psychosis secondary to sensory overload/sensory deprivation/sleep deprivation is common.

 

16. Change the assist interval as required to assess the adequacy of balloon timing. Obtain an order to change the assist interval for reasons other than timing assessment. Return the patient to the previously tolerated assist control interval if signs of intolerance are observed during weaning (e.g. chest pain, hypotension, arrhythmias, ST changes).

Notify the physician if signs of intolerance are identified.

Rationale: The assist interval must be in 1:2 or 1:3 to evaluate deflation. If the patient demonstrates evidence of myocardial ischemia/dysfunction related to weaning, prompt correction must take place to prevent permanent myocardial injury.

 

17. Take corrective action when the "helium low" light illuminates.

Note that 24 fills remain from the time when the low helium light illuminates. 

Rationale: The pump automatically refills  2 hours from the last fill.  If no additional fills are initiated, the pump should continue to operate for 48 hours following a low helium alert. A IABP approved nurse may change the helium tank or switch to a new pump, if required

 

18. In the event of sudden pump failure at night, it may be much quicker to have security assess a new pump. The System 98, made by Datascope, is very easy to initiate: 

To switch pumps, transfer the helium line, pressure transducer and ECG leads from the back of the malfunctioning pump to the new pump.

Ensure that the helium tank is open (counter-clockwise) and position the inflation and deflation markers midposition initiated.

For on-line help, select the "HELP" key.

Turn the pump on.  Wait until the ready signal appears. Pumping can now be resumed.

Obtain another pump immediately in the event of pump shutdown due to a console failure.

Initiate manual inflation and deflation of the balloon if 15-20 minutes of balloon inactivity occurs.

Inflate and deflate 8-10 time per minute with air, using a volume 10 cc less than the balloon size (the balloon size is marked on the balloon catheter).  A slip lock syringe is required to fit the helium line.

Air is instilled into the lumen where helium is normally inserted. Never instill air into the aortic or arterial lumen of the catheter.

Never manually inflate a balloon if rupture is suspected.

Notify the cardiologist/cardiovascular surgeon immediately in the event of a static balloon. Manual inflation and deflation is done to prevent clot formation; there is no attempt to provide cardiac assistance with manual inflation.

The goal is to quickly expand and collapse the balloon.  The volume of air used should be 10 cc less than the size of the balloon. Rapid deflation is desired to minimize the risk of impeding ventricular outflow.  We are not attempting to mimic the pump, therefore, the timing of the balloon movement to the cardiac cycle is not important.

 

 


The following must be done each hour:

1. Every hour, fast flush on stand by to keep clots from forming at the tip of the IABP catheter.
2. Record IABP pressures hourly, these include Ba. Assisted Peak Pressure, (APSP), Ba, Assisted Aortic End Diastolic Pressure (BaEDP), Diastolic Augmentation (DA), and Unassisted Aortic End diastolic pressure (EDP).
3. Use minimal tubing necessary in the transducer to insure accuracy.
4. Listen between second and third intercostal space for placement, the sound should be in the same location. At times, the IABP can migrate from its intended location.
5. Check urine output every hour. The balloon can migrate to the renal artery.
6. Check the left radial artery.
7. Take chest Xray flat.
8. MAP most important.
9. Limb ischemia is the most common complication.
10. Keep blood pressure low.
11. If bleeding- press one inch above site. Do not press on site.


 

 

 

 

References:

1. Christenson, J.T., et al, Optimal timing of preoperative intraaortic balloon pump support in high risk coronary patients, Annals of Thoracic Surgery 1999; 68:934-939.
2. Christenson, J.T., et al, Preoperative intraaortic balloon pump therapy in high risk coronary patients - impact on post operative ionotropic drug use, Today's Therapeutic Trends 17(3);217-225, 1999.
3. Christenson, J.T., et al, European Journal of Cardiothoracic Surgery;11 (1997):1097-1103.
4. Christenson, J.T., et al, Annals of Thoracic Surgery 1997; 64: 1237-1244.

All comments and questions about content at this site should be sent to Nurse Bob

Return to Nurse Bob's™ Page 07/25/10There have been Visitors to this page.


 

Cardiology In Critical Care

IABP Intraaortic Balloon Pump

Reference Chart

IABP PRINCIPALS
Increases heart Oxygen supply. The Intra-Aortic Balloon Pump (IABP) assists the heart muscle to rest and allows and improves perfusion to the ceronary arteries.

The IABP inflates and deflates in the patients descending aorta allowing an increase in oxygen supply to the myocardium, decreases workload of the left ventricle and increases cardiac output and perfusion of the vital organs.

POSITIONING
The positioning of the balloon is crucial to its effectiveness in coronary artery and renal artery perfusion. The balloon is to be positioned in the descending thoracic aorta just distal to the subclavian artery. Determination of proper placement is made by the visualization of the tip of the baloon on CXR.

Tip should be.
-Just below level of aortic knob.
-Should be in a straight line, curving to right would indicate balloon has entered aortic arch.


COUNTERINDICATIONS
Aortic valve regurgitation.

Aortic aneurysm.
Severe PVD.
Coagulopathy.
End stage heart disease not awaiting transplant.

 

COUNTERPULSATION-HOW ITWORKS
During diastole the balloon inflates causing blood distal to the balloon to be forced back toward the extremities and proximally into the coronary arteries and main branches of the aortic arch. This increased perfusion occurs while allowing the impaired myocardium to rest. Just prior to systole the balloon deflates decreasing pressure in the aorta and making it easier for the left ventricle to contract and expel blood.

IABP TIMING
Counterpulsation achieved by deflation of the IABP during the sestolic phase of the Cardiac Cycle, and inflation during the diastolic phase of the Cycle.
The IABP identifies the R wave as a trigger event. Upon identification of the R wave the balloon deflates. Deflation will continue though the syostolic phase ef the Cardiac Cycle. Inflation occurs during the diastolic phase of the Cardiac Cycle. By setting the inflation marker at the Diacromatic Notch inflation will continue until the R wave of the next QRS.

Baloon Sizes
Red 9.5 fr.
Yellow 8.5 fr

DO THIS
1. Every hour fast flush on standby.
2. Ba. Assisted peak pressure. (APSP)
3. Ba. Assisted aortic end diastolic pressure (BaEDP)
4. Diastolic augmentation (DA)
5. Unassisted aortic end diastolic pressure (EDP)
6. Use minimal tubing.
7. Between second and third intercostal space for placement.
8. Check urine output. It can migrate to renal artery.
9. Check left rdial artery.
10. Take chest xray flat.
11. MAP most important.
12. Limb ischemia most common complication.
13. Keep blood pressure low.
14. If bleeding - press one inch above site. Dont press on site.

 


 

Procedure

Rationale

1
The Nurse:Patient ratio for a patient with an IABP is 1:1.

The nurse assigned to relieve for breaks will be approved to care for the patient on the IABP.

1
The possible complications of IABP are numerous, consequently, these patients require constant evaluation and monitoring.

The nurse responsible for the IABP must be able to maintain and troubleshoot the pump.

2
Ensure that a set of skin and external leads are connected and functional.

2
A back-up triggering mode must be readily available.

Select the desired ECG source from the Patient Waveform box on the IABP panel.

3
Adjust trigger modes as required to ensure balloon pumping.

Use ECG trigger for most situations. 

Pressure trigger is a suitable trigger if the ECG is temporarily lost or the patient has no ECG rhythm and is receiving CPR. 

Avoid the use of the pacemaker trigger modes.

Following a change in trigger mode, the assist button must be re-selected to resume pumping.

3
Trigger modes may require changing to ensure optimal balloon function.

When using the pressure trigger during CPR or severe hypotension,  the pressure threshold can be reduced to ensure that the pump recognizes systolic events.  Adjust by using the arrows in the auxiliary trigger option. 

ECG trigger mode will work well for patients being paced.  The pacemaker trigger modes will only work for fixed rate pacing.  If the patient is in a pacemaker trigger mode, the pump will ignore native beats and only operate with paced impulses.

4
Connect the previously prepared transducer to the aortic arterial line (balloon lumen)  to the Datascope pump.

Tape aortic line pressure transducer to the patient level with the mid-axillary line.

Check the transducer position hourly, to ensure that it is level with the mid-axillary line.

Monitoring of the aortic line by the Datascope enables rapid transport of patients while on the IABP.

The Datascope pressure module provides an alternate BP source in the event that the bedside monitor should fail.

Avoid taping the transducer to the IABP or mounting on the IV pole, as it is too difficult to accurately level the transducer. 

5
Monitor and record pressures obtained from the Datascope monitor on the flow sheet hourly. Unless it is determined that the aortic BP is not accurate.

Titrate drugs to a desired MEAN BP obtained from the Datascope monitor. Use the BP obtained from the Datascope pump when calculating hemodynamics.

5
With optimal balloon inflation, the DBP is augmented to become higher than the SBP.

The bedside monitor displays the SBP as the highest pressure measured. 

If the balloon is successful at augmenting the DBP above the SBP, the SBP displayed by the bedside monitor will actually be the augmented DBP

If augmentation is sub optimal, the augmented pressure may not exceed the SBP...in this case, the SBP will remain the highest pressure and will be displayed by the bedside monitor appropriately.

The Datascope console differentiates between the SBP, augmented pressure and end diastolic pressure.   It will also display assisted and unassisted systole and diastole if the pump is placed in 1:2 or 1:3.

Aortic and peripheral systolic and diastolic pressures are not necessarily the same; peripheral arterial lines often amplify the SBP.  Mean BP will usually correlate much more closely and is a better indicator of BP.

Aortic pressure represents the central or core BP.  It is a better indicator of BP than a peripheral arterial line, as long as the aortic line is patent and displaying accurate values.

Pressure trends and consistency among pressure measurements are the most important findings.

6
Evaluate Cardiac Output within 1 hour of any change in the assist interval.

6
To assess whether the change is tolerated

7
Obtain an arterial timing strip and balloon waveform q.12.h. and prn

Evaluate the timing and attach the tracing to the IABP record. 

7
To evaluate timing and provide a record for future reference.

8
If the augmentation volume is reduced for the purpose of weaning, return the pump to full augmentation volume at a ratio of 1:1 for 5 minutes each hour.

Do not increase the augmentation volume if the balloon volume has been reduced due to aortic size.

8
To reduce risk of platelet aggregation.

Balloons that do not fully inflate are prone to vertical folds which can predispose the balloon to rupture.

Ideally, appropriately size balloons are inserted that permit full inflation.  Occasionally, patients can be temporarily vasoconstricted, necessitating balloon volume reduction.  Balloon volume increases may be possible as the patient's condition improves.

9
Assess capillary refill and pedal pulses q1h.

Assess capillary refill and left radial pulse at the start of each shift and q1h. 

Notify the physician of any change from the previous hour. Document on flow sheet and nursing note.

9
The balloon catheter or thrombus can obstruct flow to the distal extremities. 

If the balloon migrates too high, it can obstruct flow to the left subclavian artery.

10
Change site site dressing per CVL dressing procedure and policy for your instution.

Observe site and report any signs of infection to the physician

10
To minimize risk of infection.

11
The patient will have a daily chest x- ray.

11
To assess position of the IAB and to assess for sign of pulmonary complications.

12
Maintain HOB 300

Avoid hip flexion. 

Log roll or straight lift  for CXR.

12
Hip flexion
can put strain on the insertion site and cause vascular trauma.

Raising the head of the bed can shorten the aorta and permit migration of the IABP catheter.

Ideally, keep the HOB elevated versus supine, to reduce risk for aspiration.

13
Provide chest vibration to promote secretion clearance q4h - 6h and prn

13
Immobility and sternal pain predispose patient to secretions and atelectasis.

14
Measure urinary output q1h.

14
Decreased urine production
can occur as a result of low cardiac output, balloon placement that is too low, prerenal failure from a thrombus, or hypotensive shock.

15
Perform a neurologic assessment, using the Glasgow Coma, q1h if unconscious or q. shift if the patient is awake.

15
Decrease C.O., cerebral embolus or migration of IAB may impair cerebral function. ICU psychosis secondary to sensory overload/sensory deprivation/sleep deprivation is common.

16
Change the assist interval as required to assess the adequacy of balloon timing.

Obtain an order to change the assist interval for reasons other than timing assessment.

Return the patient to the previously tolerated assist control interval if signs of intolerance are observed during weaning (e.g. chest pain, hypotension, arrhythmias, ST changes).

Notify the physician if signs of intolerance are identified

16
The assist interval must be in 1:2 or 1:3 to evaluate deflation.

If the patient demonstrates evidence of myocardial ischemia/dysfunction related to weaning, prompt correction must take place to prevent permanent myocardial injury.

 

17
Take corrective action when the "helium low" light illuminates.

Note that 24 fills remain from the time when the low helium light illuminates. 

17
The pump automatically refills  2 hours from the last fill.  If no additional fills are initiated, the pump should continue to operate for 48 hours following a low helium alert.

18
A IABP approved nurse may change the helium tank or switch to a new pump, if required.

18
In the event of sudden pump failure at night, it may be much quicker to have security assess a new pump.

The System 98 is very easy to initiate: 

         To switch pumps, transfer the helium line, pressure transducer and ECG leads from the back of the malfunctioning pump to the new pump.

         Ensure that the helium tank is open (counter-clockwise) and position the inflation and deflation markers midposition

         Turn the pump on.  Wait until the ready signal appears. Pumping can now be initiated.

         For on-line help, select the "HELP" key.

  • Obtain another pump immediately in the event of pump shutdown due to a console failure.
  • Initiate manual inflation and deflation of the balloon if 15-20 minutes of balloon inactivity occurs.
  • Inflate and deflate 8-10 time per minute with air, using a volume 10 cc less than the balloon size (the balloon size is marked on the balloon catheter).  A slip lock syringe is required to fit the helium line.
  • Air is instilled into the lumen where helium is normally inserted. NEVER instill air into the aortic (arterial) lumen of the catheter.
  • Never manual inflate a balloon if rupture is suspected.

Notify the cardiologist/cardiovascular surgeon immediately in the event of a static balloon.

  • Manual inflation and deflation is done to prevent clot formation; there is no attempt to provide cardiac assistance with manual inflation.
  • The goal is to quickly expand and collapse the balloon.  The volume of air used should be 10 cc less than the size of the balloon. Rapid deflation is desired to minimize the risk of impeding ventricular outflow. 


 N.B.we are not attempting to mimic the pump, therefore, timing of balloon movement to the cardiac cycle is not important. 

 

 

 

 

 

 

 

 

 

 

 

 

1. Christenson, J.T., et al, Optimal timing of preoperative intraaortic balloon pump support in high risk coronary patients, Annals of Thoracic Surgery 1999; 68:934-939.
2. Christenson, J.T., et al, Preoperative intraaortic balloon pump therapy in high risk coronary patients - impact on post operative ionotropic drug use, Today's Therapeutic Trends 17(3);217-225, 1999.
3. Christenson, J.T., et al, Evaluation of preoperative intra-aortic balloon pump support in high risk coronary patients. European Journal of Cardiothoracic Surgery;11 (1997):1097-1103.
4. Christenson, J.T., et al, Preoperative intra-aortic balloon pump enhances cardiac performance and improves the outcome of redo CABG, Annals of Thoracic Surgery 1997; 64: 1237-1244.

There have been Visitors to this page. This page last updated 07/25/10All comments and questions about content at this site should be sent to nursebob@nursebob.com
Return to Nurse Bob's Page

Cardiology In Critical Care

IABP Intraaortic Balloon Pump

IABP PRINCIPALS
Increases heart Oxygen supply. The Intra-Aortic Balloon Pump (IABP) assists the heart muscle to rest and allows and improves perfusion to the ceronary arteries.

The IABP inflates and deflates in the patients descending aorta allowing an increase in oxygen supply to the myocardium, decreases workload of the left ventricle and increases cardiac output and perfusion of the vital organs.

POSITIONING
The positioning of the balloon is crucial to its effectiveness in coronary artery and renal artery perfusion. The balloon is to be positioned in the descending thoracic aorta just distal to the subclavian artery. Determination of proper placement is made by the visualization of the tip of the baloon on CXR.

Tip should be.
-Just below level of aortic knob.
-Should be in a straight line, curving to right would indicate balloon has entered aortic arch.


COUNTERINDICATIONS
Aortic valve regurgitation.

Aortic aneurysm.
Severe PVD.
Coagulopathy.
End stage heart disease not awaiting transplant.

 

COUNTERPULSATION-HOW ITWORKS
During diastole the balloon inflates causing blood distal to the balloon to be forced back toward the extremities and proximally into the coronary arteries and main branches of the aortic arch. This increased perfusion occurs while allowing the impaired myocardium to rest. Just prior to systole the balloon deflates decreasing pressure in the aorta and making it easier for the left ventricle to contract and expel blood.

IABP TIMING
Counterpulsation achieved by deflation of the IABP during the sestolic phase of the Cardiac Cycle, and inflation during the diastolic phase of the Cycle.
The IABP identifies the R wave as a trigger event. Upon identification of the R wave the balloon deflates. Deflation will continue though the syostolic phase ef the Cardiac Cycle. Inflation occurs during the diastolic phase of the Cardiac Cycle. By setting the inflation marker at the Diacromatic Notch inflation will continue until the R wave of the next QRS.

Baloon Sizes
Red 9.5 fr.
Yellow 8.5 fr

DO THIS
1. Every hour fast flush on standby.
2. Ba. Assisted peak pressure. (APSP)
3. Ba. Assisted aortic end diastolic pressure (BaEDP)
4. Diastolic augmentation (DA)
5. Unassisted aortic end diastolic pressure (EDP)
6. Use minimal tubing.
7. Between second and third intercostal space for placement.
8. Check urine output. It can migrate to renal artery.
9. Check left rdial artery.
10. Take chest xray flat.
11. MAP most important.
12. Limb ischemia most common complication.
13. Keep blood pressure low.
14. If bleeding - press one inch above site. Dont press on site.


Procedure

Rationale

1
The Nurse:Patient ratio for a patient with an IABP is 1:1.

The nurse assigned to relieve for breaks will be approved to care for the patient on the IABP.

1
The possible complications of IABP are numerous, consequently, these patients require constant evaluation and monitoring.

The nurse responsible for the IABP must be able to maintain and troubleshoot the pump.

2
Ensure that a set of skin and external leads are connected and functional.

2
A back-up triggering mode must be readily available.

Select the desired ECG source from the Patient Waveform box on the IABP panel.

3
Adjust trigger modes as required to ensure balloon pumping.

Use ECG trigger for most situations. 

Pressure trigger is a suitable trigger if the ECG is temporarily lost or the patient has no ECG rhythm and is receiving CPR. 

Avoid the use of the pacemaker trigger modes.

Following a change in trigger mode, the assist button must be re-selected to resume pumping.

3
Trigger modes may require changing to ensure optimal balloon function.

When using the pressure trigger during CPR or severe hypotension,  the pressure threshold can be reduced to ensure that the pump recognizes systolic events.  Adjust by using the arrows in the auxiliary trigger option. 

ECG trigger mode will work well for patients being paced.  The pacemaker trigger modes will only work for fixed rate pacing.  If the patient is in a pacemaker trigger mode, the pump will ignore native beats and only operate with paced impulses.

4
Connect the previously prepared transducer to the aortic arterial line (balloon lumen)  to the Datascope pump.

Tape aortic line pressure transducer to the patient level with the mid-axillary line.

Check the transducer position hourly, to ensure that it is level with the mid-axillary line.

Monitoring of the aortic line by the Datascope enables rapid transport of patients while on the IABP.

The Datascope pressure module provides an alternate BP source in the event that the bedside monitor should fail.

Avoid taping the transducer to the IABP or mounting on the IV pole, as it is too difficult to accurately level the transducer. 

5
Monitor and record pressures obtained from the Datascope monitor on the flow sheet hourly. Unless it is determined that the aortic BP is not accurate.

Titrate drugs to a desired MEAN BP obtained from the Datascope monitor. Use the BP obtained from the Datascope pump when calculating hemodynamics.

5
With optimal balloon inflation, the DBP is augmented to become higher than the SBP.

The bedside monitor displays the SBP as the highest pressure measured. 

If the balloon is successful at augmenting the DBP above the SBP, the SBP displayed by the bedside monitor will actually be the augmented DBP

If augmentation is sub optimal, the augmented pressure may not exceed the SBP...in this case, the SBP will remain the highest pressure and will be displayed by the bedside monitor appropriately.

The Datascope console differentiates between the SBP, augmented pressure and end diastolic pressure.   It will also display assisted and unassisted systole and diastole if the pump is placed in 1:2 or 1:3.

Aortic and peripheral systolic and diastolic pressures are not necessarily the same; peripheral arterial lines often amplify the SBP.  Mean BP will usually correlate much more closely and is a better indicator of BP.

Aortic pressure represents the central or core BP.  It is a better indicator of BP than a peripheral arterial line, as long as the aortic line is patent and displaying accurate values.

Pressure trends and consistency among pressure measurements are the most important findings.

6
Evaluate Cardiac Output within 1 hour of any change in the assist interval.

6
To assess whether the change is tolerated

7
Obtain an arterial timing strip and balloon waveform q.12.h. and prn

Evaluate the timing and attach the tracing to the IABP record. 

7
To evaluate timing and provide a record for future reference.

8
If the augmentation volume is reduced for the purpose of weaning, return the pump to full augmentation volume at a ratio of 1:1 for 5 minutes each hour.

Do not increase the augmentation volume if the balloon volume has been reduced due to aortic size.

8
To reduce risk of platelet aggregation.

Balloons that do not fully inflate are prone to vertical folds which can predispose the balloon to rupture.

Ideally, appropriately size balloons are inserted that permit full inflation.  Occasionally, patients can be temporarily vasoconstricted, necessitating balloon volume reduction.  Balloon volume increases may be possible as the patient's condition improves.

9
Assess capillary refill and pedal pulses q1h.

Assess capillary refill and left radial pulse at the start of each shift and q1h. 

Notify the physician of any change from the previous hour. Document on flow sheet and nursing note.

9
The balloon catheter or thrombus can obstruct flow to the distal extremities. 

If the balloon migrates too high, it can obstruct flow to the left subclavian artery.

10
Change site site dressing per CVL dressing procedure and policy for your instution.

Observe site and report any signs of infection to the physician

10
To minimize risk of infection.

11
The patient will have a daily chest x- ray.

11
To assess position of the IAB and to assess for sign of pulmonary complications.

12
Maintain HOB 300

Avoid hip flexion. 

Log roll or straight lift  for CXR.

12
Hip flexion
can put strain on the insertion site and cause vascular trauma.

Raising the head of the bed can shorten the aorta and permit migration of the IABP catheter.

Ideally, keep the HOB elevated versus supine, to reduce risk for aspiration.

13
Provide chest vibration to promote secretion clearance q4h - 6h and prn

13
Immobility and sternal pain predispose patient to secretions and atelectasis.

14
Measure urinary output q1h.

14
Decreased urine production
can occur as a result of low cardiac output, balloon placement that is too low, prerenal failure from a thrombus, or hypotensive shock.

15
Perform a neurologic assessment, using the Glasgow Coma, q1h if unconscious or q. shift if the patient is awake.

15
Decrease C.O., cerebral embolus or migration of IAB may impair cerebral function. ICU psychosis secondary to sensory overload/sensory deprivation/sleep deprivation is common.

16
Change the assist interval as required to assess the adequacy of balloon timing.

Obtain an order to change the assist interval for reasons other than timing assessment.

Return the patient to the previously tolerated assist control interval if signs of intolerance are observed during weaning (e.g. chest pain, hypotension, arrhythmias, ST changes).

Notify the physician if signs of intolerance are identified

16
The assist interval must be in 1:2 or 1:3 to evaluate deflation.

If the patient demonstrates evidence of myocardial ischemia/dysfunction related to weaning, prompt correction must take place to prevent permanent myocardial injury.

 

17
Take corrective action when the "helium low" light illuminates.

Note that 24 fills remain from the time when the low helium light illuminates. 

17
The pump automatically refills  2 hours from the last fill.  If no additional fills are initiated, the pump should continue to operate for 48 hours following a low helium alert.

18
A IABP approved nurse may change the helium tank or switch to a new pump, if required.

18
In the event of sudden pump failure at night, it may be much quicker to have security assess a new pump.

The System 98 is very easy to initiate: 

         To switch pumps, transfer the helium line, pressure transducer and ECG leads from the back of the malfunctioning pump to the new pump.

         Ensure that the helium tank is open (counter-clockwise) and position the inflation and deflation markers midposition

         Turn the pump on.  Wait until the ready signal appears. Pumping can now be initiated.

         For on-line help, select the "HELP" key.

  • Obtain another pump immediately in the event of pump shutdown due to a console failure.
  • Initiate manual inflation and deflation of the balloon if 15-20 minutes of balloon inactivity occurs.
  • Inflate and deflate 8-10 time per minute with air, using a volume 10 cc less than the balloon size (the balloon size is marked on the balloon catheter).  A slip lock syringe is required to fit the helium line.
  • Air is instilled into the lumen where helium is normally inserted. NEVER instill air into the aortic (arterial) lumen of the catheter.
  • Never manual inflate a balloon if rupture is suspected.

Notify the cardiologist/cardiovascular surgeon immediately in the event of a static balloon.

  • Manual inflation and deflation is done to prevent clot formation; there is no attempt to provide cardiac assistance with manual inflation.
  • The goal is to quickly expand and collapse the balloon.  The volume of air used should be 10 cc less than the size of the balloon. Rapid deflation is desired to minimize the risk of impeding ventricular outflow. 


 N.B.we are not attempting to mimic the pump, therefore, timing of balloon movement to the cardiac cycle is not important. 

 

 

 

 

 

 

 

 

 

 

 

 

1. Christenson, J.T., et al, Optimal timing of preoperative intraaortic balloon pump support in high risk coronary patients, Annals of Thoracic Surgery 1999; 68:934-939.
2. Christenson, J.T., et al, Preoperative intraaortic balloon pump therapy in high risk coronary patients - impact on post operative ionotropic drug use, Today's Therapeutic Trends 17(3);217-225, 1999.
3. Christenson, J.T., et al, Evaluation of preoperative intra-aortic balloon pump support in high risk coronary patients. European Journal of Cardiothoracic Surgery;11 (1997):1097-1103.
4. Christenson, J.T., et al, Preoperative intra-aortic balloon pump enhances cardiac performance and improves the outcome of redo CABG, Annals of Thoracic Surgery 1997; 64: 1237-1244.

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Cardiology In Critical

Intra Aortic Balloon Pump

Patient Information

Your heart is a muscular pump with a demanding job. It must continually pump blood to every part of your body. The blood supplies oxygen, the fuel needed to support your body tissues and their functions.

Once your body’s tissues have taken the oxygen they need, the oxygen-depleted blood is returned to the two chambers on the right side of your heart. These chambers are responsible for pumping the oxygen-depleted blood into the lungs. In the lungs the blood is replenished with a fresh supply of oxygen and returned to the left side of your heart.

On the left side of your heart, two chambers are responsible for pumping the newly-oxygenated blood throughout your body once again. This oxygen-rich blood leaves your heart through the largest artery in your body, the aorta.

Of course, your heart needs its own continuous supply of fuel. This supply line of oxygen-rich blood begins a the base of the aorta, and surrounds your heart muscle in the same way the fingers of your hand wrap around a ball. This network of supply lines is called your coronary arteries.

When the heart does not have enough oxygen due to blocked coronary arteries, or other medical problems, the heart must work harder to provide the needed oxygen. Intra-aortic balloon pump therapy helps restore the balance between the supply of oxygen-rich blood the heart receives from the coronary arteries, and the amount of oxygen the heart needs to pump.

This therapy involves two components. One is a thin balloon which is positioned within your aorta after being introduced through an artery. The second component of balloon pump therapy is the pump itself. The pump continually inflates and deflates the balloon within your aorta in time with your heart beat.

The intra-aortic balloon pump assists your heart during both its rest phase and its work phase. In the rest phase, the balloon inflates, increasing the supply of oxygen-rich blood to the coronary arteries. In the work phase, the balloon deflates, decreasing the workload on your heart.

The decrease in workload results in a decrease in the amount of oxygen the heart needs to pump.

As blood is pumped, your heart is at work.
During the work phase, your heart pumps oxygen-rich blood into the aorta and out to the far reaches of your body. This task requires a large amount of oxygen. At the end of each work phase your heart has used up a large portion of the oxygen it has been given.

As chambers fill, your heart is at rest.
Your heart is in its rest phase as the chambers are filling, preparing to pump more blood. During this phase your heart muscle is able to relax. While it is resting, it is receiving a fresh supply of oxygen-rich blood through your coronary arteries.

When the balloon deflates, your heart’s workload is reduced.
Just before your heart gets ready to work, the balloon within your aorta deflates. This deflation results in a drop in pressure in the aorta, so that when your heart pumps it doesn’t have to work against high pressure. Instead, your heart’s workload is actually reduced, and blood is pumped throughout your body more easily.

When the balloon inflates, your heart receives more oxygen.
When your heart is in its rest phase, and receiving its fresh supply of blood, the balloon placed within your aorta is inflated by the pump at your bedside. This process pushes more oxygen-rich blood through your coronary artery supply network and into your heart’s muscle tissue, providing your tired heart with extra energy for its work phase.

Relax…
Help us help you by keeping calm and making us aware of any changes in your condition.

Cough and deep breathe frequently

Report any chest pain or heaviness to a nurse or physician.

Report any pain, numbness, or tingling to a nurse or physician.

Bed rest is important…
Don’t sit up, attempt to get out of bed, or flex or bend the leg in which the balloon catheter is inserted, as these activities can interfere with the proper functioning of the balloon.

And
Don’t be concerned when the balloon pump stops, because your heart is continuously beating for itself. At pre-programmed intervals, the balloon pump will stop pumping for a brief period of time. Your heart will continue pumping. And remember too, that a nurse or health care professional trained in the operation of the balloon pump will be monitoring the machine throughout your period of therapy.

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