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H E A L T H

Intensive Care
Evidence Based Practice Guidelines
2004

Intra Aortic Balloon Pump (IABP)

Indications: : Intra-aortic balloon pump therapy is used
to improve coronary artery perfusion and to decrease left ventricular afterload. A specialised arterial catheter, which has a helium filled balloon is inserted percutaneously into the descending aorta. This catheter is attached to the IABP which pumps helium into the balloon during ventricular diastole (thereby increasing myocardial perfusion) draws back the helium prior to ventricular systole (thereby decreasing ventricular afterload). IABP increases myocardial and systemic blood flow in the following incidences: LV failure, unstable refactory angina, septic shock, mechanical complications secondary to AMI, bridge to cardiac transplantation, valvular disease, prophylaxis prior to cardiac surgery, post cardiac surgery cardiogenic shock and provides support for failed angioplasty and valvuloplasty.

Fig 1 Intra Aortic Balloon Pump (IABP)

Contraindications:
Severe aortic insufficiency as the balloon inflates, blood may be forced across the valve thereby overloading the ventricle and increasing cardiac work. Aortic aneurysm the increased pressure generated by counterpulsation may cause the aneurysm to rupture. Severe peripheral vascular disease may limit the ability to advance the catheter through atherosclerotic vessels. Severe coagulopathy

Complications:
Limb ischaemia due to occlusion of the femoral artery either by the catheter or by emboli from thrombus formation on the balloon Aortic dissection during insertion or rupture during pumping Haemorrhage from insertion site Helium emboli from the balloon Infection at site of insertion or catheter related

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H E A L T H

Intensive Care Evidence Based Practice Guidelines

2004

Intra Aortic Baloon Pump (IABP)

Equipment: Insertion kit (introducer & sheath), intra-aortic balloon and console
ECG/pressure cable from external source into the IABP console Pressure monitoring set-up (transducer, pressure cable, saline, pressure bag) Major procedure tray, gowns, gloves, masks, goggles 10 ml syringe, 21 gauge needle, lignocaine 1% or 2% (without adrenaline) Sutures & sterile transparent dressing

Procedure:
Check the patients coagulation results Explain the procedure to the patient Wash hands, gather equipment, connect patient to monitor Baseline patient assessment: colour, temperature, capillary refill, pulses & sensation/movement of both legs Check that patient has patent IV access for administration of sedatives and emergency drugs Set-up pressure monitoring system to be connected to the central lumen of the catheter and the pump console. The arterial pressure waveform should appear on the monitor. Set initial timing for inflation & deflation C pressure artifact/positive overload B IAB inflation E IAB deflation A fill pressure baseline (10-15 MM Hg)

D plateau pressure

F vacuum artifact/negative undershoot

Fig 2. Normal balloon pressure waveform

Low balloon pressure plateau could be caused by hypotension, hypovolaemia, low systemic vascular resistance, low balloon inflation volume, a balloon sized too small for the pt or positioned too low in the aorta.
Fig 3. Low balloon pressure plateau

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H E A L T H

Intensive Care Evidence Based Practice Guidelines

2004

Intra Aortic Baloon Pump (IABP)

High balloon pressure plateau may be caused by hypertension, a balloon too large for the aorta, or a restriction to gas flow within the system. The top of the plateau may be squared or rounded.

Fig 4. High balloon pressure plateau

Balloon pressure baseline elevation may be caused by a restriction of gas flow or gas system overpressurisation

Fig 5. Balloon pressure baseline elevation

Balloon pressure baseline depression usually indicates a helium leak. Other possible causes not related to helium leak include inappropriate timing settings (early inflation or late deflation) that do not permit enough time for gas to return to the console or a mechanical defect that causes failure to autofill.

Fig 6. Balloon pressure baseline depression

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H E A L T H

Intensive Care Evidence Based Practice Guidelines

2004

Intra Aortic Baloon Pump (IABP)

Setting Triggering & Timing:

For the IABP to pump effectively, two waveforms need to be set. The ECG signal to trigger the balloon and the arterial pressure signal to time the counterpulsation. The arterial waveform, a less reliable trigger, uses the systolic upstroke. The trigger allows the pump to identify the start of the cardiac cycle. The pump looks for the R wave to signal the onset of systole If an ECG is unreliable, the arterial pressure waveform can be used as a trigger whilst the ECG trace is optimised. Once the trigger is set, the arterial pressure waveform displayed on the console is used to assess timing and the effectiveness of pumping. Timing: Set the mode to 1:2 Compare the unassisted cardiac cycle with PDP peak diastolic pressure the assisted (augmented) cycle. Augmentation Unassisted systole Assisted systole There is a sharp V on the waveform at the dicrotic notch (DN). The dicrotic notch is when the aortic valve closes this Fig 7 Optimal inflation timing is the point at which the intra-aortic balloon starts to inflates. Inflation of the balloon is timed to occur at the dicrotic notch (aortic valve closure) on the arterial pressure tracing. As the balloon inflates and the pressure rises there will be an upward deflection following the dicrotic notch, referred to as diastolic augmentation and represents the pressure produced early in diastole by the inflated balloon. Because inflation increases pressure in the aorta, the peak of diastolic augmentation is higher than the peak of systole. As the balloon deflates the assisted aortic end diastolic pressure (pressure in the aorta) at the end of diastole dips down to create a U or V shaped wave form.

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H E A L T H
Timing continued: In early balloon inflation, the upstroke (arrow) of peak diastolic pressure occurs approx 9 little squares before the onset of systole.

Intensive Care Evidence Based Practice Guidelines

2004

Intra Aortic Baloon Pump (IABP)

Fig 8 Early balloon inflation

In late balloon inflation a significant portion of the dicrotic notch (arrows) is visible.

Fig 9 Late balloon inflation

In early deflation, note the U shape rather than V shape of the waveform and indication of a brief shelf (arrow) before the next systole.

Fig 10 Early balloon deflation

In late deflation, the balloon remains partly or completely inflated at the beginning of the next systole. Note the balloon assisted aortic end-diastolic pressure (arrow) is greater than the unassisted pressure.
Late deflation is an extremely dangerous timing error because the LV must eject against the resistance imposed by the inflated balloon. Fig 11 Late balloon deflation Assisted aortic end-diastolic pressure

Peak

Unassisted aortic enddiastolic pressure

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H E A L T H

Intensive Care Evidence Based Practice Guidelines

2004

Intra Aortic Baloon Pump (IABP)

Nursing Care:
Transduce the aortic arterial line (balloon lumen) to the Datascope pump and level with the patients mid-axillary line. For arterial flush bag use normal saline 500mls with heparin 1,000 u/s. Hourly monitoring of: heart rate and rhythm record systolic/diastolic/mean arterial pressures and diastolic augmentation (Use the BP obtained from the Datascope pump when titrating drugs) pedal pulses distal to the catheter site (Doppler may be necessary to assess pulse) L) radial pulse (If the catheter migrates forward it could compromise blood flow to the L) subclavian artery). colour, temperature and capillary refill sensation and movement of both lower extremities. Patient to be log rolled or jordan lifted and the end of the bed elevated no more than 300 to prevent catheter migration and arterial puncture. Careful monitoring of renal function (The catheter sits above the bifurcation of the renal arteries - backward migration may compromise blood flow to the kidneys). The balloon should not remain immobile for >20 minutes while insitu due to risk of thrombus formation. Assess insertion site each shift for redness, ooze Change dressing prn Carefully monitor the insertion site for signs of bleeding, infection, haematoma, or compartment syndrome of the affected limb. Heparinisation according to protocol may be initiated at 24 hours.

Weaning:
Counterpulsation may be reduced from 1:1 to 1:2 and finally 1:3 depending on the patients haemodynamics Do not set the pump at 1:3 unless for weaning and prior to removal. There is an increased risk of thrombus formation at counterpulsation of 1:3

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H E A L T H

Intensive Care Evidence Based Practice Guidelines

2004

Intra Aortic Baloon Pump (IABP)

Removal:
Balloon catheters are removed by medical officers experienced in this procedure. When the catheter is removed, allow a very small volume of arterial bleed to occur to expel any small clots. Apply a pressure device eg Fem-stop to provide continuous pressure to the site for at least 30 minutes. Then cover site with a sandbag for 2-4 hours (with frequent checks for signs of bleeding). Contact Cardiology CNC in hours or A5a/b after hours for assistance if required.

Cardiac Arrest:
Switch to pressure triggering once pump alarms due to loss of ECG rhythm (remember to select "assist" after changing trigger modes). Reduce the pressure threshold if balloon fails to pump from pressure trigger (decrease arrows in auxiliary box under trigger options). The balloon pump does not need to be disconnected during defibrillation. If CPR cannot generate a consistent and reliable trigger, then switch to INTERNAL mode which will maintain movement of the IAB and therefore reduce the risk of thrombus formation.

WARNING: The use of INTERNAL trigger will produce asynchronous counterpulsation and should never be used in the event that the patient has an ECG or arterial pressure source available. Once the ECG or arterial signal has been reestablished, the trigger mode must be changed from INTERNAL to an acceptable patient trigger.

References: 1. Intra-aortic balloon pump learning package and resource file. Westmead Hospital. 2. The concepts of Intra-aortic balloon pumpimg. Datascope clinical support services, 1999. Datascope Medical Co. Ltd. 3. McVeigh, J.P., 1999. Principles and physiological effects of the intra-aortic balloon pump. NSW College of Nursing. 4. Staniatis, S.J., & Spandoni. S.M., 1997. Getting to the heart of IABP Therapy, RN.

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