Professional Documents
Culture Documents
Weaning
Complications
Troubleshooting machine problems
Pretest
22. How would you tell if your IAB catheter had ruptured? What procedure would
you use if this occurred?
23. In AF what is the best way to maximise therapy?
Introduction
The Intra-Aortic Balloon Pump (IABP) is a circulatory assist device that is used to
support the left ventricle. The IABP uses counterpulsation where aortic blood is
displaced with the inflation and deflation of the balloon catheter, which is timed to the
cardiac cycle. Couterpulsation provides both an augmented diastolic arterial pressure
and an decreased end-diastolic pressure. The balloon is connected to a console that
regulates the inflation or deflation of the balloon with the passage of helium. Helium
is used as it is easily dissolved in blood and prevents the risk of air emboli if the
catheter ruptures.
Indications
The IABP is used in:
Contraindications
Insertion
The balloon catheter is inserted either percutaneously or surgically by cutdown into
the patients femoral artery. The catheter can be inserted at the bedside, in a cathlab
or operating room theatre. The catheter is threaded up through the femoral artery and
located in the descending thoracic aorta, distal to the subclavian artery and proximal
to renal arteries.
IABP Size
The size of the balloon is dependent on the patients height to prevent occlusion of
sub-clavian or renal arteries.
<160 cm
160 182cm
>182cm
use 34 cc
use 40 cc
use 50cc
For process of insertion and nursing care required, please refer to the Clinical
Resource manual for the protocol on IABP.
Note: Need to check that the guide wire has been removed post insertion as it will
make the balloon less pliable and may not unwrap completely.
Trigger:
The trigger is the way the IABP identifies the beginning of the cardiac cycle. There
are 5 ways triggering may be achieved.
1. ECG
2. Pressure
3. Internal
4. Pacer V/AV
5. Pacer A
the R wave on the ECG is the trigger, the atrial pacer spikes are
enhanced and rejected. This mode is only used if ECG trigger is
not able to interpret R wave with A pacing. Never use if
patient is ventricularly paced.
Augmentation
This is the ability of the balloon to be fully expanded and contain the full amount of
helium for the catheter. During normal pumping it should be maintained on full
(meaning all lights on) to prevent blood clots forming by the sides of the pump and
preventing thrombosis formation. The ability of the balloon to forward flow blood
when inflated may be affected if blood is allowed to flow down the sides of catheter.
Timing of IABP
Timing is the most important aspect of having an IABP insitu, as incorrect timing will
cause the heart to work harder and not give the full benefit of afterload reduction and
maximise coronary artery perfusion. The system uses helium to inflate and deflate the
balloon as it dissolves readily in the blood if the balloon leaks. The balloon is timed
by comparing the arterial pressure wave form while the balloon is augmented with the
cardiac cycle:
Note: Remember timing should never be attempted on a 1:1 ratio, you need to see a
normal beat to establish whether the timing is correct. So a 1:2 or 1:3 is necessary.
Read the policy on IABP in ICU Policy and Procedure Manual for care of patient and
machine and alarms.
Inflation: - Inflation is simply the expansion of the balloon catheter with helium,
which is timed to just after the closure of the aortic valve. This is shown on the
arterial waveform as the diacrotic notch. The diacrotic notch denotes closure of the
aortic valve, when blood has been ejected from the (L) ventricle into the aorta. If
inflated correctly a V shape should be shown on the balloon trace. The effect of
displacement of blood in the aorta causes an increase in diastolic arterial pressure and
an increase in cardiac output.
Early inflation - occurs when the balloon inflates prior to aortic valve closure, then
there will be insufficient blood in the aorta, resulting in a in supply to coronary
arteries, premature closure of aortic valve and afterload.
Late inflation - occurs when the balloon inflates to late after the closure of the Aortic
Valve and blood escapes down the aorta to the rest of the body, instead of being
directed to the coronary arteries.
Deflation - Deflation is the depression of the balloon and the transfer of helium back
into the console. Deflation of the IAB occurs in systole. Typically seen on the screen
as being half way down the down slope after the diacrotic notch, prior to the aortic
value opening. The effect is a decrease in aortic end diastolic pressure (afterload) by
the balloon deflating and creating space in the aorta. This causes less impedence to
blood being expelled from the left ventricle when the balloon is deflated. Results in an
decreased ventricle wall tension, increased stroke volume and complete emptying of
the ventricle. Cardiac work is reduced due to a decrease in left ventricular end systolic
volume and preload, which reduces the cardiac work.
Early deflation - causes retrograde blood flow to the coronary arteries and affecting
forward blood flow to other vessels and afterload.
Late deflation - has the effect of impeding (L) ventricular ejection, causes ventricular
wall stress and impedes afterload reduction.
Weaning
Weaning of the IABP is commenced when the patient is haemodynamically stable and
it is evident that it is no longer required.
Weaning can be achieved by decreasing the frequency of assistance, meaning
decreasing to 1:2, then to 1:3 and observing the patients haemodynamics. The
balloon is to be removed by a medical officer. It is important when removing the
balloon to allow the site to bleed; this allows clots to be removed, thus decreasing the
risk of emoboli.
During the weaning process the patient may show signs of increases in PAP, decrease
in BP, CO and CI. This may show that the heart is not coping with the withdrawal
process, and should not continue, therapy should be continued.
Complications of IABP
-
Limb Ischaemia
Bleeding from site and internal
Infection/Sepsis
Aortic dissection
Embolism
Thrombosis
False aneurism
Aortic Valve Rupture
Catheter obstruction due to improper positioning with renal arteries or subclavian
Inappropriate timing causing afterload and stress of left ventricle.
Pump failure
Balloon Catheter rupture and gas loss
Haemolysis
Inability to wean
Incorrect timing
Compartment syndrome
Acute renal failure
What are the two ways that ECG and pressure can be monitored to use the
IABP?
2.
3.
When should the IAB be inflated, and what is the effect of inflation?
4.
When should the IAB be deflated, and what is the effect of deflation?
5.
6.
7.
8.
What does augmentation mean on the IABP? What is the most common
problem if augmentation is not full?
Nursing Care
-
Cardiac Arrest
In the event of a cardiac arrest, the IABP can be used in normal mode of either ECG
or pressure trigger, as the system will synchronise to the rate and rhythm of chest
compressions. Internal trigger in some institutions are used, this provides a fixed rate
of 80 beats per minute. The IABP in the unit in the event of a cardiac arrest is either
left on ECG trigger or placed on standby. An IABP can remain on standby insitu for
no more than 30 minutes. Any longer may cause clots forming on catheter, resulting
in thrombosis being pushed through the system.
Defibrillation
The current IABP is completely isolated from the patient and safe to have the patient
defibrillated, ensuring staff remains clear from the IABP when shock is delivered.
Arrhythmias
In the event of AF the IABP should be triggered from ECG and deflation point should
be moved to the extreme right. This will cause an automatic deflation on the R wave,
maximising the time the IAB catheter is inflated with an irregular HR and arterial
pressure.
Pacemaker
If the ECG trigger is unable to determine an R wave with the pacing spike, then Pacer
V/AV or Pacer A may be used.
Troubleshooting:
The following are common problems that may occur when using an IABP.
a) No trigger This means that the IABP has lost its tracing of ECG or Pressure and
is unable to time the inflation and deflation:
Action: To reconnect the ECG leads or pressure cable, or change the ECG leads
or tracing lead to obtain a better trace.
b) IAB Disconnected this means the IAB catheter extension tubing has been
disconnected and the pump will stop working.
Action: Reconnect the extension tubing, PRESS IAB Fill for 3 seconds till
prompt is on the screen and the PRESS Assist/Standby to start pumping.
c) Rapid Gas Loss - This will appear if there is a leak or hole in the balloon or
extension tubing. This means the balloon may be ruptured, you will see flecks of
blood in the tubing ( no gushing blood, as blood is under pressure).
Action: If the balloon is losing its gas and filling is frequently necessary, or blood
flecks have been identified in the tubing, then stop pumping and call the RMO. It
will mean that the catheter will need to removed and replaced. Check all
connections for any leaks or disconnections.
d) Check IAB Catheter this means that the IAB Catheter is either kinked insitu or
at the insertion site or it has not unwrapped fully insitu.
Action: Examine the catheter and extension tubing for any signs of kinking.
Ensure that full augmentation is on, making sure the balloon has the ability to
expand. Examine the skin insertion, as this is a common place for kinking. If
problem continues, contact RMO.
e) Low Helium this means that the supply of helium is less than 24 fills.
Action: The helium cylinder needs replacing. Please ensure that the O ring is not
dislodged while changing the cylinder as this ensures the seal.
f) Low Battery This means the battery has less than 30 minutes of operating time.
Action: Ensure that the balloon pump is connected to the mains power at all
times, to recharge the battery.
g) IAB Failure This means that the IABP console fails to pump, usually as a result
of electrical malfunction or the presence of blood in the condensers.
Action: Contact RMO. Disconnect patient from the IAB console and obtain
another IAB console (this should only to be attempted if the balloon is not
ruptured, as the same problem will occur). Ensure that the machine is not labelled
faulty. Depending on the patients haemodynamic status, the IAB catheter maybe
removed.
h) Augmentation Below Limit Set - This means that the augmented diastolic has
fallen below the alarm set.
Action: Review the alarm set and consider lowering it in line with the patients
progress or if concerned with the drop, then contact RMO.
Post test
22. How would you tell if your IAB catheter had ruptured? What procedure would
you use if this occurred?
23. In AF what is the best way to maximise therapy?
2. What are the effects that are achieved when using IABP therapy?
The IABP has the following effects:
monitor for both ECG and pressure traces. The pressure is arterial blood pressure,
aortic which is measured in the direct method.
8. Why is correct timing important for the patient?
Timing is the most important aspect of having an IABP insitu, as incorrect timing will
cause the heart to work harder and not give the full benefit of afterload reduction and
maximise coronary artery perfusion. Incorrect timing may cause further damage to an
already failing heart if it has to work harder to achieve demand.
9. When should the IAB be inflated, and what is the effect of inflation?
Inflation of IAB should occur just after the closure of the aortic valve in diastole.
This is shown on the arterial waveform as the diacrotic notch. The diacrotic notch
denotes closure of the aortic valve, when blood has been ejected from the (L)
ventricle into the aorta. The effect is a displacement of blood in the aorta which
causes an increase in diastolic arterial pressure and an increase in cardiac output.
10. When should the IAB be deflated, and what is the effect of deflation?
Deflation of the IAB occurs in systole. Typically seen on the screen as being half
way down the down slope after the diacrotic notch, prior to the aortic value opening.
The effect is a decrease in aortic end diastolic pressure (afterload) by the balloon
deflating and creating space in the aorta. This causes less impedence to blood being
expelled from the left ventricle. Resulting in an decreased ventricle wall tension,
increased stroke volume and complete emptying of the ventricle. Cardiac work is
reduced due to a decrease in left ventricular end systolic volume and preload, which
reduces the cardiac work.
11. Discuss the complications associated with the use of the IABP?
Complications of the IABP are the following:
-
Limb Ischaemia
Bleeding from site and internal
Infection/Sepsis
Aortic dissection
Embolism
Thrombosis
False aneurysm
Aortic Valve Rupture
Catheter obstruction due to improper positioning with renal arteries or subclavian
Inappropriate timing causing afterload and stress of left ventricle.
Pump failure
Balloon Catheter rupture and gas loss
Haemolysis
Inability to wean
Incorrect timing
Compartment syndrome
Acute renal failure
12. How is weaning achieved at Liverpool Hospital? What other ways can
weaning be achieved?
Weaning of the IABP is commenced when the patient is haemodynamically stable and
it is evident that it is no longer required. It is achieved by decreasing the frequency of
assistance, meaning decreasing to 1:2, then to 1:3 and observing the patients
haemodynamics. Weaning can also be achieved by decreasing the augmentation of
the balloon, however there are dangers with the potential for thrombosis being formed
if this method is used.
13. What are the signs of failure to wean an IABP?
Signs of failure in the weaning process are increases in PAP, decrease in BP, CO and
CI. This may show that the heart is not coping with the withdrawal process, and
should not continue, therapy should be continued.
14. What does augmentation mean on the IABP? What is the most common
problem if augmentation is not full?
This is the ability of the balloon to be fully expanded and contain the full amount of
helium for the catheter. During normal pumping it should be maintained on full
(meaning all lights on) to prevent blood clots forming by the sides of the pump and
preventing thrombosis formation. The ability of the balloon to forward flow blood
when inflated may be affected if blood is allowed to flow down the sides of catheter.
15. How long should an IABP Catheter remain insitu and not operating, and why
not any longer?
The IABP catheter should remain insitu not inflating and deflating for no longer than
30 minutes. If the balloon is not being operated then blood will clot due to stasis. If
then pumping is commenced clots will be propelled through the body and thrombosis
or an anuerysm may form the aorta.
16. During a cardiac arrest, what mode should be used for the IABP?
In the event of a cardiac arrest, the IABP can be used in normal mode of either ECG
or pressure trigger, as the system will synchronise to the rate and rhythm of chest
compressions. The internal trigger may be used, this provides a fixed rate of 80 beats
per minute. The IABP in the unit in the event of a cardiac arrest is either left on ECG
trigger or placed on standby.
17. What actions should be taken if a patient requires defibrillation while
requiring IABP therapy?
The current IABP is completely isolated from the patient and safe to have the patient
defibrillated, ensuring staff remains clear from the IABP when shock is delivered.
18. What effect do pacemakers have on the timing of the IABP?
The pacemaker or pacing spike may not be able to be determined by ECG triggering,
as it relies on R wave to pump. Changing the trigger to Pacer V/AV or Pacer A may
be used.
19. Describe the nursing care required for a patient on the IABP?
-