IABP Review and Competency

IABP Indications Cardiogenic Shock Left Ventricular Failure Myocardial infarction Stunned Myocardium Unstable angina High Grade Coronary Artery Occlusions Awaiting Bypass Failure to separate from cardiopulmonary bypass Procedural support during coronary angiography and angioplasty Bridging to heart transplantation Prophylactic application prior to surgery, especially cardiac surgery

Indications

Balloon Placement Proper positioning of the IAB catheter is important in order to optimize the effects of counterpulsation. If the IAB catheter is too high, it can occlude the left subclavian artery causing decreased flow to the left arm. If the catheter is too low it can occlude the renal arteries causing decreased renal blood flow and, subsequently, decreased urine output. Daily CXR should be done to monitor IAB catheter placement. If the IAB catheter needs to be advanced or pulled back by the MD, the pump should be placed on standby while this occurs.

IABP Deflation

IABP Inflation

Triggers The signal that indicates to the IABP that systole is occurring or about to occur ECG: Best choice, R wave signals electrical event prior to systole Cannot be used: Asystole (no trigger) PEA (CPR compressions aren’t in concert with rhythm) Artifact ( ie. use of bovie in OR) Cardiopulmonary bypass (cardiac standstill) Pressure Best for Asystole, PEA, Artifact, and CPB Times to CPR compressions if they are strong enough to generate an arterial waveform Artifact and CPB, patient should still has an arterial waveform Cannot be used Loss of arterial line Irregular heart rhythm: deflates too late on premature beats

Triggers A Paced V A-V Paced Internal Best when IABP identifies Pacer spike as systole (rarely occurs) Does not require 100% pacing V A-V Paced Best when IABP double senses pacer spike and R wave as systole Needs to be 100% paced or IABP won’t recognize systole for non-paced beats Internal For asystole when Pressure trigger not effective Inflates/deflates at 80/minute not in concert with CPR

IABP Waveform In normal inflation-deflation timing, balloon inflation occurs at the onset of diastole, after aortic valve closure; deflation occurs during isovolumetric contraction, just before the aortic valve opens. In a properly timed waveform, as shown, the inflation point lies at or slightly above the dicrotic notch. Both inflation and deflation cause a sharp V shape. Peak diastolic pressure exceeds peak systolic pressure; peak systolic pressure exceeds assisted peak systolic pressure.

Timing Errors

Timing Errors

Timing Errors

Timing Errors

Timing Errors

Timing Errors

Timing Errors

Timing Errors

Problems With Diastolic Augmentation It is important to troubleshoot the IAB waveform when augmentation is suboptimal. Sometimes this indicates the patient is getting better. It can also mean a problem with the patient, catheter, or IAB pump.

Suboptimal Diastolic Augmentation Catheter Related Causes IAB size (too small) Placement (too low) Not unfolded or kinked Pump Related Causes Timing Errors (late inflation, early deflation) Augmentation not at maximum Patient Related Causes Hyperthermia Low SVR Low Stroke Volume

Balloon Pressure Waveforms

Balloon Pressure Waveforms Variations in Balloon Pressure Waveforms can be normal or indicate a problem with the catheter. It is important to be aware of the different variations and which ones require attention. Below are normal variations with changes in heart rate.

Balloon Pressure Waveforms When a patient has an irregular rhythm, the Balloon Pressure waveform with vary with the changes in heart rate. It will become narrower with tachycardia and wider with a plateau when the patient’s heart rate slows down.

Balloon Pressure Waveforms The height of the plateau rises with hypertension and lowers with hypotension.

Balloon Pressure Waveforms Other variations can indicate a potential problem with the IAB catheter. A falling baseline may indicate a gas loss. A rounding of the plateau indicates a possible kink or obstruction of the catheter. This can be from many causes including the patient bending his knee, a kink at the insertion site, a balloon that hasn’t opened fully, or blood obstructing the shuttle tubing. Troubleshooting includes checking the patient, catheter, and insertion site. It is not necessary to place the IABP on standby to assess the problem. For gas loss, checking the shuttle tubing for loose connections or small holes is important. The shuttle tubing can be replaced by placing the IABP on standby, replacing the tubing, and performing an autofill.

Balloon Leak Alarms could be: Nursing Responsibilities Blood Detected Check IAB catheter Catheter Kink Nursing Responsibilities Check IABP status, if in standby, attempt to restart Check IAB Catheter for signs of blood If blood noted, notify MD immediately small flecks:leave IABP on with plan to remove catheter within 1/2 hour large amount of blood:shut IABP off and clamp shuttle tubing Assess patient will patient be able to tolerate discontinuing IABP support will IAB catheter be changed over a wire or resited if patient still balloon dependent IABP console will have to be serviced if alarm stated “Blood Detected” notify Biomed to service autofill disc once pump changed out Complete Incident Report Bag IAB catheter on removal and send to Cath Lab for return to company for evaluation If catheter removed bedrest for minimum 4 hours with HOB </= 30 degrees

Competency Questions

Competency Assessment 1. Select all the following which may be indications for IAB placement: A. Myocardial Infarction B. Aortic Insufficiency C. Severe Left Main Disease D. End Stage Heart Disease E. Cardiogenic Shock F. Angina Resistant to Medications G. Severe Mitral Regurgitation 2. When caring for a patient with IABP support, pulse checks need to be done and documented: A. Bilat DP/PT every 2 hours B. Bilat DP/PT every hour with Left radial pulse checks C. IAB insertion site leg DP/PT hourly with left radial pulse checks D. Bilat DP/PT and left radial pulse checks every 2 hours 3. After IAB removal, the patient must stay on bedrest with HOB </= 30 degrees for a minimum of A. 8 hours B. 12 hours C. 1 hour D. 4 hours

Competency Assessment 4. Your patient’s IABP is alarming “Check Catheter” and you noticed the following Balloon Pressure Waveform, what would you do? (select all that apply) A. Place the IABP on standby and troubleshoot the cause B. Check patient position to see if the catheter is kinked C. Check IAB insertion site to see if there is a kink D. Always perform an “Autofill” 5. You notice small flecks on blood in the IAB catheter and the IABP is alarming “Blood in Catheter”. What would you do? (select all that apply) A. Notify the MD that the IAB catheter needs to be removed B. Turn off the console C. Notify Biomed that the Autofill disc will need to be serviced D. Assess how patient will tolerate discontinuing IAB support

Competency Assessment 6. When titrating medications, which pressure is most important? A. Systolic B. Diastolic Augmentation C. Mean Arterial Pressure 7. Your patient has been stable on 1:2 IABP frequency. Hemodynamics have not changed but the patient’s urine output has dropped dramatically over the last two hours. What would you do? A. Turn the IABP back to 1:1 B. Give a fluid bolus C. Get a CXR to check IAB placement D. Continue to monitor urine output for next couple of hours

Competency Assessment 8. Although ECG trigger is the preferred trigger, Pressure can be used in certain situations such as: (select all that apply) A. Irregular Rhythm B. Frequent PVCs C. Code Situation D. Loss of ECG trigger (ie. artifact, lead removal) E. With R-wave deflate function 9. If the patient needs defibrillation, which should you do? A. Put the IABP on standby while defibrillating B. Continue pumping and defibrillate C. Place the IABP on Internal Trigger before defibrillating D. Unplug the IABP 10. When setting up to slave the IAP arterial waveform to the bedside monitor, you have all the cables set up correctly but no waveform is coming up on the IABP screen. The Pressure source on the side of the screen says “Direct”. What should you try first? A. Get a new slave cable B. Select AP sources on Pump console and change “Direct” to “External” C. Rezero the arterial line D. Change trigger to pressure

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