Download CLINICAL SUPPORT SERVICES MANAGING IABP THERAPY

CLINICAL SUPPORT SERVICES
MANAGING IABP THERAPY - CS100
DATASCOPE IS NOW MAQUET CARDIOVASCULAR
CS100 Color Display and Keypad Controls
Datascope is now MAQUET Cardiovascular
In early 2009, the purchase agreement between Datascope and Getinge AB was completed.
As a result, Datascope’s innovative cardiovascular product portfolio will be integrated into MAQUET
Cardiovascular, a global leader representing the Medical Systems Business area of Getinge AB.
Cardiac professionals have always relied on gold-standard Cardiac Assist products from Datascope,
helping them to feel confident that they are delivering the highest quality of care to their patients.
Now, as a part of MAQUET Cardiovascular, Datascope is even better positioned to focus on the future
advancement of Cardiac Assist products and seeks to explore the full potential of this technology
through our continued dedication to innovation, service and clinical excellence.
Quality Products:
Expect the same great quality products you have relied on over the years with names you are familiar
with like: Fidelity, Linear and Sensation IAB’s, CS300 balloon pumps, SafeGuard and StatLock.
Quality Service:
Rest assured that you will receive the same amazing service and clinical support you have become
accustomed to from Datascope. We are still here for you 24/7 with technical support, loaner
equipment and clinical help.
Worldwide:
MAQUET ranks among the leading providers of medical products, therapies and services for Surgical
Workplaces, Critical Care and Cardiovascular applications. Since its foundation more than 170 years
ago, MAQUET has stood for innovation and the advancement of patient care technologies in the field
of medicine. The portfolio of MAQUET products is extensive, providing a comprehensive solution that
is designed for efficient workflows, safety and the improvement of patient lives and outcomes.
Welcome to MAQUET Cardiovascular:
With a fresh vision of the future, this new, combined organization is committed to providing the highest
quality patient care solutions for cardiologists, interventional radiologists, cardiothoracic and vascular
surgeons, critical care clinicians and their teams.
For further information please visit www.datascope.com
Managing Intra-Aortic Balloon Therapy
Course Description
This six hour program is designed for the experienced healthcare professional directly involved with the care of
the patient requiring intra-aortic balloon pump therapy. Participants should have experience with hemodynamic
monitoring and 6 months critical care experience. Previous experience with intra-aortic balloon pump therapy
is preferred.
This program is comprised of 3 modules consisting of theoretical, technical, and clinical considerations for a
patient requiring IABP therapy. The theoretical module will briefly review cardiac physiology and the theory of
intra-aortic balloon pumping. The technical module will discuss percutaneous insertion and removal of the intra
aortic-balloon catheter followed by a detailed explanation of the Datascope IABP, highlighting troubleshooting
in the clinical setting. Case studies will be utilized to further reinforce troubleshooting techniques. The clinical
module provides a discussion of clinical considerations for patients requiring IABP therapy. A skills workshop
utilizing the system trainer and Abbreviated Operator’s Guide will be provided.
Behavioral Objectives
At the conclusion of this program, the participants will be able to:
1)
Define the two physiologic effects achieved by the mechanics of inflation and deflation of the IAB as it
relates to the cardiac cycle illustrated by an augmented arterial pressure waveform.
2)
Identify four indications and three contraindications for IABP therapy.
3)
Identify the potential complications associated with IABP therapy.
4)
Demonstrate the set up, operation, and troubleshooting of the Datascope IABP utilizing the system trainer
for practice and the abbreviated operators guide for reference.
Caution: U.S. Federal Law restricts this device to sale by or on the order of a physician
Refer to package insert for current indications, warnings, contraindications, precautions and instructions for
use.
1
Course Schedule
8:00 – 8:10
Introduction
Review Program
8:10 – 9:30
MODULE I - Theoretical Aspects
Review Cardiac Mechanics
Measurement of Cardiac Performance
Left Ventricular Failure
Theory of IABP
Factors Affecting Diastolic Augmentation/Timing Errors
Indications/Contraindications
9:30 – 9:45
Break
9:45 – 10:45
MODULE II IAB - Catheter and Technical Introduction to IABP
IAB Catheter Insertion
Technical Features of the IABP
Break
10:45 – 11:00
11:00 – 12:00
12:00 – 12:30
Troubleshooting Alarm and Advisory Messages
Hands On
Lunch
12:30 – 1:15
Additional Hands on
1:15 – 1:45
MODULE III - Clinical Considerations
Side Effects/Potential Complications
Care Management/Case Studies
1:45 – 2:00
Open Discussion
Program Evaluation
2
Module I
Theoretical Aspects of IABP
3
I. Review Physiology of Cardiac Mechanics
A. Cardiac Cycle
1. Atrial Systole
2. Isovolumetric Contraction
3. Ventricular Ejection
a. Slow Ejection
b. Rapid Ejection
c. Slow Ejection
4. Isovolumetric Relaxation
5. Ventricular Filling
a. Rapid Filling
b. Slow Filling
4
B. Pressure Waves
1. Ventricular Waveform
a. Pressure
b. Volume
2. Arterial
a. Radial/Brachial
b. Aortic
5
6
C. Myocardial Oxygen Supply and Demand
SUPPLY
DEMAND
1.
2.
3.
4.
1.
2.
3.
4.
Coronary artery anatomy
Diastolic pressure
Diastolic time
O2 extraction
a. HBG
b. PaO2
MVO2
Heart Rate
Afterload
Preload
Contractility
D. Frank-Starling Law of Heart
Ventricular function curve. As the end-diastolic volume increases, so does the force of ventricular contraction.
Thus the stroke volume becomes greater up to a critical point after which stroke volume decreases. [Cardiac
failure]
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LV Failure
8
II. Theory of IABP Therapy
A. Counterpulsation
1. Balloon Structure and Position
2. Increased Coronary Perfusion
a. Inflation
b. Augmentation of Diastolic Pressure
3. Decreased Left Ventricular Workload
a. Deflation
b. Afterload Reduction
4. Physiological Pressure Wave Changes
a. Dicrotic Notch
b. Diastole: Augmentation
c. Decreased End-Diastolic Pressure
d. Systole: Decreased Assisted Systolic Pressure
9
10
Arterial Waveform Variations During IABP Therapy
1:1 IABP Frequency
1:2 IABP Frequency
11
1:3 IABP Frequency
B. Effects of IABP
1. Primary
a. Supply
b. Demand
2. Secondary
a. CO/CI
b. HR
c. PAD-PCWP
d. SVR
e. B/P-SYSTOLIC
DIASTOLIC
MAP
DIASTOLIC AUGMENTATION
3. Systemic
a. Neuro
b. Renal
c. Vascular
d. Respiratory
12
C. Factors Affecting Diastolic Augmentation
1. Patient Hemodynamics
a. Heart Rate
b. Stroke Volume
c. Mean Arterial Pressure
d. System Vascular Resistance
2. Intra-Aortic Balloon
a. IAB in Sheath
b. IAB Not Unfolded
c. IAB Position
d. Kink in IAB Catheter
e. IAB Leak
f. Low Helium Concentration
3. IABP
a. Timing
b. Position of IAB Augmentation Control
13
D. Timing Errors
1. Early Inflation
Inflation of the IAB prior to aortic valve closure
Waveform Characteristics
• Inflation of IAB prior to dicrotic notch
• Diastolic augmentation encroaches onto
systole (may be unable to distinguish)
Physiologic Effects:
• Potential premature closure of aortic valve
• Potential increase in LVEDV and LVEDP or PCWP
• Increased left ventricular wall stress or afterload
• Aortic Regurgitation
• Increased MVO2 demand
2.
Late Inflation
Inflation of the IAB markedly after closure
of the aortic valve
Waveform Characteristics:
• Inflation of the IAB after the dicrotic notch
• Absence of sharp V
• Sub-optimal diastolic augmentation
Physiologic Effects:
• Sub-optimal coronary artery perfusion
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3.
Early Deflation
Premature deflation of the IAB
during the diastolic phase
Waveform Characteristics
• Deflation of IAB is seen as a sharp
drop following diastolic augmentation
• Sub-optimal diastolic augmentation
• Assisted aortic end diastolic pressure
may be equal to or less than the
unassisted aortic end diastolic pressure
• Assisted systolic pressure may rise
Physiologic Effects:
• Sub-optimal coronary perfusion
• Potential for retrograde coronary and
carotid blood flow
• Angina may occur as a result of retrograde
coronary blood flow
• Sub-optimal afterload reduction
• Increased MVO2 demand
4.
Late Deflation
Waveform Characteristics:
• Assisted aortic end-diastolic pressure
may be equal to the unassisted aortic
end diastolic pressure
• Rate of rise of assisted systole is prolonged
• Diastolic augmentation may appear widened
Physiologic Effects:
• Afterload reduction is essentially absent
• Increased MVO2 consumption due to the
left ventricle ejecting against a greater
resistance and a prolonged isovolumetric
contraction phase
• IAB may impede left ventricular
ejection and increase the afterload
15
E. Indications
1. Refractory Unstable Angina
2. Impending Infarction
3. Acute MI
4. Refractory Ventricular Failure
5. Complications of Acute MI [i.e. acute MR or VSD, or papillary muscle rupture]
6. Cardiogenic Shock
7. Support for diagnostic, percutaneous revascularization, and interventional procedures
8. Ischemia related intractable ventricular arrhythmias
9. Septic Shock
10. Intraoperative pulsatile flow generation
11. Weaning from bypass
12. Cardiac support for non-cardiac surgery
13. Prophylactic support in preparation for cardiac surgery
14. Post surgical myocardial dysfunction/low cardiac output syndrome
15. Myocardial contusion
16. Mechanical bridge to other assist devices
17. Cardiac support following correction of anatomical defects
F.
Contraindications
1. Severe aortic insufficiency
2. Abdominal or aortic aneurysm
3. Severe calcific aorta-iliac disease or peripheral vascular disease
4. Sheathless insertion with severe obesity, scarring of the groin, or other contraindications to
percutaneous insertion
Please Refer to the Instructions for Use Prior to Insertion of the IAB
16
Module II
Technical Aspects
17
I. Intra-Aortic Balloon Catheter
A. Designed for sheathless or sheathed insertion
18
B. Clinical Considerations for Central Aortic Pressure Monitoring
PRECAUTION: For optimal signal quality,
use no more than 8 feet (2.5 meters)
maximum of pressure tubing between the
transducer and female luer hub of the Yfitting.
When monitoring pressure through the inner
lumen, use a standard arterial pressure
monitoring apparatus connected to a three-way
stopcock. Connect the three-way stopcock to
the female luer hub of the inner lumen. A
3cc/hour continuous flow through the inner
lumen is recommended. The anticoagulation
dosage should be in accordance with standard
hospital practice for arterial pressure lines and
may be modified, on physician discretion, for
patients receiving anticoagulation therapy. Per
hospital policy, a fast forward flush may be
performed hourly to help maintain patency of
the inner lumen.
PRECAUTIONS DURING PRESSURE
MONITORING THROUGH IAB CATHETER
RECOMMENDATIONS FOR ACHIEVING
OPTIMAL PRESSURE SIGNAL QUALITY
1. Use a standard flushing apparatus for
arterial pressure monitoring with the inner
lumen. Careful technique should be used in
the set up and flushing of the arterial
pressure monitoring apparatus to minimize
the risk of an embolus entering the aorta
where it could potentially enter the carotid or
coronary arteries.
2. Aspirate and discard a 3cc volume of blood
from the inner lumen prior to attaching a
flushing apparatus to the female luer hub.
3. Ensure that all air bubbles are removed from
the inner lumen and flushing apparatus. In
addition, tap the Y-fitting to remove all air
bubbles.
4. Prior to fast flushing, stop IAB pumping to
reduce the risk of an embolus entering the
aortic arch should an embolus be ejected
from the inner lumen.
5. For optimal signal quality the inner lumen
should not be used for blood sampling.
6. Always aspirate 3cc initially if the inner
lumen aortic pressure line or the inner lumen
becomes damped. If you meet resistance
during aspiration, consider the inner lumen
to be occluded. Discontinue the use of the
inner lumen by placing a luer cap on the
female luer hub.
7. The use of in-line filters or other devices can
potentially alter the appearance of the
arterial pressure waveform.
8. Do not over-tighten connections.
1. Use no more than 8 ft. (2.5 m) of a low
compliance pressure tubing such as that
supplied by Datascope in the IAB Insertion
Kit between the transducer and Y-fitting of
the catheter.
2. Once the catheter is in place, aspirate and
discard 3cc of blood from the inner lumen
and then immediately perform a manual
flush using a syringe filled with 3cc to 5cc of
flush solution. This will minimize the chances
of stagnant blood clotting in the inner lumen.
3. Apply only gentle force to the syringe when
aspirating the inner lumen.
4. Do not use a R.O.S. E. (Resonance Over
Shoot Eliminator) or other damping device.
5. Remove air from flush bag prior to
pressurizing.
6. Prime the pressure set-up using gravity
flush.
7. Maintain 300 mmHg of pressure on the flush
solution and elevate it above the transducer.
8. Whenever the inner lumen of the IAB
becomes filled with blood (such as after
aspiration), the flush valve should be
activated for a minimum of 15 seconds in
addition to the time it takes to clear the
pressure tubing of blood.
9. Ensure that all air bubbles are removed from
the inner lumen and flushing apparatus.
10. Use room temperature flush solution.
19
II. Technical Components of the CS100 Intra-Aortic
Balloon Pump
20
A. Rear Panel
1.
2.
3.
4.
21
Safety Disk/
Condensate Removal System
a.
DC Input
b.
IAB Fill Port
c.
Drain Port
Helium Supply
a.
Pressure Gauge
b.
Manual Fill Port
Patient Connections
a.
ECG
b.
Pressure
c.
Monitor Input
d.
ECG/Pressure Output
Data Communications Outputs
a.
RS-232
b.
Phone Line
c.
Diagnostic Output
5.
Power Cord/Mains
6.
System Timer
B. Monitor CS100
1. Alarm Messages
2. Advisories
3. ECG
a. Lead
b. Gain
4. Pressure Source
5. IAB Fill Mode
6. Slow Gas Alarm Status
7.
8.
9.
10.
11.
12.
13.
14.
22
Operation Mode
IAB Status Indicator
Trigger
Heart Rate Display
Pressure Display
Augmentation Alarm
Battery Indicator
Helium Indicator
C. CS100 IABP Key Pad Controls
1. Operation Mode Keys
a. AUTO
b. Semi-Auto
c. Manual
2. Zero Pressure Key
3. START key and Indicator
4. STANDBY Key and Indicator
5.
6.
7.
8.
9.
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Trigger Source Key
a. ECG
b. Pressure
c. Pacer V/AV
d. Pacer A
e. Internal
IAB Frequency
IAB Augmentation
IAB Inflation Controls
IAB Deflation Controls
D. CS100 Key Pad Control Panel
1. Alarm Mute Key
2. IAB Fill Key
3. Help Key Indicator
4. Menu Guide
a. Ref Line
b. Aug. Alarm
c. ECG/AP Sources
d. Pump Options
e. User Preferences
5. Inflation Interval Key
6. Freeze Display Key
7. Print Strip Key
24
E. Recorder
1. ECG
2. Pressure
3. Balloon Pressure Waveform
25
F.
System Battery
1. Charge Status
2. Portable Operation
G. Doppler Storage
26
The inflation marker shows the period of inflation. Vertical timing marks located below the arterial waveform
are also available to aid with initial timing.
A unique automatic timing algorithm allows effective balloon pumping even during atrial fibrillation. Press the
Inflation Interval key to observe the period of inflation while pumping. Vertical markers located below the arterial
waveform and the highlighted portion indicate the period of balloon inflation.
27
III. Troubleshooting
A. Alarm Messages
1. Trigger Alarms
AUTO Operation Mode
a. No Trigger
b. Poor Signal Persists
Semi-Auto or Manual Operation Modes
a. No Trigger
b. No Pressure Trigger
c. Check Pacer Timing
d. Trigger Interference
2. Catheter Alarms
a. Leak in IAB Circuit
b. Rapid Gas Loss
c. IAB Disconnected
d. Check IAB Catheter
e. Blood Detected
f. AutoFill Failure - No Helium
g. AutoFill Failure
h. AutoFill Required
3. Pneumatic Alarms
a. High Drive Pressure
b. Low Vacuum
4. System Surveillance Alarms
a. Electrical Test Fails Code # ________________
b. System Failure
c. Safety Disk Test Fails
28
B. Advisory Messages
1. Alert Messages
AUTO Operation Mode
a. Poor Signal Quality
b. No Pressure Source Available
c. Unable to Update Timing
Semi-Auto or Manual Operation Modes
a. Irregular Pressure Trigger
b. Verify Proper Timing
c. ECG Detected
d. IAB Not Filled
e. Manual Fill IAB
All Operation Modes
a. Prolonged Time in Standby
b. Maintenance Required Code # _________________
c. No Patient Status Available
d. Low Helium
e. Low Battery
f. Low Battery [EXT]
2. Status Messages
AUTO Operation Mode
a. Function Unavailable in the AUTO Operation Mode
Semi-Auto and Manual Operation Modes
a. Automatic Operation Mode is Disabled
b. Gas Loss and Catheter Alarms Disabled
c. Auto R-Wave Deflate
d. R-Wave Deflate
All Operation Modes
a. System Trainer
b. System Test OK
c. Autofilling
d. Leak Testing Safety Disk
e. Slow Gas Alarm Is Off
f. Battery in Use
g. Battery in Use [EXT)
3. Prompt Messages
a. Unplug Disk Outlet
b. Plug Disk Outlet
c. Manual Fill IAB
29
C. Patient Conditions
1. Atrial Fibrillation
2. Ectopics
3. Cardiac Arrest
4. Cardioversion/Defibrillation
D. Changing Helium Tank
E. Safety Disk Leak Test
F.
Manual Fill
G. Manual Timing
30
IV. Normal Balloon Pressure Waveform
31
A. Variations in Balloon Pressure Waveforms
Variations in balloon pressure waveforms may be due to the following conditions:
1.
Heart Rate
Bradycardia
Increased duration of
plateau due to longer
diastolic phase
2.
Tachycardia
Decreased duration of
plateau due to shortened
diastolic phase.
Rhythm
Varying R-R intervals result in irregular plateau
durations.
3.
Blood Pressure
Hypotension
Decreased height or
amplitude of the
waveform
Hypertension
Increased height or
amplitude of the
waveform.
32
4.
Gas Loss
Leak in the closed system causing the balloon pressure waveform to
fall below zero baseline. This may be due to a loose connection, a leak
in the IAB catheter, H2O condensation in the external tubing, or a
patient who is tachycardiac and febrile which causes increased gas
diffusion through the IAB membrane.
5.
Catheter Kink
Rounded balloon pressure waveform, loss of plateau resulting from a
kink or obstruction of shuttle gas. This may be caused by a kink in the
catheter tubing, improper IAB catheter position, sheath not being pulled
back to allow inflation of the IAB, the IAB is too large for the aorta, the
IAB is not fully unwrapped, or H2O condensation in the external tubing.
6.
Sustained Inflation
Theoretical possibility if the IAB remains inflated longer than 2
seconds. System 90 Series intra-aortic balloon pump will activate
the System Failure alarm and deflate the IAB.
33
Datascope CS100 IABP Performance Checklist
Name:
Date:
Date and initial the following as completed:
Review of hospital policy and procedures:
Attends IABP Seminar:
Written exam taken:
Score:
For the following: indicate 1 for Satisfactory, 2 for Repeat Performance Necessary.
Initial Set Up
Establish Power, verify Mains power switch On &
IABP On/Off switch ON
System Trainer
Establish Gas Pressure
Establish ECG and Pressure
Zero Transducer
Confirm Initial Control Settings
a. IABP controls
b. Auxiliary controls
c. Override controls
Initial Timing
Identify Inflate Point
Identify Deflate Point
Fill the IAB Catheter and Initiate Pumping
a. Attach IAB to appropriate connector
b. Attach connector to safety disk/condensate
removal module
c. Press START – observe for the “Autofilling”
message
d. Verify optimal augmentation
e. Fine tune deflation timing
f. Assess hemodynamic benefits
1. augmentation
2. afterload reduction
g. Record pressures
1. assisted
2. unassisted
34
Clinical
Instructor
Initials
Troubleshooting
For the following sections indicate 1 for SATISFACTORY OR 2 FOR REPEAT PERFORMANCE
NECESSARY:
SCORE:
A. TRIGGER - DEMONSTRATES ABILITY TO IDENTIFY VARIABLE TRIGGER SELECTION
CRITERIA AND APPROPRIATE USE OF EACH TRIGGER
WHICH TRIGGER IS THE MOST APPROPRIATE FOR:
1.
Atrial Fibrillation
2.
Demand Ventricular Pacemaker, Rate 60
3.
AV sequential pacemaker, demand mode
4.
Unobtainable ECG signal, regular rhythm, BP 100/50
5.
Cardiac arrest with good chest compressions
6.
Sinus Tachycardia
7.
Sinus Rhythm with frequent PVCs
8.
Fixed rate AV sequential pacemaker
9.
Atrial pacemaker - 100% paced
B. IAB CATHETER - DEMONSTRATES UNDERSTANDING OF SITUATIONS THAT MAY CAUSE
AN IAB CATHETER ALARM AND DESCRIBES APPROPRIATE INTERVENTION
DESCRIBE WHY THE FOLLOWING SITUATIONS MAY CAUSE AN IAB CATHETER ALARM
1.
Pt. sitting straight up in bed
2.
IAB has not exited the sheath
C. GAS LOSS - IDENTIFIES AND RECOMMENDS APPROPRIATE ACTION FOR POTENTIAL
LOSS OF HELIUM
1.
2.
3.
What does blood in the IAB catheter shuttle gas tubing indicate
Describe the nursing considerations that would be involved
What status message would appear if the IAB catheter became disconnected from the console
D. DEMONSTRATES UNDERSTANDING OF THE HEMODYNAMIC RELATIONSHIP BETWEEN
THE PATIENT AND IABP THERAPY
DESCRIBE WHY THE FOLLOWING FACTORS WOULD CAUSE THE DIASTOLIC AUGMENTATION ALARM
TO SOUND:
1.
2.
3.
4.
5.
Increased heart rate
Decrease in patient stroke volume
Ectopy
Decrease in patient BP
Decreased SVR
35
E. TIMING - RECOGNIZES, INDICATES POTENTIAL CLINICAL IMPLICATIONS, AND
DEMONSTRATES APPROPRIATE INTERVENTION FOR THE FOLLOWING:
1.
2.
3.
4.
Early inflation
Late inflation
Early deflation
Late deflation
F. MISCELLANEOUS
1.
2.
PORTABLE OPERATION:
a. Initiates and terminates portable operation
b. Identifies location of battery charge light
SLAVE CABLES: (IF APPLICABLE)
a. Identifies location and use of ECG and/or pressure cables
b. Describes proper use of ECG slave cable in the presence of pacemakers
INSTRUCTOR SIGNATURE:
COMMENTS:
36
Module III
Clinical Considerations
37
I. Side Effects/Complications
II. Weaning and Removal
A. Frequency
B. Balloon Augmentation
III. Nursing Care Kardex/System Review Care Plan
IV. Critical Pathway/Clinical Progression
V. Considerations for Transport
38
I. Side Effects and Complications of IABP Therapy
Assessment
Prevention
Treatment Options
1. Limb Ischemia
• Check distal pulses, color,
temp. and capillary filling Q30
min x 2 hrs, then Q2 hrs.
• Monitor differential toe
temperatures.
• Use smallest sheath/catheter
sizes indicated.
• Risk factors: female, diabetics,
peripheral vascular diseases.
• Select limb with best pulse.
• Remove sheath and observe
for bleeding.
• Subcutaneous Xylocaine
injection for arterial spasm.
• Change insertion site to
opposite limb.
• Bypass graft femoral artery.
2. Excessive bleeding from
insertion site
• Observation - anteriorly and
posteriorly for blood or
hematoma.
• Careful insertion technique.
• Monitor anticoagulation therapy.
• Prevent catheter movement at
insertion site.
• Apply pressure. Assure distal
flow.
• Surgical repair.
3. Thrombocytopenia
• Daily platelet count.
• Avoid excessive heparin.
• Replace platelets as needed.
4. Immobility of balloon catheter.
• DATASCOPE RECOMMENDS
THAT THE IAB NOT BE LEFT
IMMOBILE IN THE PATIENT
FOR MORE THAN 30".
• Observation of IAB status
indicator movement.
• Observation of augmentation.
• Maintain adequate trigger.
• Observe movement of IAB
Status indicator.
• If unable to inflate the IAB with
the IABP, inflate and deflate the
IAB by hand, using a syringe
and stopcock once every 3-5
min.
• Notify the physician if the IAB is
immobile for > 30".
39
Prevention
Assessment
Treatment Options
5. Balloon leak
• Observe tubing for blood with
or without the presence of a
blood detect, low augmentation,
and/or gas loss or IAB catheter
alarm.
• Do not remove the IAB from its
tray until it is ready to be
inserted.
• If blood is observed in the
pneumatic tubing, disconnect
the balloon from the IABP and
notify the physician
immediately.
6. Infection
• Observation of insertion site.
• Blood cultures for symptoms of
infection.
• Sterile technique during insertion
and dressing changes as per
infection control policy.
• Antibiotics.
7. Aortic Dissection
• Assess for pain between
shoulder blades.
• Daily hematocrit.
• If suspected, aortogram may be
indicated.
• Insertion of IAB over guide wire
with fluoroscopic control.
• Balloon removal.
• Surgical repair.
8. Compartment syndrome may
develop after IAB removed.
• Observation of limb for swelling
and/or hardness.
• Measure calf girth.
• Monitor interstitial pressure.
• Use the smallest catheter/
sheath appropriate.
• Maintain adequate colloid
osmotic pressure.
• Fasciotomy if necessary.
40
Plan of Care for IABP Patient
Vital Signs:
Monitor Q15'-Q30' until stable
Including hemodynamic parameters
Heart Rate
Mean Arterial Pressure
CVP
Pulmonary Artery Pressure
Pulmonary Capillary Wedge Pressure
Note and record: Cardiac Output/Cardiac Index
System Vascular Resistance
Notify physician if:
Accepted hemodynamic parameters deviate
Significant change ABG studies or chest film
afterload
Low urine output < 30cc/hr
Signs of limb ischemia
IABP non-functioning > 15"
Intake/Output:
Q1H (Strict)
Urine Specific Gravity - Q8H
Sugar/Acetone PRN
IABP:
Refill IAB Q2H/PRN
Maintain optimal augmentation
Reduction by adjusting timing PRN
Zero transducer PRN
Note placement IAB on chest X-ray
Change Helium tank PRN
Special Treatment Needs:
Note and record quality of pedal pulses Q30" after insertion x 2H, then Q2H
Change IABP dressing - PRN with sterile technique
Utilize air mattress/heel protectors PRN
Maintain anti-coagulant protocol
Observe for side effects/complications of IABP
Routine care associated with:
Respiratory and O2 therapy
N-G tube
Hemodynamic monitoring lines
Chest tube
IV’s
Foley catheter
Unit Number:
Bedspace:
Name:
Activity:
Bedrest with log rolling
Do not elevate HOB > 30o-45o
Do not flex balloon leg at groin or knee
Utilize fracture bedpan
ROM Q8H to uninvolved extremity
Dorsiflexion of involved foot
Diet:
NPO - clear liquid - soft as tolerated
Supplemental nutritional support
Tube feedings - hyperalimentation
Respiratory Therapy:
Evaluate breath sounds Q4H & PRN
Routine respiratory care of patient with endo tube/trach
Sterile suction technique
Modified respiratory therapy
Coughing and deep breathing, incentive spirometry and nasotrachial
suctioning may be utilized
Daily Lab Work/PRN Blood Work:
SMA - 18 QD
Monitor K+, BUN, creatinine closely PRN
Cardiac enzymes CPK, isoenzymes QD
CBC with Diff. QD/PRN
Platelets, PT, PTT, clotting times QD/PRN
ABG - monitor closely QD/PRN
Chest X-ray QD
Urine and serum osmolarity - QD
EKG QD - rhythm strips PRN
Blood, urine and sputum cultures for temperature 102o
DX:
Physician:
41
Nursing Care of the Patient on an Intra-Aortic Balloon Pump
System
Potential Problems
Nursing Interventions
Cardiac
Left Ventricular Failure
Monitor Vital Signs q15-30" until stable
Blood Pressure MAP, Syst, DA, AOEDP
Heart Rate
PAP
PCWP/LAP
Cardiac Output/Cardiac Index
CVP
SVR (Systemic Vascular Resistance)
Maintain Optimal Diastolic Augmentation and Afterload Reduction
Maintain Clarity of ECG Pattern Serving as Trigger
Rhythm Strips prn
12 Lead ECGs QD and prn
Cardiac Enzymes
Check Pacer Function
Caution: In the event of Asystole, assure balloon movement by placing Trigger on ECG, Arterial Pressure or
Internal (bear in mind a Mean Arterial Pressure of about 50 mmHg is required to visualize augmentation).
Respiratory
Pulmonary Edema
Pulmonary Emboli
Atelectasis
Pneumonia
Pleural Effusions
Monitor ABGs closely prn
Observe Chest X-ray QD
Lung fields
Balloon position
Provide appropriate ventilatory support
Standard respiratory care on intubated patient with sterile suctioning technique
Post-extubation, modified respiratory therapy is utilized
Deep breathing, coughing, chest physiotherapy and naso-tracheal suctioning may be used
Elevate HOB 30o
Turning (if hemodynamically stable) cautiously
Neurological
Psychiatric
Altered Level of Consciousness
Psychosis
Over Sedation
Cerebral Embolization
Neurological assessment q2h/prn
(Pupils, LOC, motor function)
Appropriate sedation
Normalization of environment (TV and radio, if appropriate)
Uninterrupted rest periods are essential to these patients
Emotional support regarding fears and anxieties should be provided to patient and family
42
Nursing Care of the Patient on an Intra-Aortic Balloon Pump
System
Potential Problems
Nursing Interventions
Renal
Prerenal Failure
acute Renal Failure
Observe urine output q1h
Notify physician if < 30cc or > 200 cc/hr. In absence of diuretics or fluid challenge
Urinary Tract Infection
Occlusion of Renal Artery
Strict Intake and Output
Observe patient’s fluid volume status - Intake and output
Daily Serum K+, BUN, Creatinine or Blood chemistries qd/prn
Daily weight
Urine Specific Gravity q8h
Urine Electrolytes and Osmolarity qd
Note appearance of urine
Watch for sings of urinary tract infection
Check position of IAB catheter on chest film
Vascular
Peripheral Ischemia
Thrombocytopenia
Peripheral Embolism
Bleeding from Anticoagulation
Check peripheral pulse (q15" x 1 hr, then q2h post-insertion
Pedal, Posterior Tibial, Popliteal
Observe color and temperature of involved leg q2h
Maintain anticoagulation protocol:
Heparin
Aspirin
Rheomacrodex
Observe coagulation studies: PT, PTT, Platelets, Hbg and Hct
Observe for side effects of anticoagulation therapy: petechiae, ecchymosis, excessive bleeding
from catheter insertion sites
Avoid flexing the patient’s hip and knee of involved leg due to IAB catheter
Apply anti-embolism stockings to non-involved leg
Immunologic
Wound Infection
Systemic Sepsis
Monitor temperature
Observe WBC
Maintain antibiotics
Change IAB dressing qd - strict sterile technique
Maintain “Best Practice” for all hemodynamic lines and observe for drainage
Culture appropriate sites including blood, urine and sputum if specific signs and symptoms
of infection process are present.
43
Nursing Care of the Patient on an Intra-Aortic Balloon Pump
System
Potential Problems
Nursing Interventions
Gastro-intestinal
Nutritional
Stress Ulceration
Paralytic Ileus
May have diet as tolerated (clear liquid/soft)
Hyperalimentation or tube feedings may be necessary with prolonged intubation
Measure abdominal girth q8h
Assess bowel sounds q8h
Observe for abdominal distention. Use stool softeners and fracture bedpan as appropriate
Portable KUB X-ray may be required without interrupting IABP
Naso-Gastric tube if appropriate
Naso-Gastric drainage q8h for occult blood
Provide appropriate antacid regimen
Musculoskeletal
Thrombosis
Decubitus Ulcer
Foot Drop
ROM - Active and Passive to uninvolved leg
Dorsiflexion of foot on involved leg
Turn (log roll) q1-2h – cautiously if hemodynamically stable
Apply air mattress and utilize heel and elbow protectors
Use footboard or high top tennis shoes to prevent foot drop
Patient and Family
Teaching
Family anxiety
Late Distal Emboli
Late Aortic Dissection
Reinforce simple explanation to patient and family
Discharge planning – communication of progress to nursing floor
Observe for and instruct in manifestations of late peripheral ischemia or emboli
Cardiac Assist
Device
Mechanical Function of IABP
Note and record settings according to hospital policy
Obtain optimal diastolic augmentation and optimal afterload
Reduction prn
Notify physician of difficulty
Prevent inflation of IABP during Ventricular Ejection
Maintain adequate ECG and arterial trace
Change Helium tank prn
Note IAB autofill q2h/refill prn
Watch for signs of balloon leak: frequent loss of augmentation, blood in extender tubing
If IAB catheter is immobile for greater than 30 minutes, notify physician for appropriate intervention
44
Critical Pathway of the Intra-aortic Balloon Pump Patient
Insertion
Pumping
Weaning
Blood Work
H&H, pt, ptt
Platelet count, WBC
Prior to removal, obtain: H&H, pt, ptt, platelet count
Diagnostic Procedures
Fluoroscopy
Portable CXR
Routine CXR qd, radiopaque tip at 2nd to 3rd ICS
Treatments
Shave and prep both potential
insertion sites
Monitor insertion site frequently.
Arterial line care per policy.
Dressing change per policy.
Activity
Maintain bed rest:
Do not raise HOB > 30 degrees.
Do not flex or bend the leg in which the IAB was inserted.
Assist the patient with log rolling and positioning.
Nutrition
Will depend on the patient’s condition and the indication for IAB insertion.
Nursing Interventions
Patient Teaching
Assess patient and monitor hemodynamic alterations per ICU routine.
Administer IV fluids, vasodilator and/or inotropic agents per orders.
Assess patient for pain or discomfort and medicate per physician order.
Assess vascular status (color, sensation and movement) as well as pulse quality
(pedal, posterior tibial, popliteal, femoral, and radial bilaterally).
* Note: diminished left radial pulse may indicate IAB migration.
Maintain anticoagulation protocol per physician order and observe for side effects.
Encourage deep breathing.
Assist the patient with turning and positioning at least q2h.
Observe for urine output > 30cc/hr
* Note: urine output < 30cc/hr may be an indication that the IAB is occluding the renal arteries.
Assure IAB movement, verify IABP controls in accordance with hospital policies.
* Note: IAB should not remain immobile for > 30 minutes in situ.
* Note: change of pedal pulses in affected leg could be a sign of limb ischemia.
Educate the patient and family members on IABP therapy utilizing the patient education brochure.
Explain each phase of the IABP process. Instruct patient to:
- apply pressure to insertion site if they should cough or sneeze
- report any chest pain or heaviness
- report any pain, numbness or tingling in their arms or legs
45
Removal
Pressure applied and site
dressed per policy.
Bed rest per policy.
OOB as tolerated.
Critical Pathway of the Intra-aortic Balloon Pump Patient
Insertion
Pumping
Weaning
Removal
Patient and family will have adequate knowledge base of IABP therapy.
Relief of patient and family anxiety.
The patient will experience clinical improvement from the IAB by:
- increasing the supply of myocardial oxygen
- decreasing the demand for myocardial oxygen
Expected Outcomes
This will be evidenced by:
- increased cardiac output
- increased MAP
- decreased PAP/PCWP
- decreased chest pain
Smooth progression through IABP therapy.
Patient hemodynamically stable.
The foregoing is intended to serve as a guideline for the development of a critical pathway. It is not a recommendation from Datascope Corp.
46
Clinical Progression - Intra-aortic Balloon Pump Therapy
Insertion
Pumping
Weaning
Removal
Description of
Phases
A balloon is positioned in your
aorta after being introduced
through an artery.
The IABP shuttles gas
from the console to the
balloon and is timed with
your heart beat.
Decreasing the
amount of assistance
your heart needs from
the IABP
Removing the balloon
from your artery.
Teaching
Most insertions of the IAB can be
completed in approx. 15 minutes.
The insertion site will be numbed
prior to insertion. During the
insertion, you may feel some
pressure at the insertion site.
The IABP is helping your
heart but not beating for it.
Pumping will stop every 2
hours for a short period of
time. This is normal.
The amount of time it
takes to wean varies
for each patient.
Removal is typically done
at the bedside and only
takes a few minutes to
complete.
Bed Rest
Activity
- To ensure that the IAB remains in the proper position, you should not sit up or attempt to get
out of bed.
- The leg in which the IAB is inserted should not be bent or flexed.
Your nurse will assist you with turning and changing your position.
Take deep breaths frequently.
Nursing
Interventions
Your condition will be monitored according to ICU routine.
The nurse will assess your vital signs, which include:
- Heart rate and rhythm, blood pressure, respirations, pulse checks and other measurements as
your condition warrants.
The insertion site will be checked frequently by your nurse.
The dressing will be changed on a regular basis.
Your nurse will give you pain medication. Please report any of the following:
- chest pain or heaviness, pain, numbness or tingling in your arms or legs.
Diagnostic
Procedures
Fluoroscopy (X-ray guidance) may
be utilized during insertion. Chest
X-ray will be done to verify
placement of the IAB.
Routine chest X-rays will be obtained during IABP therapy.
47
Once the IAB is removed,
you will remain in bed for
a specific length of time
depending on what your
physician has ordered.
This is usually 6-8 hours.
Report any wetness at
the insertion site.
Clinical Progression - Intra-aortic Balloon Pump Therapy
Insertion
Pumping
Weaning
Nutrition
Your diet will depend on your condition and the reason the IAB was inserted.
Lab Tests
Blood tests will be obtained
prior to the insertion.
Removal
Blood tests will be obtained as your condition warrants it.
The foregoing is intended to serve as a guideline for developing a clinical progression for IABP Therapy. It is not a recommendation from Datascope Corp.
Patient Questions
Comments
Patient Name
Date of IAB insertion
This clinical progression is an outline of what to expect for patients and families who require Intra-aortic Balloon Pump Therapy.
The process will vary for each patient.
48
V. Considerations for Transport
A. Purpose of Transport Program
B. Planning the Transport Program
1. Retrieval vs. Referral
2. Coordinator of Transport Team
C. Transport Team
1. Physician
2. Nurse, IABP Technician
D. Transport Program Considerations
1. Team Leader
2. Liabilities
3. Communication and Response Procedure
4. Consent Form and Patient Chart
5. Family Education
6. Patient Management During Transport
E. Vehicle Used for Transport
1. Ambulance
a. power supply
b. equipment on board
c. ramp
d. response time
2. Aircraft
a. power supply
b. equipment on board
F.
Equipment Considerations
1. IABP Supplies
2. Drugs
3. Infusion Pumps
4. Respiratory Care
G. Post Transport Considerations
1. Equipment Check
2. Follow-up
49
Reference List
Claflin, N.; guest editor, AACN Clinical Issues in Critical Care Nursing - Standards and Quality Assurance, Vol.
2, No. 1, J.B. Lippincott Company, Philadelphia, February 1991
Gould, K.A., Critical Care Nursing Clinics of North America, Mechanical Assist For The Failing Heart, W.B.
Saunders Company, Philadelphia, 1989
Guyton, A.C., Textbook of Medical Physiology, Seventh Edition; W.B. Saunders Company, Philadelphia, 1986
Kinney, M.R.; Dear, C.B.; Packa, D.R.; Voorman, D.N., AACN's Clinical Reference For Critical Care Nursing,
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Millar, S.; Sampson, L.K.; Soukup, M., AACN Procedure Manual for Critical Care, W.B. Saunders Company,
Philadelphia, 1985
Quaal, S.J., Comprehensive Intra-aortic Balloon Pumping, CV Mosby Company, St.Louis, 2nd Edition 1993
Quaal, S.J.; guest editor, AACN Clinical Issues in Critical Care Nursing - Cardiac Assist Devices, Vol 2, No. 3,
J.B. Lippincott Company, Philadelphia, August 1991
Underhill, S.l.; Wood, S.L.; Sivarajan, E.S.; Halpenny, C.J., Cardiac Nursing, Second Edition; J.B. Lippincott,
Philadelphia, 1989
Vazquez, M.; Engman Lazear, S.; Larson, E.L., Critical Care Nursing, Second Edition, W.B. Saunders
Company, Philadelphia, 1992
Vender, J.S.; guest editor, Critical Care Clinics - Intensive Care Monitoring, W.B. Saunders Company,
Philadelphia, 1989
50
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Kvilekval KHV, et al. Complications of Percutaneous Intra-aortic Balloon Pump Use in Patients With Peripheral
Vascular Disease. Archives of Surgery 1991 May;126:621-623
Lazar HL, et al. Outcome and Complications of Prolonged Intraaortic Balloon Counterpulsation in Cardiac
Patients. American Journal of Cardiology 1992 Apr;69:955-958
Schecter D, Murali S, Uretsky BF. Vascular Entrapment of Intra-aortic Balloon After Short Term Balloon
Counterpulsation. Catheterization and Cardiovascular Diagnosis 1991;22:174-176
Shin H, Yozu R, Sumida T, Kawada S. Acute ischemic hepatic failure resulting from intraaortic balloon pump
malposition. European Journal of Cardiothoracic Surgery 2000 Apr;17(4):492-4
Stahl KD, et al. Intra-aortic Balloon Rupture. ASAIO Journal 1988;XXXIV:496-499
Insertion
Gorton ME, Soltanzadeh H. Easy Removal of Surgically Placed Intra-aortic Balloon Pump Catheter. Annals of
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Heebler RF. Simplified Technique for Open Placement and Removal of Intra-aortic Balloon. Annals of Thoracic
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Shahian DM, Jewell ER. Intra-aortic Balloon Pump Placement through Dacron Aortofemoral Grafts. Journal of
Vascular Surgery 1988 Jun;7:795-7
56
Pediatrics
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Nurse 1990 Apr;10(4):24-28
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1983;68(5):1095-1100
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Transport
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Nursing Care
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Weinberg LA. Buying Time with an Intra-Aortic Balloon Pump. Nursing 1988 Sep;44-49
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58
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Managing IABP Therapy
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59
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