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CASE REPORT
Axillary Intra-aortic Balloon Pump
Placement as a Means for Safe
Mobility in a Patient Awaiting Left
Ventricular Assist Device
Implantation: A Case Report
Kara Marie Shumock, PT, DPT; Jessica Appel, PT, DPT; Amy Toonstra PT, DPT
Department of Physical Medicine and Rehabilitation, The Johns Hopkins Hospital, Baltimore, MD
Introduction: Although there is no cure for heart failure, placement of an intra-aortic balloon pump (IABP) can
act as temporary treatment. Historically, IABPs are inserted through the femoral artery and patients are placed
on bed rest. The purpose of this case report was to demonstrate the physical therapy management of a patient
with IABP catheter placement through axillary artery, including safe ambulation. Case Presentation: A 54-yearold South Asian man presented with profound cardiogenic shock. He had prolonged hospital course
complicated by several femoral IABP placements, extracorporeal membrane oxygenation, and mechanical
ventilation. He eventually received axillary IABP placement to allow for increased mobility. The patient was
able to ambulate up to 182.88 m with a rolling walker while the axillary IABP was in place before left ventricular
assist device placement, which occurred on hospital day 40. Conclusions: Physical therapy interventions,
including functional mobility and gait training, were safely performed in a patient with axillary IABP access.
However, additional studies are needed to support mobility as standard practice for this patient population.
(Cardiopulm Phys Ther J. 2015;26:53–57) Key Words: intra-aortic balloon pump, physical therapy, mobility
INTRODUCTION
Heart failure (HF) is a common medical condition that
affects approximately 5.1 million people in the United States.1
There is no cure for HF; however, a variety of treatment
options exist including medication, lifestyle adjustments,
surgical intervention, and heart transplantation.1 Advanced
HF may require patients to remain hospitalized for medical
management or while awaiting further treatment options
such as surgery. Due to the deconditioning effects of HF,
physical therapists (PTs) in the acute care setting are likely to
encounter these patients at various stages of the disease.
Copyright © 2015 Cardiovascular and Pulmonary Section, APTA
Correspondence: Kara Marie Shumock, PT, DPT, Department of Physical
Medicine and Rehabilitation, The Johns Hopkins Hospital, 1800 Orleans
Street, Meyer-2 109, Baltimore, MD 21287 ([email protected]).
The authors declare no conflict of interest.
DOI: 10.1097/CPT.0000000000000010
Cardiopulmonary Physical Therapy Journal
One temporary treatment for HF is placement of an intraaortic balloon pump (IABP).2 An IABP provides cardiovascular support in 2 ways: it maximizes coronary perfusion and
increases cardiac output by reducing left ventricular afterload.3,4 This device is traditionally inserted through the
femoral artery and is positioned in the aorta; however, this
approach greatly restricts mobility.2,4 If the patient does not
tolerate weaning of the IABP, the patient must often remain on
bed rest while awaiting a more definitive intervention, such as
left ventricular assist device (LVAD) placement or cardiac
transplant. In addition to decreased mobility, femoral IABP
placement carries other limitations including risk of infection.5 An alternative placement of the IABP in the axillary
artery allows the patient to mobilize out of bed and continue
working with physical therapy while supported by the IABP.5
Current literature suggests that axillary placement of an IABP
provides excellent support to patients while awaiting transplant with few adverse effects.5
In a patient population predisposed to physical
deconditioning, strict bed rest, such as that associated
Axillary Intra-aortic Balloon Pump Placement
53
Copyright Ó 2015 by the Cardiovascular and Pulmonary Section, APTA. Unauthorized reproduction of this article is prohibited.
with femoral IABP placement, is detrimental to the
musculoskeletal system.6 Immobility associated with bed
rest has been linked to intensive care unit (ICU) acquired
weakness.7 Bed rest has also been associated with other
complications such as hypotension, dehydration, decreased
lung functioning, and increased risk of deep vein thrombosis.8 Physical therapists play an important role in preventing
these negative consequences through early assessment and
development of an individualized patient plan of care to
meet functional goals.9 Early mobility has been shown to
decrease ICU and hospital length of stay and improve
functional outcomes at discharge.10,11 To optimize function
and reduce complications, PTs are a vital part of mobilization. Physical therapists typically play a smaller role in
patients with femoral IABP providing limited bed-level
exercises. However, in patients with axillary IABP, the role
of PTs expands to include creation of individualized plans of
care based on patient impairment and goals. Skilled care also
includes continual assessment of response to interventions
and progression of safe mobility.
Despite the benefits of axillary IABP, this alternative
placement is underused in cardiac ICUs. To the authors’
knowledge, there is no current literature surrounding the
development, initiation, and management of a physical
therapy plan of care with patients who have axillary IABPs.
We are reporting on this patient’s case study to highlight
the benefits of axillary IABP placement in a patient with
complex end-stage HF. Given the limited research available, our aim was to focus on the management and
feasibility for participation in mobility with physical
therapy and nursing in a complex critically ill patient with
an IABP through axillary artery.
supine in bed with the head of bed elevated no more than
30° and the involved limb extended. An occupational
therapist evaluated the patient on HD 21 and issued him
a bed-level exercise program. A physical therapy evaluation was performed on HD 23 after axillary IABP
placement. The patient was hemodynamically stable at
this time (Table 1). Upon observation, the patient had
right axillary IABP access with continuous monitoring,
telemetry, a peripheral intravenous line, and a Foley
catheter. He was alert and oriented to person, place, and
time, and was also able to follow 3-step commands. The
patient had 4/5 strength grossly in his bilateral lower
extremities and left upper extremity. Formal manual
muscle testing with resistance was not provided to the
right upper extremity due to the sensitivity of the IABP
access point. The patient’s range of motion, sensation, and
pulmonary status were within normal limits. Moderate
(21) edema was found in his bilateral upper and lower
extremities. The patient was taking opioid medication to
control tenderness and radiating right shoulder pain.
Additional notable medications include angiotensinconverting enzyme inhibitor, P2Y12 platelet inhibitor,
statin, loop diuretic, anticoagulant, antihypertensive,
insulin, nitrate vasodilator, magnesium sulfate, potassium chloride, phenothiazine, and selective serotonin
reuptake inhibitor. Relevant laboratory values included
point of care glucose 156 to 176 mg/dL, blood urea
nitrogen 30 mg/dL, creatinine 1.7 mg/dL, red blood cells
3.19 M/mm3, hemoglobin 8.8 g/dL, hematocrit 28.3%,
international normalized ratio 1.2, and activated partial
thromboplastin time 48.3 to 59.3 seconds.
CLINICAL IMPRESSION
CASE PRESENTATION
A 54-year-old South Asian man with a history of
diabetes, hypertension, peripheral venous insufficiency,
peripheral neuropathy, and cardiac arrhythmias presented
with profound cardiogenic shock. He was admitted to
a 12-bed ICU in a large tertiary hospital and was found to
have ST elevated myocardial infarction with peak troponin
at .102.00 ng/mL. Echocardiography revealed an ejection
fraction of 5% to 10%. Due to multivessel disease and the
inability to revascularize the left anterior descending coronary
artery, the patient was considered for an emergent coronary
artery bypass graft; however, he was not medically stable
enough to tolerate surgery, so a femoral IABP was placed. The
patient developed respiratory and circulatory failure resulting
in intubation, extracorporeal membrane oxygenation, percutaneous coronary intervention, and multiple reinsertions of
a femoral IABP throughout his ICU stay. On hospital day
(HD) 22, the femoral IABP was removed and reinserted
through axillary artery to permit mobility.
INITIAL EXAMINATION (HOSPITAL DAY 23)
At this hospital, patients with femoral access IABP are
not eligible for out-of-bed mobility. Patients must remain
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Shumock et al
In light of the patient’s recent axillary IABP line
placement and deconditioned state, the interdisciplinary
team set a mobility goal of transferring to the chair for the
initial physical therapy session/evaluation. Goals for
physical therapy were developed based on his functional
baseline and personal goals, which included independence
for all transfers, ambulation, and stair navigation. Physical
therapy interventions focused on preventing deconditioning and weakness in anticipation of a prolonged hospital
course.
Given the patient’s hemodynamic stability and tolerance to upright posturing in the chair, the interdisciplinary
team cleared the patient for ambulation on HD 26. Nursing
assisted in ambulation by managing the wheeled IABP
monitor and IV pole, whereas the PT provided guarding
and assistance to the patient who was using a rolling walker
(Fig. 1). Both nursing and the PT monitored the patient’s
vitals with particular focus on mean arterial pressure
(MAP) and heart rate (HR) as read on the IABP monitor, as
well as physical appearance for signs of exercise intolerance, such as shortness of breath, during all mobility
activities. Eventually, to progress the patient’s endurance
and functional mobility, he was encouraged to ambulate
once with the PT and once with nursing daily.
Cardiopulmonary Physical Therapy Journal
Copyright Ó 2015 by the Cardiovascular and Pulmonary Section, APTA. Unauthorized reproduction of this article is prohibited.
TABLE 1
Cardiopulmonary Response to Physical Therapy Interventions and Associated Percentage of Disability
HD
Ambulation Distance and Assistance
Required
23
OOB to chair with min A
25
26
27
28
29
30
33
Preintervention Vital Signs Postintervention Vital Signs AM-PAC (% Disability)
BP: 87/55 mm Hg
HR: 123 beats per minute
SpO2: 93%
OOB to chair with min A
BP: 85/43 mm Hg
MAP: 79 mm Hg
HR: 116 beats per minute
RR: 35 breaths per minute
SpO2: 98%
2.44 m with min A/HHA
BP: 91/55 mm Hg
HR: 108 beats per minute
SpO2: 93%
12.19 m with min A
BP: 94/64 mm Hg
HR: 109 beats per minute
RR: 27 breaths per minute
SpO2: 100%
27.43 m with min A using rolling walker BP: 80/53 mm Hg
MAP: 77 mm Hg
HR: 104 beats per minute
RR: 22 breaths per minute
60.96 m with min A using rolling walker BP: 93/63 mm Hg
MAP: 93 mm Hg
HR: 103 beats per minute
RR: 29 breaths per minute
SpO2: 100%
60.96 m with CGA using rolling walker BP: 85/51 mm Hg
MAP: 74 mm Hg
HR: 104 beats per minute
182.88 m with S/SBA using rolling
BP: 91/54 mm Hg
walker
MAP: 88 mm Hg
HR: 103 beats per minute
SpO2: 100%
BP: 86/53 mm Hg
HR: 127 beats per minute
SpO2: 94%
BP: 100/62 mm Hg
MAP: 93 mm Hg
HR: 113 beats per minute
RR: 35 breaths per minute
SpO2: 96%
BP: 89/52 mm Hg
HR: 110 beats per minute
SpO2: 94%
BP: 98/61 mm Hg
HR: 104 beats per minute
RR: 32 breaths per minute
SpO2: 100%
BP: 83/50 mm Hg
MAP: 81 mm Hg
HR: 97 beats per minute
RR: 26 breaths per minute
BP: 92/56 mm Hg
MAP: 88 mm Hg
HR: 103 beats per minute
RR: 26 breaths per minute
SpO2: 95%
BP: 84/51 mm Hg
MAP: 76 mm Hg
HR: 104 beats per minute
BP: 100/68 mm Hg
57.70%
54.16%
50.57%
50.57%
50.57%
50.57%
50.57%
50.57%
MAP: 95 mm Hg
HR: 106 beats per minute
SpO2: 100%
The patient’s vital signs were stable throughout all treatments, including when the patient was symptomatic. The patient was on room air during
all physical therapist sessions. Vitals not listed in the table were not reported in the patient’s medical chart.
Abbreviations: AM-PAC, Activity Measure for Post-Acute Care; BP, blood pressure; CGA, contact guard assist; HD, hospital day; HHA, handheld
assist; HR, heart rate; MAP, mean arterial pressure; min A, minimal assistance; OOB, out of bed; RR, respiratory rate; S, supervision; SBA, stand
by assist; SpO2, saturation of peripheral oxygen.
Activity Measure for Post-Acute Care (AM-PAC)
6-Clicks basic mobility scale was used to measure function
during each physical therapy session. This instrument
includes 6 questions regarding patient’s functional mobility in the hospital.12 The therapist scores each activity from
1 (unable or total assist) to 4 (no assistance needed), and
the sum of these scores creates the raw score, which can
then be standardized to a T-score.12 The intraclass
correlation coefficient is 0.849 (95% confidence interval)
for the overall interrater reliability of the basic mobility
scale.12 Evidence regarding the validity of this scale has
Cardiopulmonary Physical Therapy Journal
also been discussed by Jette et al.13 Table 1 displays the
patient’s AM-PAC 6-Clicks basic mobility scale as a percentage of disability throughout the hospital stay. A higher
percentage indicates a higher level of disability.
INTERVENTION
The PTs incorporated the following therapeutic
interventions into the plan of care: transfer training, gait
training, balance training, endurance training, and therapeutic exercises. The patient’s cardiopulmonary response
Axillary Intra-aortic Balloon Pump Placement
55
Copyright Ó 2015 by the Cardiovascular and Pulmonary Section, APTA. Unauthorized reproduction of this article is prohibited.
vitals during all physical therapy sessions. Given that
the patient was on numerous medications affecting
hemodynamics and was critically ill, hemodynamic parameters were established with the medical team to ensure
patient safety during physical therapy interventions. These
included MAP .65 mm Hg, HR ,130 beats per minute,
orthostatic hypotension as evidenced by drop in systolic
blood pressure (BP) of .20 mm Hg and drop in diastolic BP
of .10 mm Hg, symptomatic dizziness or light-headedness,
and clinical signs of decreased cardiac output. In the
instance of any of these events, physical therapy would have
stopped or been modified until hemodynamic stability
returned. Measures were taken by the PTs to prevent any of
these potential physiological abnormalities and included
review of laboratory values and vital signs before start of
physical therapy and continuous hemodynamic monitoring,
including MAP measurements with position changes.
PATIENT OUTCOMES
Fig. 1. Patient ambulating with rolling walker while
attached to multiple lines, including intra-aortic balloon
pump monitor, with assistance from the physical therapist.
This figure is available in color in the article on the journal
website (journals.lww.com/cptj).
to physical therapy interventions can be seen in Table 1.
On HD 23, the patient was able to perform supine to/from
sit, sit to/from stand, and bed-to-chair transfers with
minimal assistance and standing for 2 minutes. The
patient’s vital signs were only notable for a resting HR in
the 120s, which remained stable throughout the therapy
session. A personalized exercise program was initiated for
further progression of strength outside of physical therapy
sessions. On HD 25, mobility was limited by symptoms of
light-headedness and nausea. Light-headedness was not
position dependent, and vital signs remained stable during
bed-to-chair transfer, which required minimal assistance.
On HD 26, the patient required supervision for supine
to sit, minimal assistance for sit to/from stand transfers,
and was able to progress his exercise program further. The
patient ambulated 2.44 m to a chair with minimal
assistance at hips and handheld assistance on the left from
the PT. On HD 27, the patient ambulated 12.19 m and
continued to progress his exercise program to address
strength and endurance deficits.
On HD 28 to 30, the patient was able to progress
ambulation distance from 27.43 m with minimal assistance
to 60.96 m with contact guard assistance while using
a rolling walker. During this time, balance activities were
also initiated. On HD 33, he ambulated 182.88 m with
supervision using a rolling walker. The patient had stable
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Shumock et al
The patient had LVAD placement as destination
therapy on HD 40. Physical therapy continued after LVAD
placement and included interventions such as transfer
training, gait training, therapeutic exercises, more advanced balance activities, endurance, and LVAD management training. The patient’s AM-PAC score decreased from
68.66% disability on HD 41 to 46.58% disability on HD 58.
The patient was discharged to home on HD 59 with
a recommendation for home physical therapy as a bridge to
phase II cardiac rehabilitation.
DISCUSSION
The benefits of early mobility over bed rest are widely
known. Prolonged bed rest leads to muscle wasting,
weakness, and ICU-acquired myopathy.7 In a healthy
individual, bed rest can lead to a 4% to 5% decrease in
maximum voluntary force in knee extensor muscles per
week.14 At this hospital, patients with femoral IABP
insertion are on flat bed rest until removal of the device.
They are permitted to partake in bed-level exercise involving
uninvolved limbs, which nursing primarily performs with
the patient. The patient in this case study had axillary IABP
access for 18 days, which allowed him greater freedom to
participate in higher level mobility, including ambulation,
during a time where he would have been bed bound, thus
avoiding the deleterious effects of prolonged bed rest.
To mobilize the patient safely, nursing was involved in
treatment sessions to assist with equipment management
and monitoring of vital signs. The PT was available to guard
the patient and provide skilled feedback, as well as develop
and modify a treatment plan to address the patient’s
functional impairments while nursing managed the portable
IABP monitor, which continuously reported BP, MAP, and
HR. Physical therapists play a specific role in evaluation of
body systems, development of individualized plans of care,
management of lines/equipment for mobility, and use of
clinical judgment surrounding safe exercise parameters with
Cardiopulmonary Physical Therapy Journal
Copyright Ó 2015 by the Cardiovascular and Pulmonary Section, APTA. Unauthorized reproduction of this article is prohibited.
critically ill patients to maximize functional strength and
endurance during hospitalization.9,15 The interventions
chosen for this patient were aimed to improve mobility,
balance, and endurance to prevent deconditioning and work
toward maintaining functional strength for discharge home.
The AM-PAC was used as an outcome measure to track
percentage of disability throughout the hospital stay.
Walking distance was also recorded to track objective
improvements in endurance.
CONCLUSIONS
Axillary IABP placement has few adverse effects,
decreases the risk of infection, and allows for patient mobility,
thus preventing secondary complications from bed rest.5 This
case study demonstrates safe and feasible mobility for a patient
with axillary IABP placement. This was the first patient
mobilized with axillary IABP placement at this hospital.
Further research should focus on comparing functional
outcomes of patients awaiting destination therapy who are on
bed rest with femoral access IABP and those patients who are
able to mobilize with axillary access IABP.
ACKNOWLEDGMENTS
The authors would like to thank our patient for allowing us to use
his hospital course for the basis of this case report. They would
also like to recognize Gabrielle Steinhorn, PT, DPT, NCS, and Paul
Ricard, PT, DPT, CCS, for their guidance and critical review of this
case report. Written patient consent was received for publication
of this case report.
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Copyright Ó 2015 by the Cardiovascular and Pulmonary Section, APTA. Unauthorized reproduction of this article is prohibited.