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Presentation duration : Presentation duration : 60-90mins.60-90mins.

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INTRA-AORTIC INTRA-AORTIC BALLOON PUMPBALLOON PUMPINTRA-AORTIC INTRA-AORTIC

BALLOON PUMPBALLOON PUMPCirculatory assist Circulatory assist

mechanical device mechanical device for the failing heart.for the failing heart.

WHAT IS I.A.B.P ?

** I.A.B.P….basically is a unique console specially designed to : - increase coronary artery perfusion - increase systemic perfusion - decrease myocardial workload - decrease afterload

I.A.B.P THERAPY IS AN ACUTE SHORT TERMTHERAPY PROVIDES TEMPORARY MECHANICAL CIRCULATORY ASSIST TO THE FAILINGHEART BY UTILIZING THE PRINCIPLE OF COUNTERPULSATION

CounterpulsatioCounterpulsationn

CounterpulsatioCounterpulsationn

WHAT IS WHAT IS COUNTERPULSATION ?COUNTERPULSATION ?

THE PRINCIPLE OF THE PRINCIPLE OF COUNTERPULSATION COUNTERPULSATION

IS REFER TO THEIS REFER TO THE

ALTERNATING INFLATION AND ALTERNATING INFLATION AND DEFLATION OF THE INTRA-AORTICDEFLATION OF THE INTRA-AORTIC

BALLOON DURING DIASTOLE AND BALLOON DURING DIASTOLE AND SYSTOLE RESPECTIVELYSYSTOLE RESPECTIVELY

Intra-aortic balloon pump therapy .

( The pump outside the heart;)1 .When the heart does not have enough

oxygen due to blocked coronary arteries, or other medical problems, the heart must work harder to provide the needed oxygen.

2 .Intra-aortic balloon pump therapy helps restore the balance between the supply of oxygen-rich blood the heart receives from the coronary arteries, and the amount of oxygen the heart needs to pump.

This therapy involves two components;

1.One is a thin balloon which is positioned within aorta after being introduced through an artery .

2.Second component of balloon pump therapy is the pump itself. The pump continually inflates and deflates the balloon within the aorta in time with the heart beat.

**The intra-aortic balloon pump assists the heart during both its rest phase and its work phase .

**In the rest phase, the balloon inflates, increasing the supply of oxygen-rich blood to the coronary arteries .

**In the work phase, the balloon deflates, decreasing the workload on your heart.

**The decrease in workload results in a decrease in the amount of oxygen the heart needs to pump .

The normal work/rest cycle of the heart.

**As blood is pumped, the heart is at work. During the work phase, the heart pumps oxygen-rich blood into the aorta and out to the far reaches of the body .

**This task requires a large amount of oxygen. At the end of each work phase the heart has used up a large portion of the oxygen it has been given .

**As chambers fill, the heart is at rest phase, preparing to pump more blood. During this phase the heart muscle is able to relax. While it is resting, it is receiving a fresh supply of oxygen-rich blood through the coronary arteries.

How the intra-aortic balloon assists the heart.**When the balloon deflates, the heart's workload is

reduced. Just before the heart gets ready to work, the balloon within the aorta deflates .

**This deflation results in a drop in pressure in the aorta, so that when the heart pumps it doesn't have to work against high pressure. Instead, the heart's workload is actually reduced, and blood is pumped throughout the body more easily .

**When the balloon inflates, the heart receives more oxygen. When the heart is in its rest phase, and receiving its fresh supply of blood, the balloon placed within the aorta is inflated by the pump .

**This process pushes more oxygen-rich blood through the coronary artery supply network and into the heart's muscle tissue, providing the tired heart with extra energy for its work phase.

**Inflation of the balloon during diastole = augmentation of the aortic diastolic pressure which increases coronary blood flow ( DPTI ) .

**Deflation of the balloon occurs just prior to the onset of systole and reduces impedance to left ventricular ejection (TTI ).

**This results in less myocardial work, decreased myocardial oxygen consumption and increased cardiac output .

PHYSIOLOGY EFFECT OF I.A.B.P.

AUGMENTATION: - augmentation of the diastole pressure

INCREASE IN: - coronary perfusion

- mean arterial pressure - cardiac output

- myocardial oxygen supplyDECREASE in:

- Aortic End-Diastolic pressure - heart rate

- afterload - systemic vascular resistance

- left ventricular End-Diastolic pressure - myocardial oxygen consumption

Increased;

Aortic diastolic pressure

MAPEarly transmitral flowEjection fraction

( cardiac output)

Coronary perfusionCerebral & renal perfusionMyocardial O2 supply

Diastolic coronary flow

Decreased;

Aortic systolic pressureLVEDPMyocardial O2 consumptionLactate productionAfterloadHeart rateSystemic vascular resistance

Cases that may consider by expert requiring IABP therapy:

Unstable anginaAltered mental status Heart rate > 110bpmDysarrthmiasSBP < 90mmHgMAP < 70mmHg with Vasopressor supportCardiac index < 2.4PAWP > 18mmHgDecreased SVO2Inadequate peripheral perfusionUrine output < 0.5ml/kg/hour

Indication and Indication and contraindicationcontraindication

INDICATON;

1.Refractory unstable angina2.Cardiogenic shock / septic shock3.Refractory left ventricular failure

4.Impending infarction5.Complication of M.I

6.Cardiac contusion7.Prophylactic support; - coronary angiography

/angioplasty - thrombolysis

- high risk intervention procedure8.Bridging device;

- cardiac transplant - total mechanical assistance

CONTRAINDICATION:

***ABSULUTE: - aortic valve insuffiency

- dissection of the aneurysm to the * aortic

* thoracic

***RELATIVE: - endstage cardiomyopathies

- atherosclerosis - endstage terminal disease

- abdominal aortic aneurysm ( not resected )

- peripheral vascular disease

CONTRAINDICATION

***Mechanical defects:

- valvular disease / insufficiency - ruptured papillary muscle

- ventricular septal defect - left ventricular aneurysm

***Surgical indication:

- post surgery myocardial dysfunction

- inability to wean from C.P.B - prophylactic support

Set up of IABPSet up of IABPSet up of IABPSet up of IABP

Insertion of IAB Insertion of IAB cathetercatheter

Malaysia : Bed side CVICU staffMalaysia : Bed side CVICU staffSFH : Cath lab staffSFH : Cath lab staff

Assist in insertion of IABAssist in insertion of IABeither bedside or in CVLeither bedside or in CVL

Malaysia : Bed side CVICU staffMalaysia : Bed side CVICU staffSFH : Cath lab staffSFH : Cath lab staff

Assist in insertion of IABAssist in insertion of IABeither bedside or in CVLeither bedside or in CVL

Technician set up IABP Technician set up IABP machinemachine

Equipment require Equipment require pre insertion :pre insertion :

Equipment require Equipment require pre insertion :pre insertion :

IABP consoleHelium gas tank(240psi)ECG & Arterial pressure monitoring setIAB catheter set & insertion kitsSkin prep requirementSterile dressing , drapes & gown.Glove,cap,mask or goggleSuture ( cutting needle / silk )Scalper bladeLocal anesthesia LA 1%/2%

2/3 way stopcock connection10/20/50ml leurlock plug syringes50ml slip tip syringeHeparinised salineHemodynamic transducer monitoring kitsMedication as per doctors order

- sedation/analgesic - Inotrops

17 .IVF(NSS/D5NS etc)

Fluoroscopy Fluoroscopy

Portable CXRPortable CXR

Emergency trolleyEmergency trolley

Lead and apronLead and apron

Special stretcherSpecial stretcher

Prepare patient :Prepare patient :explanation to pt’s explanation to pt’s

and familyand familyValidate ConsentValidate Consent

Prepare patient :Prepare patient :explanation to pt’s explanation to pt’s

and familyand familyValidate ConsentValidate Consent

*Ensure pt’s hooked on monitor*Ensure pt’s hooked on monitor*assist doctor :*assist doctor :

- invasive procedure- invasive procedure*indwelling catheter*indwelling catheter

Ventilated cases lease with RTVentilated cases lease with RT

*Ensure pt’s hooked on monitor*Ensure pt’s hooked on monitor*assist doctor :*assist doctor :

- invasive procedure- invasive procedure*indwelling catheter*indwelling catheter

Ventilated cases lease with RTVentilated cases lease with RT

Responsible as a Responsible as a nursing provider in IABP nursing provider in IABP management and caremanagement and care

Responsible as a Responsible as a nursing provider in IABP nursing provider in IABP management and caremanagement and care

**Establish ECG input to the IABP console**Obtain ECG configuration with optimal

‘ R’ wave amplitude**Or – indirect ECG input can be obtained

via bedside ECG to IABP console**Setting a trigger:

‘ - R’ wave - QRS complex

- arterial pressure waveform( may be used as a trigger for balloon inflation

and deflation)NB:Pt’s with PPM-set trigger to reject the pacemaker artifact

**Obtained base data and investigation prior procedure.

**Ensure patient’s condition allow to proceed with the insertion of IAB catheter

**Notify doctor if any abnormality from the data collection prior insertion and obtain written order for IAB insertion.

Insertion of IAB catheter team :Insertion of IAB catheter team :- doctor - doctor

- scrub nurse- scrub nurse-circulating nurse-circulating nurse

-technician-technician

Insertion of IAB catheter team :Insertion of IAB catheter team :- doctor - doctor

- scrub nurse- scrub nurse-circulating nurse-circulating nurse

-technician-technician

Catheter insertion approach :Catheter insertion approach :* * percutaneously ( common )percutaneously ( common )

* cut down* cut down* via transthoracic placement* via transthoracic placement

(during cardiac surgery)(during cardiac surgery)

Catheter insertion approach :Catheter insertion approach :* * percutaneously ( common )percutaneously ( common )

* cut down* cut down* via transthoracic placement* via transthoracic placement

(during cardiac surgery)(during cardiac surgery)

Pre-insertion consideration:(IAB KITs)**Prior insertion of IAB catheter keep the IAB

cath in its package until absolutely ready to insert the balloon and to completely drawn the vacuum before the insertion, to ensure balloon clear the sheath.

**Complete IABP console(OK function test)**

- ready set of pressure transducer - correct ECG & related cables

- helium tank(240psi)** Complete prep trolley for IAB insertion

1.Prior to removal of IAB from tray. - connect the one way valve to the male luer on

the short drive line tube attached to the IAB.

2.Slowly aspirate a full syringe of air - make sure the one way valve remain connected

to IAB until the balloon is properly positioned in the patient.

3.Remove the cath from the tray, keeping it in line with the IAB membrane

- grasp the cath close to the tray & pull it straight out.

- keep the cath level with the tray - DO NOT LIFT or BEND the cath during removal

- Remove stylet from central lumen (if applicable)4.Flush the central lumen with Heparinised saline

solution

For sheath insertion only :For sheath insertion only :* Remove Peel-Away hemostsasis * Remove Peel-Away hemostsasis

device prior to IAB catheter device prior to IAB catheter insertion.insertion.

* Push tabs to break,then peel * Push tabs to break,then peel away.away.

For sheath insertion only :For sheath insertion only :* Remove Peel-Away hemostsasis * Remove Peel-Away hemostsasis

device prior to IAB catheter device prior to IAB catheter insertion.insertion.

* Push tabs to break,then peel * Push tabs to break,then peel away.away.

IAB sizing recommendation:IAB sizing recommendation:IAB sizing recommendation:IAB sizing recommendation: 30cc 40cc 50cc30cc 40cc 50ccHeight < 162cm 162-182cm >182cmHeight < 162cm 162-182cm >182cm < 5’4” 5’4”-6’0” >6’0”< 5’4” 5’4”-6’0” >6’0”

BSA < 1.8m2 > 1.8m2BSA < 1.8m2 > 1.8m2

TRIGGERING**To achieve optimal effect of counterpulsation,

inflation and deflation need to be correctly timed to the patient’s cardiac cycle .

**This is accomplished by either using the patient’s ECG signal, the patient’s arterial waveform or an intrinsic pump rate .

**The most common method of triggering the IAB is from the R wave of the patient’s ECG signal. Mainly balloon inflation is set automatically to start in the middle of the T wave and to deflate prior to the ending QRS complex.

**Tachyarrhythmias, cardiac pacemaker function and poor ECG signals may cause difficulties in obtaining synchronization when the ECG mode is used .

In such cases the arterial waveform for triggering may be used

TIMING and WEANING1.It is important that the inflation of the

IAB occurs at the beginning of diastole, noted on the dicrotic notch on the arterial waveform .

2.Deflation of the balloon should occur immediately prior to the arterial upstroke .

3.Balloon synchronization starts usually at a beat ratio of 1:2 .

4.This ratio facilitates comparison between the patient’s own ventricular beats and augmented beats to determine ideal IABP timing .

5.Errors in timing of the IABP may result in different waveform characteristics and a various number of physiologic effects

Weaning consideration;

**If the patient’s cardiac performance improves

**weaning from the IABP may begin by gradually decreasing the balloon augmentation ratio (from 1:1 to 1:2 to 1:4 to 1:8) under control of

hemodynamic stability .

**After appropriate observation at 1:8 counterpulsation the balloon pump is removed.

**Consider discontinue heparin therapy 4-6hours before IAB cath removal.

IABP support maybe IABP support maybe discontinued if the discontinued if the

patient clinical picture patient clinical picture present the following:present the following:

IABP support maybe IABP support maybe discontinued if the discontinued if the

patient clinical picture patient clinical picture present the following:present the following:

Absent of low cardiac output syndromeUrine output > 30ml/hr (>0.5ml/kg/hr)Minimal inotopics supportHR < 100bpm

Absence of lethal/unstable Dysarrthmias MAP >70mmHg

PAWP < 18mmHg CI > 2.4

Spo2 60-80% Capillary refill < 2sec

7 .Angina free.

Removal of balloon Removal of balloon cathetercatheter

Removal of balloon Removal of balloon cathetercatheter

Done without an operative approachCan be done quickly & safelyExplained procedure to patientPrep area & requirementDisconnect the balloon from the console permitting the IAB cath to vent to atmosphere

( pt BP will collapse, the balloon membrane for withdrawal)

Remove all dressing & suture prior to attempt to withdrawn the IAB cath.

Post removal, continue observe hemodynamic status, check distal pulses & assess if risk of complication.

Secure hemostasis -direct firm pressure at site 30-45min

-beside pressure at site,firm digital pressure to the femoral artery immediately above insertion site

-then apply pressure dressing -apply sand bag pressure for at lease 4-

6hr.

Notify doctor for risk of complication.

Clinical factor increase IABP complication;Clinical factor increase IABP complication;* peripheral vascular disease* peripheral vascular disease

* old age* old age* female gender* female gender* Diabetic cases* Diabetic cases* Hypertension* Hypertension

* prolonged support* prolonged support* large cath size > 9.5fr* large cath size > 9.5fr

* body surface area < 1.8m2* body surface area < 1.8m2* cardiac index < 2.2L/min/m2* cardiac index < 2.2L/min/m2

Clinical factor increase IABP complication;Clinical factor increase IABP complication;* peripheral vascular disease* peripheral vascular disease

* old age* old age* female gender* female gender* Diabetic cases* Diabetic cases* Hypertension* Hypertension

* prolonged support* prolonged support* large cath size > 9.5fr* large cath size > 9.5fr

* body surface area < 1.8m2* body surface area < 1.8m2* cardiac index < 2.2L/min/m2* cardiac index < 2.2L/min/m2

Management for IABP trouble shooting

Theory of IABPTheory of IABPTheory of IABPTheory of IABP

Refer to lecture theory for Refer to lecture theory for IABPIABP