1

IABP- Instrumentation Indications and Complications

Dr Sajeer KTSenior ResidentDeptof Cardiology MCH Calicut

2

Intra aortic balloon counter pulsation( IABP)

Most common and widely available methods of mechanical circulatory support

Temporary support for the left ventricle by mechanically displacing blood within the aorta

Concepts - Systolic unloading - Diastolic augmentation

Traditionally used in surgical and non surgical patients with cardiogenic shock

3

4

Indications for IABP1 Cardiogenic shock

2 In association with CABG Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion

- Postcardiotomy cardiogenic shock

- Associated with acute MI - Mechanical complications of MI - MR VSD

3 In association with nonsurgical revascularization- Hemodynamically unstable infarct patients- High risk coronary interventions

- severe LV dysfunction LMCA complex coronary artery disease

4 Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia

5

6

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

7

8

LV contraction - Isovol Contraction (b) - maximal ejection (c)

LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)

LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)

Cardiac cycle

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

2

Intra aortic balloon counter pulsation( IABP)

Most common and widely available methods of mechanical circulatory support

Temporary support for the left ventricle by mechanically displacing blood within the aorta

Concepts - Systolic unloading - Diastolic augmentation

Traditionally used in surgical and non surgical patients with cardiogenic shock

3

4

Indications for IABP1 Cardiogenic shock

2 In association with CABG Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion

- Postcardiotomy cardiogenic shock

- Associated with acute MI - Mechanical complications of MI - MR VSD

3 In association with nonsurgical revascularization- Hemodynamically unstable infarct patients- High risk coronary interventions

- severe LV dysfunction LMCA complex coronary artery disease

4 Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia

5

6

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

7

8

LV contraction - Isovol Contraction (b) - maximal ejection (c)

LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)

LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)

Cardiac cycle

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

3

4

Indications for IABP1 Cardiogenic shock

2 In association with CABG Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion

- Postcardiotomy cardiogenic shock

- Associated with acute MI - Mechanical complications of MI - MR VSD

3 In association with nonsurgical revascularization- Hemodynamically unstable infarct patients- High risk coronary interventions

- severe LV dysfunction LMCA complex coronary artery disease

4 Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia

5

6

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

7

8

LV contraction - Isovol Contraction (b) - maximal ejection (c)

LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)

LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)

Cardiac cycle

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

4

Indications for IABP1 Cardiogenic shock

2 In association with CABG Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion

- Postcardiotomy cardiogenic shock

- Associated with acute MI - Mechanical complications of MI - MR VSD

3 In association with nonsurgical revascularization- Hemodynamically unstable infarct patients- High risk coronary interventions

- severe LV dysfunction LMCA complex coronary artery disease

4 Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia

5

6

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

7

8

LV contraction - Isovol Contraction (b) - maximal ejection (c)

LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)

LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)

Cardiac cycle

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

5

6

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

7

8

LV contraction - Isovol Contraction (b) - maximal ejection (c)

LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)

LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)

Cardiac cycle

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

6

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

7

8

LV contraction - Isovol Contraction (b) - maximal ejection (c)

LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)

LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)

Cardiac cycle

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

7

8

LV contraction - Isovol Contraction (b) - maximal ejection (c)

LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)

LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)

Cardiac cycle

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

8

LV contraction - Isovol Contraction (b) - maximal ejection (c)

LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)

LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)

Cardiac cycle

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

9

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

11

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

12

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

13

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

14

Interpreting IABP waveforms

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

15

IABP ndashinstrumentation and techniques

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

16

The IAB Counter pulsation system - two principal parts A flexible catheter -2 lumen

bull first - for distal aspirationflushing or pressure monitoring

bull second - for the periodic delivery and removal of helium gas to a closed balloon

A mobile console bull system for helium transfer bull computer for control of the inflation and deflation cycle

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

17

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

18

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

Blood is displaced to the proximal aorta by inflation during diastole

Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

19

Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock

- Decrease in SBP by 20

- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)

- Increase in MAP

- Reduction of the HR by 20

-Decrease in the mean PCWP by 20

- Elevation in the COP by 20

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

20

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

21

IABP catheter

10-20 cm long polyurethane bladder

25cc to 50cc capacity

Optimal 85 of aorta occluded (not 100)

The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire

- for monitoring of central aortic pressure after installation

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

22

Intra Aortic Balloon

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

23

IABP sizing chart

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

24

Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

25

Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock

IABP Kit Contents

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

26

Intraaortic balloon

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

27

Connect ECG

Set up pressure lines

Femoral access ndash followed by insertion of the supplied sheath(75 F)

0030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view)

STEP BY STEP- IABP insertion

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

28

Before taking the Catheter out of Tray

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

29

Take the entire catheter and T handle as one unit

(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)

Pull out the T- handle only as shown

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

30

bull Remove styletaspirateFlush

bull Insert the balloon only over the guide wire

bull Hold the catheter close to skin insertion point

bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance

bull The IABP should advance freely

Inserting the Balloon catheter

- Many vascular complications occur during insertion itself

- Resistance during insertion either indicates PVOD or dissection

- Kinking of IABP raquo improper inflationdeflation

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

31

- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery

- Position should be confirmed by fluoroscopy or chest x-ray

Positioning

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

32

Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank

- The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure

- Zero the transducerInitial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

33

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

34

Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted1ECG - uses the slope of QR segment to detect triggering point

2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger

3 IN(Internal trigger)

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

35

ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave

bull Pacer (va)

bull Arterial waveform

bull An intrinsic pump rate (VF CPB)

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

36

Auto Operation Mode1048657 Automatic lead and trigger

selection1048657 Automatic and continuous

inflation and deflation timing

management- User has ability to fine-

tune deflation timing

1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode

1048657 Operator selects most appropriate

lead and trigger source

Initial settings

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

37

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

38

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

39

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

40

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

41

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

42

Not all Sub optimal augmentation is due to Timing errorskinks

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

43

Factors affecting diastolic augmentationPatient

- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance

Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration

Intra aortic balloon pump- Timing- Position of IAB augmentation control

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

44

How to check waveform is acceptable First change from 11 to 12 augmentation

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

45

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

46

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

47

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

48

How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

49

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

50

Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics

bull Inflation of IAB after the dicrotic notchbull Absence of sharp V

bull Sub optimal diastolic augmentation

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

51

Early Deflation Premature deflation of the IAB during the diastolic phase

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

52

Late Deflation Late deflation of the IAB during the diastolic phase

Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to

the unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

53

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

54

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

55

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

56

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

57

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

58

Variation in balloon pressure wave formsGas leak

Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline

- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

59

Catheter Kink

Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas

- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

60

ldquoBalloon too largerdquo

syndrome

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

61

Patient Management During IABP support

Anticoagulation-- maintain apTT at 50 to 70 seconds

CXR daily ndash to RO IAB migration

Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)

Prophylactic antibiotics --

Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

62

Never leave in standby by mode for more than 20 minutes gt thrombus

formation

Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary

to distal migration of IABP catheter)

Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications

Patient Management During IABP support

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

63

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

64

Weaning of IABP

Timing of weaning

- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio

ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely

ndash If patient becomes unstable weaning should be immediately discontinued

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

65

IABP Removal-Discontinue heparin 1 hour prior to removal

-Disconnect the IAB catheter from the IAB pump

- Patient blood pressure will collapse the balloon membrane for withdrawal

- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath-Remove the IAB catheter and the introducer sheath as a unit

- Check for adequacy of limb perfusion after hemostasis is achieved

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

66

THANK YOU

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

67

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

68

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

69

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

A) Decrease in SBP by 20

B) Increase in aortic DP by 30

C) Decrease in MAP by 10

D) Reduction of the HR by 20

E)Decrease in the mean PCWP by 20

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

70

4 late inflation of the balloon can result in

A) premature augmentationB) increased augmentationC) decreased augmentationD) increased coronary perfusion

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

71

5 A rounded balloon pressure wave form indicate

A) helium leakB) power failureC) hypovolemiaD) balloon occluding the aorta

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

72

6 width of balloon pressure wave form corresponds to

A) length of systoleB) length of diastoleC) arterial pressureD) helium level

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

73

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

74

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythmC) Varying R-R interval result in regular

plateau durations in Balloon pressureWave form

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

75

9 Identify the tracing abnormality

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

76

10 Identify the tracing abnormality

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

77

bull 1 Major physiological effects of counter pulsation include

A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption

B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption

C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption

D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

78

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening B) aortic valve closureC) isovolumetric contractionD)rapid ejection

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

79

3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except

bullA) Decrease in SBP by 20

bullB) Increase in aortic DP by 30

bullC) Decrease in MAP by 10

bullD) Reduction of the HR by 20

bullE)Decrease in the mean PCWP by 20

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

80

4 late inflation of the balloon can result in

bullA) premature augmentationbullB) increased augmentationbullC) decreased augmentationbullD) increased coronary perfusion

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

81

5 A rounded balloon pressure wave form indicate

bullA) helium leakbullB) power failurebullC) hypovolemiabullD) balloon occluding the aorta

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

82

6 width of balloon pressure wave form corresponds to

bullA) length of systolebullB) length of diastolebullC) arterial pressurebullD) helium level

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

83

7 true statement

a) Dicrotic notch- land mark used to set deflation

b) Deflation is timed to occur during period of iso volumetric contraction

c) Most common trigger used is arterial pressure wave method

d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

84

8 true statementA) pacing spikes are automatically rejected

in ECG triggered modesB) pacing trigger modes can be used in a

patient of 50 paced rhythC) Varying R-R interval result in regular

plateau durations in Balloon press Wave form

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

85

9

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10

86

10

• IABP- Instrumentation Indications and Complications
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• 9 Identify the tracing abnormality
• 10 Identify the tracing abnormality
• Slide 77
• Slide 78
• Slide 79
• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• 9
• 10