IABP- Instrumentation Indications and Complications

Dr Sajeer KTSenior ResidentDeptof Cardiology MCH Calicut

1

2

Intra aortic balloon counter pulsation( IABP)

Concepts - Systolic unloading - Diastolic augmentation

3

4

Indications for IABP

1 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

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

6

7

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

8

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

2

Intra aortic balloon counter pulsation( IABP)

Concepts - Systolic unloading - Diastolic augmentation

3

4

Indications for IABP

1 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

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

6

7

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

8

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

3

4

Indications for IABP

1 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

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

6

7

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

8

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

4

Indications for IABP

1 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

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

6

7

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

8

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

5

Contraindications to IABP

Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism

6

7

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

8

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

6

7

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

8

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

7

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

8

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

8

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

9

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

10

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

11

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

12

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

13

Interpreting IABP waveforms

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

14

IABP ndashinstrumentation and techniques

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

15

The IAB Counter pulsation system

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

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

16

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

17

HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon

bull Blood is displaced to the proximal aorta by inflation during bull diastole

bull Aortic volume ( afterload) is reduced during systole through a

vacuum effect created by rapid balloon deflation

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

18

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

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

19

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

20

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

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

21

Intra Aortic Balloon

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

22

IABP sizing chart

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

23

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

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

24

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

IABP Kit Contents

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

25

Intraaortic balloon

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

26

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

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

27

Before taking the Catheter out of Tray

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

28

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

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

29

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

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

30

- 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

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

31

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 transducer

Initial 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

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

32

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

33

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 interrupted

1ECG - 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)

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

34

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)

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

35

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

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

36

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

37

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

38

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

39

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

40

Increased coronary perfusion

The ldquonormalrdquo augmented waveform

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

41

Not all Sub optimal augmentation is due to Timing errorskinks

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

42

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

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

43

How to check waveform is acceptable

First change from 11 to 12 augmentation

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

44

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

45

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

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

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 Check if diastolic augmented wave is rsaquo systolic wave

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

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

Confirm if end diastolic wave following the augmented wave is less than an non augmented wave

Is Deflation slope ok

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

48

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

49

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

Sub optimal diastolic augmentation

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

50

Early Deflation Premature deflation of the IAB during the diastolic phase

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

51

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

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

52

Once Arterial waveform is ok check balloon waveform

Normal Balloon Pressure Waveform

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

53

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

54

Variation in balloon pressure wave forms

Increased duration ofplateau due to longer

diastolic phase

Decreased durationof plateau due to

shortened diastolicphase

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

55

Variation in balloon pressure wave forms

Varying R-R intervalsresult in irregularplateau durations

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

56

Variation in balloon pressure wave forms

Increased heightor amplitude ofthe waveform

Decreased heightor amplitude of thewaveform

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

57

Variation in balloon pressure wave forms

Gas 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

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

58

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

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

59

ldquoBalloon too largerdquo

syndrome

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

60

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

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

61

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

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

62

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

63

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

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

64

IABP Removal

- Discontinue heparin six hours 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

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

65

Thank you

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

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

66

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

67

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

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

68

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

4 late inflation of the balloon can result in

A) premature augmentation

B) increased augmentation

C) decreased augmentation

D) increased coronary perfusion

69

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

5 A rounded balloon pressure wave form indicate

A) helium leak

B) power failure

C) hypovolemia

D) balloon occluding the aorta

70

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

6 width of balloon pressure wave form corresponds to

A) length of systole

B) length of diastole

C) arterial pressure

D) helium level

71

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

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

72

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhythm

C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

73

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

9 Identify the tracing abnormality

74

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

10 Identify the tracing abnormality

75

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

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

76

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

2 the dicrotic notch on the arterial wave form reflects

A) aortic valve opening

B) aortic valve closure

C) isovolumetric contraction

D)rapid ejection

77

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

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

78

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

4 late inflation of the balloon can result in

bull A) premature augmentation

bull B) increased augmentation

bull C) decreased augmentation

bull D) increased coronary perfusion

79

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

5 A rounded balloon pressure wave form indicate

bull A) helium leak

bull B) power failure

bull C) hypovolemia

bull D) balloon occluding the aorta

80

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

6 width of balloon pressure wave form corresponds to

bull A) length of systole

bull B) length of diastole

bull C) arterial pressure

bull D) helium level

81

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

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

82

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

8 true statement

A) pacing spikes are automatically rejected in ECG triggered modes

B) pacing trigger modes can be used in a patient of 50 paced rhyth

C) Varying R-R interval result in regular plateau durations in Balloon press Wave form

83

9

84

10

85

9

84

10

85

10

85