liverpool sdl iabp

8/17/2019 Liverpool SDL IABP

http://slidepdf.com/reader/full/liverpool-sdl-iabp 1/26

Liverpool Health ServiceIntensive Care Unit

Self Directed Learning Package:

Intra-Aortic Balloon Pumping

Written by: Linda Williams



How to use this package

This package is designed to be used in the clinical area as a self directed learning tool.

At the start of the package is a pre test which covers the information contained inside.

You should read through the pretest and answer the questions. If you have any

problems with any of the questions, this will provide you with some guidance as to

the areas that you should focus on in the package.

The package is divided into sections. At the end of each section is a self test to

determine how well you have understood the information contained in that section.

You will need to complete the self tests at the end of each section and ensure that you

have mastered the content before moving on to the next section.

If you have any trouble with the self test, go back over the section and revise the

content. If you are still unsure then you will need to speak with one of the educators in

your area.

Once you have worked through the entire package, you should complete the post test.

The answers to the post test are contained at the end of the package. If you have any

trouble with the post test, go back to the section in the package and revise it. If you

are still unsure, contact the educator in your area.

GOOD LUCK!!!



Learning package objectives

By the completion of this package, the registered nurse will be able to:

1. Discuss the indications for intra-aortic balloon pumping in the Intensive Care

Unit.

2. Discuss the insertion procedure and catheter position

3. Identify correct timing of balloon inflation and deflation

4. Describe the physiological effects of IABP

5. Discuss trouble shooting timing errors in balloon inflation and deflation

6. Discuss nursing management of IABP

• Weaning

• Complications

• Troubleshooting machine problems



Pretest

1. Why is an IABP used?

2.

What are the effects that are achieved when using IABP therapy?

3. Describe the mechanism of counterpulsation?

4. Why is helium used to inflate the balloon?

5. Describe the correct positioning of the IAB Catheter. Why is it important?

6. Why is the size of the IABP important?

7.

What are the two ways that ECG and pressure can be monitored to use the IABP?

8. Why is correct timing important for the patient?

9. When should the IAB be inflated, and what is the effect of inflation?

10. When should the IAB be deflated, and what is the effect of deflation?

11.

Discuss the complications associated with the use of the IABP?

12. How is weaning achieved at Liverpool Hospital? What other ways can weaning

be achieved?

13. What are the signs of failure to wean an IABP?

14. What does augmentation mean on the IABP? What is the most common problem

if augmentation is not full?

15. How long should an IABP Catheter remain insitu and not operating, and why not

any longer?

16. During a cardiac arrest, what mode should be used for the IABP?

17. What actions should be taken if a patient requires defibrillation while requiring

IABP therapy?

18. What effect do pacemakers have on the timing of the IABP?

19. Describe the nursing care required for a patient on the IABP?

20. What is the correct procedure if the IABP fails?

21.

What would you do if you lose your trigger for the IABP?



22. How would you tell if your IAB catheter had ruptured? What procedure would

you use if this occurred?

23. In AF what is the best way to maximise therapy?



Introduction

The Intra-Aortic Balloon Pump (IABP) is a circulatory assist device that is used to

support the left ventricle. The IABP uses counterpulsation where aortic blood is

displaced with the inflation and deflation of the balloon catheter, which is timed to the

cardiac cycle. Couterpulsation provides both an augmented diastolic arterial pressureand an decreased end-diastolic pressure. The balloon is connected to a console that

regulates the inflation or deflation of the balloon with the passage of helium. Helium

is used as it is easily dissolved in blood and prevents the risk of air emboli if the

catheter ruptures.

The IABP has the following effects:

• Increases coronary artery perfusion

•

Increases myocardial oxygen supply

• Decreases myocardial oxygen demand

• Decreases myocardial work by reducing afterload

• Increases blood pressure

• Decreases Pulmonary artery pressure

Indications

The IABP is used in:-

• Acute left ventricular failure post cardiac surgery

• Severe unstable angina

• Cardiogenic shock post myocardial infarction

• Bridge to cardiac transplantation

• Stunned myocardium after myocardial infarction

Contraindications

• Severe aortic insufficiency

• Aortic or abdominal aneurism

• Severe peripheral vascular disease



Diagram of Aorta & Position of IABP



Insertion

The balloon catheter is inserted either percutaneously or surgically by cutdown into

the patients’ femoral artery. The catheter can be inserted at the bedside, in a cathlab

or operating room theatre. The catheter is threaded up through the femoral artery and

located in the descending thoracic aorta, distal to the subclavian artery and proximalto renal arteries.

IABP Size

The size of the balloon is dependent on the patients height to prevent occlusion of

sub-clavian or renal arteries.

<160 cm use 34 cc

160 – 182cm use 40 cc

>182cm use 50cc

For process of insertion and nursing care required, please refer to the Clinical

Resource manual for the protocol on IABP.

Note: Need to check that the guide wire has been removed post insertion as it will

make the balloon less pliable and may not unwrap completely.



Before you go any further, try the following self test.

Self test 1.


2. What are the effects that are achieved when using IABP therapy?







Trigger:

The trigger is the way the IABP identifies the beginning of the cardiac cycle. There

are 5 ways triggering may be achieved.

1. ECG Uses R wave on the ECG to initiate the pumping.

2. Pressure the arterial pressure waveform is used to trigger.

3. Internal this allows a synchronous trigger set at 80 beats/min. Internal

mode should never be used if a patient is generating a cardiac

output.

4. Pacer V/AV uses ventricular spike to trigger an event, is not an appropriate

trigger for demand pacing.

5. Pacer A the R wave on the ECG is the trigger, the atrial pacer spikes are

enhanced and rejected. This mode is only used if ECG trigger is

not able to interpret R wave with A pacing. Never use if

patient is ventricularly paced.

Augmentation

This is the ability of the balloon to be fully expanded and contain the full amount of

helium for the catheter. During normal pumping it should be maintained on full

(meaning all lights on) to prevent blood clots forming by the sides of the pump and

preventing thrombosis formation. The ability of the balloon to forward flow blood

when inflated may be affected if blood is allowed to flow down the sides of catheter.



Setting Up the Machine to Commence Pumping.

1. Connect to mains power to ensure the battery is preserved. The battery can

withstand pumping for approximately 24 hours (depending on the battery charge).

2. Check the helium tank is open at the back of the pump.

3. Ensure both an ECG and pressure trace can be obtained from the patient on the

screen of the IABP. This can be obtained from either direct monitoring or the use

of the slave cables taking the signal from the monitor.

4.

The IABP can obtain a trigger, which stimulates the pumping of the balloon.

5.

Frequency when first commencing pumping is on 1:1, which means that for each

heart beat the balloon, will be inflated. When proceeding to weaning or timing the

frequency is changed.

6. To commence balloon pumping, inflation and deflation points should be set at the

midline and then once pumping is established, timing should be reassessed.

7.

Connect the extension tubing to the balloon catheter and on the balloon console at

the back.

Note: The tubing is made to be easily pulled apart if the patient moves their leg, this

avoids the balloon catheter being dislodged. So the tubing is not to have any tape

applied to the connections at any time.

Once connected, press the IAB fill button, holding it down for a second. A prompt on

the screen will come up so you know it is filling.

8. Once filled, commence pumping by pressing the assist/standby button. Then

increase slowly the augmentation to maximum. This will unwrap the balloon; if

done too fast, the balloon may unwrap incompletely. Maximum augmentation is

maintained at all times to ensure that the balloon is fully inflated and blood clots

are not able to form beside the balloon or in wrapping.



Timing of IABP

Timing is the most important aspect of having an IABP insitu, as incorrect timing will

cause the heart to work harder and not give the full benefit of afterload reduction and

maximise coronary artery perfusion. The system uses helium to inflate and deflate the

balloon as it dissolves readily in the blood if the balloon leaks. The balloon is timed

by comparing the arterial pressure wave form while the balloon is augmented with thecardiac cycle:

Note: Remember timing should never be attempted on a 1:1 ratio, you need to see a

normal beat to establish whether the timing is correct. So a 1:2 or 1:3 is necessary.

Read the policy on IABP in ICU Policy and Procedure Manual for care of patient and

machine and alarms.



Inflation: - Inflation is simply the expansion of the balloon catheter with helium,

which is timed to just after the closure of the aortic valve. This is shown on the

arterial waveform as the diacrotic notch. The diacrotic notch denotes closure of the

aortic valve, when blood has been ejected from the (L) ventricle into the aorta. If

inflated correctly a V shape should be shown on the balloon trace. The effect of

displacement of blood in the aorta causes an increase in diastolic arterial pressure andan increase in cardiac output.

Early inflation - occurs when the balloon inflates prior to aortic valve closure, then

there will be insufficient blood in the aorta, resulting in a ↓ in supply to coronary

arteries, premature closure of aortic valve and ↑ afterload.

Late inflation - occurs when the balloon inflates to late after the closure of the Aortic

Valve and blood escapes down the aorta to the rest of the body, instead of being

directed to the coronary arteries.



Deflation - Deflation is the depression of the balloon and the transfer of helium back

into the console. Deflation of the IAB occurs in systole. Typically seen on the screen

as being half way down the down slope after the diacrotic notch, prior to the aortic

value opening. The effect is a decrease in aortic end diastolic pressure (afterload) by

the balloon deflating and creating space in the aorta. This causes less impedence to blood being expelled from the left ventricle when the balloon is deflated. Results in an

decreased ventricle wall tension, increased stroke volume and complete emptying of

the ventricle. Cardiac work is reduced due to a decrease in left ventricular end systolic

volume and preload, which reduces the cardiac work.

Early deflation - causes retrograde blood flow to the coronary arteries and affecting

forward blood flow to other vessels and ↑ afterload.

Late deflation - has the effect of impeding (L) ventricular ejection, causes ventricular

wall stress and impedes afterload reduction.



Weaning

Weaning of the IABP is commenced when the patient is haemodynamically stable and

it is evident that it is no longer required.

Weaning can be achieved by decreasing the frequency of assistance, meaningdecreasing to 1:2, then to 1:3 and observing the patients haemodynamics. The

balloon is to be removed by a medical officer. It is important when removing the

balloon to allow the site to bleed; this allows clots to be removed, thus decreasing the

risk of emoboli.

During the weaning process the patient may show signs of increases in PAP, decrease

in BP, CO and CI. This may show that the heart is not coping with the withdrawal

process, and should not continue, therapy should be continued.

Complications of IABP

- Limb Ischaemia

-

Bleeding from site and internal

- Infection/Sepsis

- Aortic dissection

- Embolism

- Thrombosis

- False aneurism

-

Aortic Valve Rupture

- Catheter obstruction due to improper positioning with renal arteries or subclavian

- Inappropriate timing causing ↑ afterload and stress of left ventricle.

- Pump failure

-

Balloon Catheter rupture and gas loss

- Haemolysis

- Inability to wean

- Incorrect timing

- Compartment syndrome

- Acute renal failure




Self test 2.

1. What are the two ways that ECG and pressure can be monitored to use the

IABP?




5. Discuss the complications associated with the use of the IABP?

6. How is weaning achieved at Liverpool Hospital? What other ways can

weaning be achieved?


8. What does augmentation mean on the IABP? What is the most common

problem if augmentation is not full?



Nursing Care

- Hourly haemodynamics recorded

- Hourly circulation observations

- Hourly IABP ratio and level of augmentation

-

Nursed supine, 30o

elevated or on side (ensuring that the leg which has the ballooninserted through the groin is straight at all times, avoid bending it.

- Hourly urine output to indicate an early sign of IAB catheter migration.

- Daily CXR to monitor position of IAB catheter

- Observe insertion site for infection and bleeding.

- Observe and maintain normal coagulation and electrolyte balance

- Monitor and observe the external tubing from the catheter to pump for any

condensation or bloodstains.

- Ensure patient is quiet and relaxed with minimal movement around the bed.

Sedation may be required.

- Maintain a patient airway. The patient may be extubated if awake and orientated

and satisfies extubation protocol.

Cardiac Arrest

In the event of a cardiac arrest, the IABP can be used in normal mode of either ECG

or pressure trigger, as the system will synchronise to the rate and rhythm of chest

compressions. Internal trigger in some institutions are used, this provides a fixed rate

of 80 beats per minute. The IABP in the unit in the event of a cardiac arrest is either

left on ECG trigger or placed on standby. An IABP can remain on standby insitu for

no more than 30 minutes. Any longer may cause clots forming on catheter, resulting

in thrombosis being pushed through the system.

Defibrillation

The current IABP is completely isolated from the patient and safe to have the patient

defibrillated, ensuring staff remains clear from the IABP when shock is delivered.

Arrhythmias

In the event of AF the IABP should be triggered from ECG and deflation point should be moved to the extreme right. This will cause an automatic deflation on the R wave,

maximising the time the IAB catheter is inflated with an irregular HR and arterial

pressure.

Pacemaker

If the ECG trigger is unable to determine an R wave with the pacing spike, then Pacer

V/AV or Pacer A may be used.



Troubleshooting:

The following are common problems that may occur when using an IABP.

a) No trigger – This means that the IABP has lost its tracing of ECG or Pressure and

is unable to time the inflation and deflation:

Action: To reconnect the ECG leads or pressure cable, or change the ECG leads

or tracing lead to obtain a better trace.

b) IAB Disconnected – this means the IAB catheter extension tubing has been

disconnected and the pump will stop working.

Action: Reconnect the extension tubing, PRESS IAB Fill for 3 seconds till

prompt is on the screen and the PRESS Assist/Standby to start pumping.

c) Rapid Gas Loss - This will appear if there is a leak or hole in the balloon or

extension tubing. This means the balloon may be ruptured, you will see flecks of

blood in the tubing ( no gushing blood, as blood is under pressure).

Action: If the balloon is losing its gas and filling is frequently necessary, or blood

flecks have been identified in the tubing, then stop pumping and call the RMO. It

will mean that the catheter will need to removed and replaced. Check all

connections for any leaks or disconnections.

d) Check IAB Catheter – this means that the IAB Catheter is either kinked insitu or

at the insertion site or it has not unwrapped fully insitu.

Action: Examine the catheter and extension tubing for any signs of kinking.

Ensure that full augmentation is on, making sure the balloon has the ability toexpand. Examine the skin insertion, as this is a common place for kinking. If

problem continues, contact RMO.

e)

Low Helium – this means that the supply of helium is less than 24 fills.

Action: The helium cylinder needs replacing. Please ensure that the O ring is not

dislodged while changing the cylinder as this ensures the seal.



f) Low Battery – This means the battery has less than 30 minutes of operating time.

Action: Ensure that the balloon pump is connected to the mains power at all

times, to recharge the battery.

g) IAB Failure – This means that the IABP console fails to pump, usually as a result

of electrical malfunction or the presence of blood in the condensers.

Action: Contact RMO. Disconnect patient from the IAB console and obtain

another IAB console (this should only to be attempted if the balloon is not

ruptured, as the same problem will occur). Ensure that the machine is not labelled

faulty. Depending on the patients haemodynamic status, the IAB catheter maybe

removed.

h) Augmentation Below Limit Set - This means that the augmented diastolic has

fallen below the alarm set.

Action: Review the alarm set and consider lowering it in line with the patients

progress or if concerned with the drop, then contact RMO.




Self test 3.


any longer?



IABP therapy?



6.

What is the correct procedure if the IABP fails?

7. What would you do if you lose your trigger for the IABP?

8.

How would you tell if your IAB catheter had ruptured? What procedure would





Post test


2.

What are the effects that are achieved when using IABP therapy?





7. What are the two ways that ECG and pressure can be monitored to use the IABP?





12. How is weaning achieved at Liverpool Hospital? What other ways can weaning

be achieved?


14. What does augmentation mean on the IABP? What is the most common problem

if augmentation is not full?


any longer?

16.

During a cardiac arrest, what mode should be used for the IABP?


IABP therapy?


19.

Describe the nursing care required for a patient on the IABP?

20.

What is the correct procedure if the IABP fails?




22. How would you tell if your IAB catheter had ruptured? What procedure would





Post test - answers


The Intra-Aortic Balloon Pump (IABP) is used to provide circulatory assist to support

a failing left ventricle. It is used for the following conditions:

• Acute left ventricular failure post cardiac surgery

• Severe unstable angina

• Cardiogenic shock post myocardial infarction

• Bridge to cardiac transplantation

• Stunned myocardium after myocardial infarction

2. What are the effects that are achieved when using IABP therapy?

The IABP has the following effects:

•

Increases coronary artery perfusion• Increases myocardial oxygen supply

• Decreases myocardial oxygen demand

• Decreases myocardial work by reducing afterload

• Increases blood pressure

• Decreases Pulmonary artery pressure


Counterpulsation is the process where blood is displaced with the inflation and

deflation of the balloon catheter, this is timed to the cardiac cycle. Meaning that blood

is expelled against a force, being the balloon in an opposite direction.


Helium is used as it is easily dissolves in blood than air and prevents the risk of air

emboli if the catheter ruptures.


The IAB catheter is threaded up through the femoral artery and is positioned in the

descending thoracic aorta, distal to the subclavian artery and proximal to renal

arteries. It is important to avoid obstruction of these arteries as CVA and/or renal

failure may be caused.


The size of the balloon is important, as it’s based on the height of the patient.

Incorrect sizing will cause occlusion of sub-clavian or renal arteries as the balloon

will be too long. If the balloon is too short then sub-optimal therapy will be provided

and the Left Ventricle will not have and assistance.

7. What are the two ways that ECG and pressure can be monitored to use the

IABP?

ECG and pressure monitoring can be achieved by directly from the patient, meaning

another set of ECG dotes and pressure measurement from the balloon. These are

usually called direct monitoring. The other way is indirect or slaving from the



monitor for both ECG and pressure traces. The pressure is arterial blood pressure,

aortic which is measured in the direct method.


Timing is the most important aspect of having an IABP insitu, as incorrect timing will

cause the heart to work harder and not give the full benefit of afterload reduction andmaximise coronary artery perfusion. Incorrect timing may cause further damage to an

already failing heart if it has to work harder to achieve demand.


Inflation of IAB should occur just after the closure of the aortic valve in diastole.

This is shown on the arterial waveform as the diacrotic notch. The diacrotic notch

denotes closure of the aortic valve, when blood has been ejected from the (L)

ventricle into the aorta. The effect is a displacement of blood in the aorta which

causes an increase in diastolic arterial pressure and an increase in cardiac output.

10. When should the IAB be deflated, and what is the effect of deflation?Deflation of the IAB occurs in systole. Typically seen on the screen as being half

way down the down slope after the diacrotic notch, prior to the aortic value opening.

The effect is a decrease in aortic end diastolic pressure (afterload) by the balloon

deflating and creating space in the aorta. This causes less impedence to blood being

expelled from the left ventricle. Resulting in an decreased ventricle wall tension,

increased stroke volume and complete emptying of the ventricle. Cardiac work is

reduced due to a decrease in left ventricular end systolic volume and preload, which

reduces the cardiac work.


Complications of the IABP are the following:

-

Limb Ischaemia

- Bleeding from site and internal

- Infection/Sepsis

- Aortic dissection

- Embolism

- Thrombosis

- False aneurysm

-

Aortic Valve Rupture

-

Catheter obstruction due to improper positioning with renal arteries or subclavian -

Inappropriate timing causing ↑ afterload and stress of left ventricle.

- Pump failure

-

Balloon Catheter rupture and gas loss

- Haemolysis

- Inability to wean

- Incorrect timing

- Compartment syndrome

- Acute renal failure



12. How is weaning achieved at Liverpool Hospital? What other ways can

weaning be achieved?

Weaning of the IABP is commenced when the patient is haemodynamically stable and

it is evident that it is no longer required. It is achieved by decreasing the frequency of

assistance, meaning decreasing to 1:2, then to 1:3 and observing the patients

haemodynamics. Weaning can also be achieved by decreasing the augmentation ofthe balloon, however there are dangers with the potential for thrombosis being formed

if this method is used.


Signs of failure in the weaning process are increases in PAP, decrease in BP, CO and

CI. This may show that the heart is not coping with the withdrawal process, and

should not continue, therapy should be continued.

14. What does augmentation mean on the IABP? What is the most common

problem if augmentation is not full?

This is the ability of the balloon to be fully expanded and contain the full amount ofhelium for the catheter. During normal pumping it should be maintained on full

(meaning all lights on) to prevent blood clots forming by the sides of the pump and

preventing thrombosis formation. The ability of the balloon to forward flow blood

when inflated may be affected if blood is allowed to flow down the sides of catheter.

15. How long should an IABP Catheter remain insitu and not operating, and why

not any longer?

The IABP catheter should remain insitu not inflating and deflating for no longer than

30 minutes. If the balloon is not being operated then blood will clot due to stasis. If

then pumping is commenced clots will be propelled through the body and thrombosis

or an anuerysm may form the aorta.


In the event of a cardiac arrest, the IABP can be used in normal mode of either ECG

or pressure trigger, as the system will synchronise to the rate and rhythm of chest

compressions. The internal trigger may be used, this provides a fixed rate of 80 beats

per minute. The IABP in the unit in the event of a cardiac arrest is either left on ECG

trigger or placed on standby.

17. What actions should be taken if a patient requires defibrillation while

requiring IABP therapy?The current IABP is completely isolated from the patient and safe to have the patient

defibrillated, ensuring staff remains clear from the IABP when shock is delivered.


The pacemaker or pacing spike may not be able to be determined by ECG triggering,

as it relies on R wave to pump. Changing the trigger to Pacer V/AV or Pacer A may

be used.




- Hourly haemodynamics recorded

- Hourly circulation observations

- Hourly IABP ratio and level of augmentation

-

Nursed supine, 30o

elevated or on side (ensuring that the leg which has the ballooninserted through the groin is straight at all times, avoid bending it.

- Hourly urine output to indicate an early sign of IAB catheter migration.

- Daily CXR to monitor position of IAB catheter

- Observe insertion site for infection and bleeding.

- Observe and maintain normal coagulation and electrolyte balance

- Monitor and observe the external tubing from the catheter to pump for any

condensation or bloodstains.

- Ensure patient is quiet and relaxed with minimal movement around the bed.

Sedation may be required.

- Maintain a patient airway. The patient may be extubated if awake and orientated

and satisfies extubation protocol.

20. What is the correct procedure if the IABP fails? The IABP console failure is usually as a result of electrical malfunction or the

presence of blood in the condensers. Action is to contact RMO. Disconnect the

patient from the IAB console and obtain another IAB console (this should only be

attempted if the balloon is not ruptured, as the same problem will occur). Ensure that

the machine is not labeled faulty. Depending on the patients haemodynamic status,

IABP therapy may be ceased and IAB catheter removed.


If the IABP tracing of ECG or Pressure is lost the IABP can not function. Action is to

reconnect the ECG leads or pressure cable, or change the ECG leads or tracing lead to

obtain a better trace. Then commence pumping.

22. How would you tell if your IAB catheter had ruptured? What procedure

would you use if this occurred?

A ruptured IAB catheter will not show the classic blood gushing out as it is under a

pressure. Blood flecks will be seen in the tubing and the IABP will have gas loss and

check catheter alarms. These after a few silences will no longer be able to be rectified

this way and the pump will stop working to prevent blood contamination of the

condensers. Then stop pumping and call the RMO. It will mean that the catheter willneed to removed and replaced. Check all connections for any leaks or disconnections.


In the event of AF the IABP should be triggered from ECG and deflation point should

be moved to the extreme right. This will cause an automatic deflation on the R wave,

maximising the time the IAB catheter is inflated with an irregular HR and arterial

pressure.

liverpool sdl iabp

Documents