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Aidah Abu Elsoud Alkaissi RN, BSN, MSN, PhD

Intra-aortic Balloon Pump Counterpulsation

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Journal of Cardiothoracic and Vascular Anesthesia, Vol 17, No 6 (December), 2003: pp 736-739

Intraoperative Transesophageal Echocardiographic Imaging of an Intra-aortic Balloon Pump Placed via the Ascending Aorta
Kent H. Rehfeldt, MD,* and Roger L. Click, MD
THE USE OF A perioperative intra-aortic balloon pump(IABP) in cardiac surgical patients is relatively common, occurring in 2% to 12% of cases.1 Although a femoral arteryinsertion site is typically used, the failure rate for IABP insertion via the femoral artery has been reported to be around 5%.2,3In patients in whom the IABP cannot be inserted from a femoral approach, placement via the ascending aorta may bepossible. When this transthoracic approach is used, intraoperative transesophageal echocardiography (TEE) is especiallyuseful in confirming correct position of the IABP in the thoracic aorta, as described in the following cases.
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From the Section of Cardiology and Cardiovascular Surgery, Norfolk General Hospital and Eastern Virginia Medical School, Norfolk, Virginia

Prophylactic Use of Intra-aortic Balloon Pump in Aortocoronary Bypass for Patients with Left Main Coronary Artery Disease
H. R. RAJAI, M.D., et al Aortocoronary bypass surgery in patients with left main coronary artery disease is reported to have an operative mortality of between 1.4 and 39%. It is generally accepted that the operative mortality in this group of patients is considerably greater than in routine bypass candidates, presumably due to the large amount of myocardium threatened by a single lesion. In an effort to preserve threatened left ventricular myocardium, intraaortic balloon pumping was instituted prophylactically prior to sternotomy in 20 consecutive patients with left main coronary artery disease (luminal narrowing greater than 50%). Sixty per cent of these patients had New York Heart Association Class IV angina, 25% had Class III, and 15% Class II. Fifty per cent of the patients in this group presented with unstable angina. Operative patients requiring left ventricular aneurysmectomy and/or valve replacement, were excluded. No operative deaths have been encountered in 20 consecutive patients managed in this manner. One patient displayed signs of myocardial infarction in the postoperative period. Correctable peripheral vascular ischemic complications of pump insertion were encountered in three patients. Preliminary results from this ongoing study support the hypothesis that 10/16/2013 6 prophylactic intra-aortic balloon pumping is a low risk procedure that should be utilized

Objectives
Demonstrate a basic understanding of the purpose

and desired outcomes of IABP


Identify key patient safety issues associated with the

use and monitoring of IABP


Describe nursing interventions related to IABP use

and monitoring

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IABP PURPOSE
Improves cardiac function during cardiogenic

shock. 26-28 cm balloon surrounds end of centrally placed catheter (from groin) Placed into descending thoracic aorta Inflates in diastole - fills coronary arteries retrograde Deflates in systole - decreases LV afterload
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Indications
1. Refractory ventricular failure

2. Cardiogenic shock
3. Unstable refractory angina 4. Impending (To threaten to happen) infarction

5. Mechanical complications due to acute

myocardial infarction 6. Ischemia related intractable (Difficult to manage) ventricular arrhythmias

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Indications
7. Cardiac support for high-risk general surgical

and coronary angiography/ angioplasty patients


8. Septic shock 9. Weaning from cardiopulmonary bypass 10. Support for failed angioplasty and

valvuloplasty
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Contraindications
Severe aortic insufficiency 2. Abdominal or aortic aneurysm 3. Severe calcific aorta-iliac disease or

peripheral vascular disease


4. Scarring of the groin

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Contraindications
Contraindications: Incompetent aortic valve

(because inflation increases aortic regurgitation) Nursing: Head of bed must be kept 30 degrees or lower. Must monitor for infection or bleeding IABP augments cardiac output by 15% & provides total support for the heart; which allows the heart to recover

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What is an IABP?

The Intra-Aortic Balloon

Counterpulsation system is a volume displacement device.


A device used to reduce left

ventricular systolic work, left ventricular end-diastolic pressure, and wall tension
Decreases oxygen consumption Increases cardiac output,
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perfusion, pressure and volume to Coronary Artries 10/16/2013

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The System 97e is a helium charged, mobile, Intra-Aortic Balloon Pump (IABP).
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Intra-Aortic Balloon Pump (IABP) -.

It is inserted into the descending aorta via the femoral artery either percutaneously or by surgical cut-down. The balloon rapidly deflates just before ventricular systole to reduce the impedance (A measure of the total opposition to current flow in an alternating current circuit) to left ventricular ejection

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It consists of a catheter

and a drive console.


The catheter has a long

balloon mounted on the end.


It should be positioned

so that the tip is approximately 1 to 2 cm below the origin of the left subclavian artery and above the renal arteries.
On chest x-ray the tip
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should be visible in the 2nd or 3rd

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Surgical Indications
Post Surgical Myocardial Dysfunction

Support for weaning from Cardiopulmonary Bypass

(CPB)
Cardiac support following correction of anatomical

defects
Maintenance of graft patency post CABG 19

Pulsatile flow during CPB

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Desired Outcome
Appropriately timed blood volume displacement (30

50 mL) in the aorta by the rapid shuttling of helium gas in and out of the balloon chamber, resulting in changes in inflation and deflation hemodynamics

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Insertion Techniques
A percutaneous placement of the IAB via the femoral

artery using a modified Seldinger technique (a needle is used to puncture the structure and a guide wire is threaded through the needle; when the needle is withdrawn, a catheter is threaded over the wire; the wire is then withdrawn, leaving the catheter in place.)
After puncture of the femoral artery a J-shaped guide

wire is inserted to the level of the aortic arch and then the needle is removed.
The arterial puncture side is enlarged with the
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successive placement of an 8 to 10,5Fr dilator/sheath 10/16/2013 combination. Only the dilator needs to be removed

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Insertion Techniques
Continuing, the balloon is threaded over the guide

wire into the descending aorta just below the left subclavian artery.
The sheath is gently pulled back to connect with

the leak-proof cuff on the balloon hub, ideally so that the entire sheath is out of the arterial lumen to minimize risk of ischemic complications to the distal extremity.
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Insertion Techniques
There are alternative routes for balloon insertion.
In patients with extremely severe peripheral vascular

disease or in pediatric patients the ascending aorta or the aortic arch may be entered for balloon insertion.
Other routes of access include subclavian, axillary or

iliac arteries.
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Intra-aortic balloon catheter


A balloon catheter comprising

an outer tube, a balloon, a tip and an inner tube, a proximal portion of said inner tube disposed within the outer tube and a distal portion of said inner tube extending beyond a distal end of the outer tube, the tip, a distal end of the inner tube, and a distal end of the 25 balloon membrane are

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Arterial Pressure
Balloon Pump 26 Console

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IABP correct placement

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Inflation
It inflates immediately

following aortic valve closure to to augment diastolic coronary perfusion pressure.

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the intra-aortic balloon positioned in the descending thoracic aorta, just below the left subclavian artery, but above the renal arteries.
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The principles of

counterpulsation state that the balloon should be inflated at the start of diastole, just prior to the Dicrotic Notch.
Aortic volume and pressure are

increased through displacement


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1. 2. 3.

4.

5.

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Increased coronary perfusion pressure Increased systemic perfusion pressure Increased O2 supply to both the coronary and peripheral tissue Increased baroreceptor response Decreased sympathetic stimulation causing decreased Heart Rate, decreased Systemic Vascular

Inflation of IABP Causes

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Deflation
The balloon rapidly

deflates just before ventricular systole to reduce Left Ventricular work


Deflation creates a

"potential space" in the aorta, reducing aortic volume and pressure

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1.

Afterload reduction and therefore a reduction in myocardial oxygen consumption (MVO2) Reduction in peak systolic pressure, therefore a reduction in LV work Increased Cardiac Output Improved ejection fraction (The amount of blood pumped out of a ventricle during each heart beat. The ejection fraction

Deflation of the IABP Causes

2.

3. 4.

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Factors Affecting Diastolic Augmentation


1. Patient Hemodynamics

Heart Rate Stroke Volume Mean Arterial Pressure Systemic Vascular Resistance

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Factors Affecting Diastolic Augmentation


2. Intra-aortic Balloon Catheter

IAB in sheath IAB not unfolded IAB position Kink in IAB catheter IAB leak Low Helium concentration

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Factors Affecting Diastolic Augmentation


3. IABP

Timing Position of the IAB augmentation control

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Review of Arterial Pressure Landmarks


AVO = Aortic valve

opens, beginning of systole PSP = Peak systolic pressure, 65-75% of stroke volume has been delivered

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DN = Dicrotic notch, signifies aortic valve closure and the beginning of diastole

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The rule of inflation is: inflate just prior to the Dicrotic Notch
To accomplish the goals

of inflation, the balloon must be inflated at the onset of diastole


The result of properly

timed inflation is a pressure rise PDP/DA = Peak diastolic pressure or diastolic augmentation, this is the pressure generated in 39 the aorta as the result of

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Review of Arterial Pressure Landmarks in 1:2 Assist


PAEDP = Patient aortic end diastolic

pressure, this is the patient's unassisted diastole PSP = Peak systolic pressure, this is the patient's unassisted systole PDP/DA = Peak diastolic pressure or diastolic augmentation, this is the pressure generated in the aorta as the result of inflation BAEDP = Balloon aortic end diastolic pressure, this is the lowest pressure produced by deflation of the IAB APSP = Assisted peak systolic pressure, this systole follows balloon deflation and should reflect the

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Inflation Hemodynamics
Coronary artery blood flow and pressure are

increased
Increased renal and cerebral blood flow

Increased diastolic pressure increases perfusion to

distal organs and tissues

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Triggering
It is necessary to establish a reliable trigger

signal before balloon pumping can begin


The computer in the IAB console needs a

stimulus to cycle the pneumatic system, which inflates and deflates the balloon
The trigger signal tells the computer that another

cardiac cycle has begun


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Triggering
In most cases it is preferable to use the R wave of

the ECG as the trigger signal


However, there are other trigger options for instances

when the R wave cannot be used or is not appropriate

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Trigger Loss
The console MUST see a trigger to initiate an

inflate/deflate cycle
If no trigger is seen when the clinician attempts to

start pumping, no pumping will occur and an alarm will be sounded


If the trigger is lost after pumping starts, no

further pumping will occur until a trigger is reestablished


The pump will go to STANDBY and an alarm will
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be sounded

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Trigger Loss
If the current trigger is lost the clinician can

choose an alternate, available trigger to resume pumping


For example, if the ECG lead becomes

disconnected the Arterial Pressure trigger may be selected until the ECG is re-established

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ECG Trigger

Since triggering on the R wave of the ECG is

preferred, it is very important to give the IABP a good quality ECG signal and lead

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Poor ECG Choices


Note: changing QRS

morphology may cause wandering timing


Note: tall T waves may cause

double triggering or may alter previously set timing points


Note: wandering baseline may

cause skipped trigger


Note: artifact may cause

inappropriate triggering

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ECG Gain

In addition to selecting a lead with a QRS morphology that

provides consistent, appropriate triggering, it is important to ensure the QRS complex has adequate amplitude
The computer has a minimum height requirement to

recognize the initial deflection as an R wave, whether upright or negative in configuration


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Triggering on the Arterial Pressure Waveform


Arterial pressure provides another signal to the

IABP to determine where the cardiac cycle begins and ends


It is used when the ECG has too much

interference from patient movement or poor lead connection


There are limitations to triggering on the arterial

pressure curve
Therefore AP trigger should be considered a backup
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trigger and not the one used as the primary trigger

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Valid Trigger Indications


Accurate Heart Rate displayed on pump Assist marker on/under ECG in same ratio as assist

ratio, e.g. if in 1:1 there should be one assist marker per ECG complex
Flash heart symbol next to HR on screen

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Trigger Loss

Possible Cause
1.

Operator Action
1.

ECG

2.

3. 4. 5.

6.

Loose or disconnected ECG leads Current type of ECG trigger is not appropriate ECG signal too small Very noisy ECG Monitor input disconnected Patient's cardiac activity ceased

2.

3.

4. 5.

6.

Check electrodes, lead wires and connections. Change to alternate appropriate ECG trigger. Change lead selection; change trigger source; check electrode placement. Increase ECG gain if applicable. Change to AP trigger. Check connections from monitor and secure. CHECK PATIENT FOR CARDIAC ACTIVITY

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Trigger Loss

Possible Cause

Operator Action

Arterial Pressure

1.

Arterial line dampened, disconnected or turned OFF

1.

Check arterial tracing; flush line; check transducer and monitor input; change to ECG trigger.
Change to ECG trigger CHECK PATIENT FOR CARDIAC ACTIVITY

2.

Heart Rate is irregular Patient's cardiac activity ceased

2.

3.

3.

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TIMING and WEANING


Balloon synchronization starts usually at a beat

ratio of 1:2.
This ratio facilitates comparison between the

patients own ventricular beats and augmented beats to determine ideal IABP timing.
Errors in timing of the IABP may result in different

waveform characteristics and a various number of physiologic effects.


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TIMING and WEANING


If the patients cardiac performance improves,

weaning from the IABP may begin by gradually decreasing the balloon augmentation ratio (from 1:1 to 1:2 to 1:4 to 1:8) under control of hemodynamic stability.
After appropriate observation at 1:8 counterpulsation

the balloon pump is removed.

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Gas Alarms/Balloon Pressure Waveform


During a cycle of inflation/deflation, helium is rapidly moved in and out

of the balloon. The environment within the balloon and the surrounding forces that affect balloon behavior all contribute to a predictable pattern of gas flow and pressure.
The Arrow International IABP consoles have in-line transducers that

relay the pattern of gas pressure during the inflate/deflate cycle.


The gas pressure characteristics are converted into a waveform that is

reflective of the behavior of the gas.


This transduced waveform can tell us much about the interaction of

the balloon within the patient's aorta.


Thorough understanding of the balloon pressure waveform is also
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important for efficient troubleshooting of the console as most of the alarms are based on this gas surveillance system. 10/16/2013

Normal Waveform Variations


Tachycardia Bradycardia

Hypertension

Hypotension

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Abnormal Waveform Variation: Wide Inflation and/or Deflation Artifact


Note the wide inflation and

deflation artifacts. This is generally indicative of something impeding the rapid inflation and deflation of the IAB, such as kinking of the gas lumen. This may result in poor augmentation and/or poor afterload reduction. It may also lead to helium/gas loss alarms in higher Heart Rates when in a 1:1 assist ratio. It may precede high pressure/kinked line alarms. The goal is to eliminate the partial obstruction, if 10/16/2013 possible, to enable the

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Abnormal Waveform Variation: Helium Loss / Gas Loss / Gas Leakage Alarms

Note the BPW

baseline is below 0.
This indicates that a

portion of the gas that went out to the balloon did not return to the pump.
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1.

Observe for blood in the gas tubing. If even a slight amount were present, it would indicate a balloon rupture.
1. Do not resume pumping. Notify physician

immediately and prepare for IAB removal.


2.

Check connections where gas tubing connects to IAB and to pump. 1. Secure if loose. Check for kinks, as they may trap gas in the IAB. If water is present in the gas tubing, remove the condensation. Pushing the helium through the water during inflation and deflation slows down 10/16/2013 gas transition. If gas transition is prolonged too

3. 1.
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Abnormal Waveform Variation: High Pressure / Kinked Line Alarm


Note that the plateau

pressure is still greater than 250mmHg when it is time to deflate.


This indicates that not

all of the gas could enter the balloon.


It is generally due to a

kink in the catheter, 10/16/2013 either internal to the

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1.

Reposition patient. Keep affected leg straight. Use rolled towel under hip to hyperextend hip. Apply slight traction to the catheter if suspect kinking at the insertion site or in the artery.

2.

3.

Introducer sheath may be kinked which in turn is kinking the balloon. Suspect this particularly if placement of the sheath was difficult. Pull sheath back or rotate sheath a partial turn.

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1.

Check placement of the balloon; it may be too high or too low. IAB may be partially wrapped if alarm occurs shortly after insertion. Take steps to facilitate unwrapping (consult IAB manufacturer). The balloon may be too large for the patient. Reduce the helium volume the balloon is inflated with. It is recommended to not reduce the volume below 2/3 of maximum. For example, do not decrease volume in a 40cc IAB below 27cc.

2.

1.

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Abnormal Waveform Variation: High

Baseline / Fill Pressure

Indicates too

much gas in the system.

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1.
2.

Check for intermittent obstruction of gas lumen.


Overfill of system.

3.

This condition may occur during ascent (an upward slope) in air transport since gas expands as you go up in altitude (elevation). Reset the alarm and restart pumping.
The volume will be adjusted automatically for current barometric pressure. In the AutoCAT, ensure that the tubing to the condensation bottle (located behind the helium tank) is not kinked. 10/16/2013

4.
5.

6.
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Potential Side Effects and Complications


Bleeding at the insertion site

Thrombocytopenia
Immobility of the balloon catheter Balloon leak

Infection
Compartment syndrome

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IABP COMPLICATIONS
Aortic dissection during insertion
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Reduction of platelets, RBC destruction Peripheral emboli Balloon rupture with gas embolus Renal failure (balloon occlusion of renal artery) Vascular insufficiency of catheterized limb
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Complications of IABP
The following patients are at the greatest risk of

developing complications associated with IABP:


Peripheral vascular disease (PVD), female,

diabetic, HTN, smokers, obese, high SVR, shock

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Complications of IABP
Aortic wall dissection, rupture or local vascular

injury Care as indicated


Emboli: thrombus, plaque or air Care as indicated

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Treatment of an air embolism is as follows Administer 100% oxygen and intubate for significant
respiratory distress or refractory hypoxemia.
Oxygen may reduce bubble size by increasing the

gradient for nitrogen to move out.


Promptly place patient in Trendelenburg (head

down) position and rotate toward the left lateral decubitus position.
This maneuver helps trap air in the apex of the
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ventricle, prevents its ejection into the pulmonary 10/16/2013 arterial system, and maintains right ventricular

Complications of IABP
IABP Rupture: Helium embolus or catheter

entrapment (take or catch as if in a snare or trap) COFFEE GROUNDS seen in the drive line is a precursor to a rupture NOTIFY RT & PHYSICIAN!!!!! IF THERE IS A FLAGRANT (bad or offensive) RUPURE OF THE IABP CLAMP THE GAS LINE!!!!!
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Complications of IABP
Infection Check catheter insertion site often STRICT ASEPTIC TECHNIQUE Restrict movement while IABP in place

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Complications of IABP
Obstruction Malposition Too high obstruction of left subclavian, carotids CHECK LEFT RADIAL ARTERY PULSE Too low obstruction of renal and mesenteric

arteries MONITOR URINE OUTPUT


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Complications of IABP
Compromised circulation due to catheter Ischemia
Routine nursing care and monitoring

Compartment syndrome
Rare complication seen in the LE (lupus erythematosus)

, usually related to infection Monitor calf circumference


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Complications of IABP
Hematologic ALL PATIENTS Typed & Crossmatched!!! Bleeding REMOVE THE DRESSING!!! PUT ON STERILE GLOVES!!! HOLD PRESSURE!!!

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Thrombocytopenia Routine monitoring

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1. 2. 3. 4. 5. 6. 7. 8. 9.

Zero Baseline (on console) Balloon Pressure Baseline Rapid Inflation Peak Inflation Artifact Balloon Pressure Plateau (IAB fully inflated) Rapid Deflation Balloon Deflation Artifact Return to Baseline (IAB fully deflated) Duration of Balloon Cycle

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European Journal of Cardio-thoracic Surgery 11 (1997) 11761179

Case report Successful surgery for perforation of the thoracic aorta caused by the tip of an intra-aortic balloon pump Thomas Wolff *, Peter Stulz Klinik fur Herz- und Thoraxchirurgie, Kantonsspital, Spitalstrasse 21, CH-4031 Basel, Switzerland We describe a case of perforation of the thoracic aorta caused by the tip of an intraaortic balloon pump. The perforation was confirmed by computed tomography (CT) scan and immediate surgical repair was successful. Vascular injury due to the insertion of an intra-aortic balloon pump is quite common but is predominantly confined to limb ischemia or injury to the femoral or iliac artery. Iatrogenic aortic perforation leading to significant bleeding is much less common and usually fatal. 1997 Elsevier Science B.V.Keywords: Aortic injury; Intra-aortic balloon pump; Complication
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Circ J 2002; 66: 423 424 Perforation of the Descending Aorta by the Tip of an Intra-Aortic Balloon Pump Catheter
Ryo Shiraishi, MD*; Yukio Okazaki, MD; Kozo Naito, MD; Tsuyoshi Itoh, MD Perforation of the proximal descending aorta occurred in a patient on intra-aortic balloon pump (IABP) supportafter emergency coronary intervention for acute myocardial infarction. The IABP catheter was inserted under fluoroscopic guidance into the right femoral artery without difficulty, but after 8 h on IABP support the patient went into shock with a left hemothorax. Emergency surgery was performed with cardiopulmonary bypass and a perforation of the proximal descending aorta with active bleeding was found and successfully repaired. A distorted descending aorta in which the IABP catheter was kinked, as in the aortic arch, was discovered during surgery and confirmed postoperatively with 3-dimensional computed tomography scans, particularly in the lateral view. Not only the antero-posterior but also the lateral fluoroscopic view is recommended to prevent aortic perforation by a kinked IABP catheter. (Circ J 2002; 66: 423 424)

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Heart Inst J 1995;22: 202-3J

Thrombosis of the Abdominal Aorta


Elisabeth Leude, MD et al A Rare Complication of the lntraaortic Balloon Pumping Device We describe a patient who died due to thrombosis of the abdominal aorta and its branches after placement of an intraaortic balloon pumping device. This rare complication, which occurred despite careful insertion technique, underscores the need to select balloon size as a function of the individual patient's morphology. (C omplication rates associated with the use of an intraaortic balloon pump(IABP) range from 10% to 20%.'5 Trauma-related complications are themost frequent, including dissection, perforation, and thromboembolism.We describe a patient who died of thrombosis of the abdominal aorta and itsbranches subsequent to intraaortic balloon pumping. To our knowledge, this complication has been reported only once before in the literature.
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Conclusions
1.The consistent application of intra-aortic balloon

pump support of patients with coronary artery disease and its complications has provided a therapeutic platform for direct surgical intervention on otherwise unstable patients with cardiac ischemia, heart failure, and shock.
This integrated approach to the treatment of

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patients with coronary artery disease has profoundly affected how this disease process is 10/16/2013 managed throughout the world.

Maintain systemic arterial pressure with fluid

resuscitation and vasopressors/beta-adrenergic agents if necessary.


Consider transfer to a hyperbaric chamber.

Potential benefits of this therapy include (1) compression of existing air bubbles, (2) establishment of a high diffusion gradient to speed dissolution of existing bubbles, and (3) improved oxygenation of ischemic tissues and lowered intracranial pressure.
Circulatory collapse should be addressed with
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CPR and consideration of more invasive

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Thank you

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