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History
In 1950 and 1960 several physicians began looking at ways to assist the failing heart. In 1958 Dr. Harken and co-worker developed a model based on the idea by withdrawing a quantity of blood from the arterial system during systole and returning it during diastole. In 1960 SD Moulopolous introduce the concept of intra aortic balloon counterpulsation. IABP was first successfully used by Kantrowitz et al. in 1967
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What is IABP
It consists of a cylindrical balloon that sits in the aorta and counter-pulsates (Inflates during diastole and deflate during
systole).
It is in fact a system of volume displacement device which is used to decrease myocardial oxygen demand while at the same time increase the cardiac output as well as coronary blood flow.
Different parts
Double lumen catheter with a distal sausage shaped nonthrombogenic polyurethane balloon. Pump, equipped with a console display to view the ECG, aortic and balloon pressure waveforms. Central lumen extends to the catheter tip. Serves as a transducer to measure aortic pressure.
Central lumen is concentric with and situated inside the helium channel which is used for balloon inflation.
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ECG
Arterial waveform
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Catheter Inner Pressure Lumen Gas Shuttle Lumen Catheter Tip Membrane Sheath
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IAB Inflation
The balloon is timed to inflate at the onset of diastole and will remain inflated throughout diastole. The balloon is timed to begin inflation when the aortic valve closes. The dicrotic notch is used as a landmark for this event in the cardiac cycle.
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IAB Deflation
Occurs in systole Just before ventricular ejection Just prior to the pre-ejection period (PEP), or isovolumetric contraction.
The goal of deflation is to reduce LV workload, creating a "potential space" in the aorta, reducing aortic volume and pressure
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Insertion Of IABP
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Connection to IABP
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Animation of Insertion
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The IAB catheter should be positioned between the second and third intercostal space.
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If fluoroscopy is not available, measure the tip of the IAB from the sternal Angle of Louis to the umbilicus and then obliquely to the femoral insertion site.
(Note: An x-ray must be taken as soon as possible after insertion to correctly identify placement.)
Too High
Ideal
Too Low
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Balloon catheter volume is selected according to patient height. The most frequently used balloon catheter is the 40 cc. 36
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Animation of mechanism
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Coronary Artery Anatomy Diastolic Pressure Diastolic Time Oxygen Extraction Hemoglobin PaO2
In different pathology
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Effects of IABC
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Indications
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3. Acute MI
4. Refractory ventricular failure 5. Complications of acute MI 6. Cardiogenic shock 7. Support for diagnostic, percutaneous revascularization, and interventional procedures
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Indications..
8. Ischemia related intractable ventricular arrhythmias 9. Septic shock
10. Intra-operative pulsatile flow generation 11. Weaning from bypass 12. Cardiac support for non-cardiac surgery
Indications..
14. Post surgical myocardial dysfunction/low cardiac output syndrome 15. Myocardial contusion
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Cardiogenic shock (18.8%) Weaning from cardiopulmonary bypass (16.1%) Preoperative use in high risk patients (13%) Refractory unstable angina (12.3%) Refractory ventricular failure (6.5%) Mechanical complication due to acute MI (5.5%)
Contraindications
Absolute Severe Aortic Valve insufficiency Dissecting aortic aneurysms (Abdominal or Thoracic) Relative Severe calcific aorta-iliac disease or peripheral vascular disease (atherosclerosis) Abdominal aortic aneurysm Sheathless insertion with severe obesity, scarring of the groin Blood dyscrasias Thrombocytopenia
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Triggering
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Trigger is the physiologic signal used by the balloon pump to identify the beginning of a new cardiac cycle and to deflate the IAB if it is not already deflated. In most cases it is preferable to use the R wave of the ECG as the trigger signal
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Trigger Event
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Timing Assessment
120 C Increased Coronary Artery Perfusion F D Balloon Inflation
mm 100 Hg B 80
B E
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IAB Inflation
IAB Deflation
Zero Baseline
Hypertension
Hypotension
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Clinical Considerations
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Limb Ischemia
Assessment Check distal pulses, color, temperature, and capillary refill q30 minutes x 2 hours, then q2 hours Monitor differential toe temperatures Prevention Use smallest sheath/catheter size available Evaluate for risk factors: female, diabetic, PVD Select the limb with the best pulse
Treatment Options Subcutaneous Xylocaine injection for arterial spasm Change insertion site to opposite limb Bypass graft the femoral artery insertion site
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Prevention Employ careful insertion technique Monitor anticoagulation therapy Prevent catheter movement at insertion site
Treatment Options Apply direct pressure at insertion site, assuring distal blood flow Surgical repair of the insertion site
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Thrombocytopenia
Assessment Assess platelet count daily Prevention Avoid excessive heparin administration Treatment Options Replace platelets as needed
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Balloon Leak
Assessment Observe helium tubing for blood with or without the presence of a blood detected, low augmentation, gas loss, and/or IAB catheter alarm Prevention Do not remove IAB from T-handle/tray until ready to insert Treatment Options If blood is observed in catheter extender tubing, disconnect IAB from pump.
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Balloon Leak
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Infection
Assessment Observe insertion site for signs of infection Culture blood if symptoms of infection present
Prevention
Use sterile technique during insertion of the IAB catheter Change dressings using sterile technique per infection control policy Treatment Options Antibiotics
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Aortic Dissection
Assessment Assess patient for pain between shoulder blades Monitor hematocrit daily If dissection is suspected, an aortogram may be indicated Prevention Insertion of the IAB over a guidewire with fluoroscopic control Treatment Options Balloon removal Surgical repair of the dissection
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Compartment Syndrome
Assessment
Prevention
Use smallest catheter/sheath available Maintain adequate colloid osmotic pressure Treatment Options Fasciotomy if necessary
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Weaning of IABP
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Timing of weaning Patient should be stable for 24 hours. Cardiac output is satisfactory on minimal inotropic support (Dopa/Dobua < 5mics or Epinephrin <1mics) Winning is initiated by decreasing the inflation ratio from 1:1 to 1:2 for about 2-4 hours, then 1:3 or 1:4 for 1-2 more hours. Decrease augmentation Monitor patient closely If patient becomes unstable, weaning should be
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A 16% reduction of time on cardiopulmonary bypass was achieved when IABP therapy was used preoperatively.
Christenson, JT, et al. Eur J Cardiothorac Surg 1997;11:1097-1103
There was a significant reduction [p<0.0001] in the consumption of dopamine, dobutamine and norepinephrine
Christenson, JT, et al, Todays Therapeutic Trends 1999;17(3):217-225
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Patients who received preoperative IABP support experienced 34% shorter stays in the intensive care unit (p<0.004).
Christenson, JT, et al. Eur J Cardiothorac Surg 1997;11:1097-1103
Cardiac performance, including cardiac output and cardiac index, was significantly improved in patients who received IABP therapy prior to surgery. There was a 60% reduction in mortality in the IABP group [p<0.05]
Christenson, JT, et al. Eur J Cardiothorac Surg 1997;11:1097-1103
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The use of preoperative balloon pump therapy in patients undergoing CABG with EF 0.25 Reduced 30-day mortality Shortened the median post-operative hospital stay
Dietl, CA, et al. Efficacy and Cost-Effectiveness of Preoperative IABP in Patients with Ejection Fraction of 0.25 or Less. Ann Thorac Surg 1996;62:401-409
The use of balloon pumping in elderly high risk CABG patients reduced the risk of death and postoperative complications to the level seen in non-high risk patients.
Gutfinger, DE, et al. Aggressive Preoperative use of Intraaortic Balloon Pump in Elderly Patients Undergoing Coronary Artery Bypass Grafting. Ann Thorac Surg 1999; 67:610-613
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In conclusion the use of preoperative balloon pump therapy in high risk patients undergoing CABG
Reduces time on bypass Reduced drug consumption Shortens length of stay in the ICU Reduced cost of hospitalization Lowers in-hospital mortality
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References
Wiegand DJ, Carlson KK; AACN Critical Care Procedures, Performance Evaluation Checklists 3rd Edition. American Association of Critical Care Nurses 2005. Little C; Your guide to the intra-aortic balloon pump. ProQuest Information and Learning Company Springhouse Corporation Dec 2004. Schreuder JJ, Maisano F, Donelli A, Jansen JR, Hanlon P, Bovelander J, Alfieri O; Beat-to-beat effects of intraaortic balloon pump timing on left ventricular performance in patients with low ejection fraction. Annuls of Thoracic Surgery: 2005 Mar;79(3):87280. Linley GH, Bakker EW, de Vroege R, Spijkstra JJ; When the bloodback detection system fails: an IABP case report. Perfusion. 2003 Nov;18(6):369-71. Christenson JT, Badel P, Simonet F, Schmuziger M; Preoperative intraaortic balloon pump enhances cardiac performance and improves the outcome of redo CABG. Annuls of Thoracic Surgery. 2001 Apr;71(4):1400-1. Reference and Educational Materials for Intra-Aortic Balloon 93 Pumping Arrow International. www.arrowintl.com.
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