Unit II (b) Intra-aortic

Balloon Pump
Counter pulsation
FACILITATOR:
TANZEEL UL RAHMAN
NURSING INSTRUCTOR
BSN, RN, M.PHIL PUBLIC HEALTH
Objectives

 1. Discuss Hemodynamics of IABP

 2. Describe the hemodynamic benefits of properly timed
balloon pumping
 3. List indications, contraindications and complications of
IABP
 4. Discuss Nursing responsibilities associated with IABP
 Intraaortic Balloon Pump
Counterpulsation
 In intraaortic balloon pump (IABP) counterpulsation,
inflation and deflation of a balloon in the thoracic aorta
is used to increase oxygen supply to the myocardium,
decrease left ventricular work, and improve cardiac
output
 The desired results of IABP therapy are increased
coronary artery perfusion and decreased afterload with
a subsequent increase in cardiac output.
 4
Intra Aortic Balloon
Indications for IABP
 Acute ventricular failure
 Cardiogenic shock
 Myocardial infarction
 Cardiac Surgery
 Bridge therapy for Heart Transplantation
 In combination with PCI
 Intractable angina
 High risk surgery
 Indications for IABP

1. Cardiogenic shock:
- Associated with acute MI
- Mechanical complications of MI - MR , VSD

2. In association with CABG :

Preoperative insertion
- Patients with severe LV dysfunction
- Patients with intractable ischemic
arrhythmias Postoperative insertion
- Postcardiotomy cardiogenic shock
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 VAD

Post infarction angina

Ventricular arrhythmias related to ischemia
Contraindication
 Aortic insufficiency
 Severe peripheral vascular occlusive disease
 Aortic aneurysm
 Aortic dissection
 Limb ischemia
 Thrombo embolism
 INSERTION AND OPERATION

• The balloon used in IABP counter-pulsation is positioned in

the thoracic aorta via the femoral artery. It is positioned just
distal to the great vessel and proximal to the renal artery.
- Once in place the balloon catheter is attached to a console
that displays the patient’s ECG and an arterial waveform for
timing of the balloon inflation and deflation.
- The console also displays a balloon waveform that illustrate
the inflation and deflation of the balloon itself. The balloon is
inflated and deflated in accordance with the cardiac cycle
Cont..
 Inflation occurs during diastole, increasing aortic pressure and
retrograde blood flow back towards the aortic valve. This increases
coronary artery perfusion pressure and blood flow, thus improving
oxygen supply to coronary arteries .
 Deflation occurs just before systole (i.e., just before blood is ejected
from the left ventricle). This decreases the impedance to
ejection(i.e., afterload), the ventricular workload and myocardial
oxygen demand.
 Timing of inflation and deflation must coincide with the cardiac
cycle to ensure the effectiveness of IABP therapy.
Conventional Timing or triggering

 Conventional timing uses the arterial waveform as the

triggering mechanism to determine both inflation and
deflation of the balloon. Balloon inflation occurs at the
dicrotic notch (which signals the closure of the aortic
valve and the beginning of diastole on the arterial
waveform). Deflation is timed to occur at end diastole,
just before the next sharp systolic upstroke on the arterial
waveform
Real timing or trigging

 Real timing uses the same point of reference on the

arterial waveform for balloon inflation but uses the ECG
signal as the trigger for balloon deflation. The QRS complex
is recognized as the onset of ventricular systole. Triggering
off the R wave allows for balloon deflation to occur at the
time of systolic ejection. Inflation - middle of T wave Real
timing is more effective in patients with irregular heart
rhythms because balloon deflation occurs on recognition
of the R wave. Real timing can also be achieved with a
special IABP catheter that has a fi beroptic pressure sensor
in the tip. The pressure sensor determines the precise time
when the aortic valve closes with each contraction of the
heart, regardless of the patient’s heart rhythm.
Expected changes with IABP support in hemodynamic profile in 15
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%

 Improper timing reduces the effectiveness of therapy and can be
detrimental to the patient
• Early inflation shortens systole abruptly and increases ventricular
workload as ejection is suddenly interrupted.
• Late inflation does not increase the coronary artery perfusion pressure
sufficiently.
• Early deflation allows pressure to rise to normal end-diastolic levels
preceding systole, resulting in no decrease in afterload.
• Late deflation encroaches on the next systole and increases
afterload because of the presence of the still-infl ated balloon during
early systolic ejection.
 17
Patient Management During IABP support

 Anticoagulation-- maintain apTT at 50 to 70 seconds

 CXR daily – to R/O IAB migration

 Check lower limb pulses - 2 hourly.

- If not palpable » ? - 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 30°.
 18
Patient Management During IABP support

 Never leave in standby by mode for more than 20 minutes >

thrombus formation

 Daily
– Haemoglobin (risk of bleeding or haemolysis)
– Platelet count (risk of thrombocytopenia)
– 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
Nursing consideration

 IABP counter pulsation is usually an unplanned, emergent

intervention for a deteriorating condition.
 Preparing family members prior to their fi rst visit with the
patient following device insertion and providing ongoing
explanations of the patient’s status and care can help to
alleviate anxiety.
 Honest communication helps family members recognize
changes in the patient’s condition and make informed,
realistic decisions regarding the patient’s care.
 Place pulse oximeter on left arm
 Tip should be in 2nd intercostal space anteriorly on Chest cxr
Nursing consideration
 Nurse must be able to recognize and correct problems
in balloon pump timing.
 Cardiovascular monitoring is also important in
determining the effectiveness of IABP therapy.
 Effective IABP therapy causes a decrease in heart rate ,
MAP and PAOP(Pulmonary artery occlusion pressure ).
 Heart rhythm and regularity must also be considered.
Irregular dysrhythmias may inhibit efficient IABP therapy
with some types of console because timing is set by the
regular R-R interval on ECG. Urine output , skin perfusion ,
and mentation are important assessment parameters for
determining the adequacy of cardiac output.
Nursing consideration

 Following insertion, the nurse assesses and documents

the quality of pulses, skin perfusion, and neurological
status per protocol, and notifies the physician of any
changes.
 Avoid hip flexion, which ma obstruct flow to the affected
extremity, by keeping the cannulated leg straight and
the head of the bed at an angle less than 30 degrees.
 Monitor for bleeding problems because heparine is
administered through out the therapy
Complication
 Mechanical problems
 Impaired circulation - obstruction
 Bleeding- groin heamatomas
 Infection
 Thrombosis
 Thromboembolism
 Vascular damage
 Aortic perforation or dissection
 Gas embolism
 Heparine induced thrombocytopenia
Weaning from IABP

 Weaning patients from balloon assistance usually can

begin 24 to 72 hours after insertion; some patients require
longer periods of support because of hemodynamic
instability. Indications for weaning from IABP therapy are
given in Box 13-9. Weaning is commonly achieved by
decreasing the assist ratio from 1:1 to 1:2 and so on until
the minimal assist ratio is achieved. A patient may be
assisted at the first decrease for up to 4 to 6 hours. The
minimal amount of time is 30 minutes. During this time,
the nurse assesses the patient for any change in
hemodynamic status.