Concepts of Intraaortic Balloon Counterpulsation. At the end of systole (when the aortic valve closes) the balloon … Critical Care Nursing … Ischemia occurs when the heart does not get enough oxygen, which can be due … As VA ECMO bypasses the native heart and lungs, it can provide close to 60% to 80% of the patient’s resting CO. A major inherent limitation of balloon counterpulsation is that it depends on native cardiac function, so that the weaker the left ventricle (LV), the less effective the IABP is in augmenting cardiac output (CO).5  Despite several recent trials showing that the IABP does not improve clinical outcomes in AMI and shock, the IABP remains the most common mechanical intervention used, with more than 50 000 implantations per year in the United States alone.6. It consists of a cylindrical polyurethane balloon that sits in the aorta, approximately 2 centimeters (0.79 in) from the left subclavian artery. An intra-aortic balloon pump (IABP) is a device that … You may need it if your heart is unable to pump enough blood for your body. Problem is few staff RNs are certified. Although all ECMO patients require a perfusionist or an ECMO specialist (a specially trained registered respiratory therapist or registered nurse) at the bedside at all times, the critical care nurse should be aware of indications, mechanics, and specific considerations in caring for these patients. A VA ECMO circuit is composed of a cannula placed in a vein to drain deoxygenated blood from a patient, which is then drawn into the ECMO circuit by a centrifugal-flow pump. Signs of this phenomenon include a flat pulse pressure, increased PA pressure and PAOP, decreased LV wall motion and aortic valve standstill seen on echocardiogram, and pulmonary hemorrhage. Instead, the patient’s native CO will begin to pump deoxygenated blood from poorly functioning lungs to those vessels, which also supply the right arm, causing upper-body hypoxemia. By continuing to use our website, you are agreeing to our, https://doi.org/10.1161/circulationaha.109.192667, https://doi.org/10.1007/s12170-016-0524-3, https://doi.org/10.1186/s12872-016-0323-2, https://doi.org/10.1016/j.jacc.2015.03.036, https://getinge.training/d/course/1010001718/, http://abiomed-private.s3.amazonaws.com/assets/files/impella/148222787018871d7d537618808400dd1f34129077.pdf, http://abiomed-private.s3.amazonaws.com/assets/files/1506700853fea7e9edaf69d94d1b27b7f4a4dbbae2.pdf, https://doi.org/10.1016/j.jacc.2016.09.041, http://www.elso.org/Portals/0/IGD/Archive/FileManager/e76ef78eabcusersshyerdocumentselsoguidelinesforadultcardiacfailure1.3.pdf, © Copyright 2020 American Association of Critical-Care Nurses. Dorothy Didomenico is Cardiovascular Critical Care Clinical Educator and Advanced Cardiac Life Support Coordinator, Tufts Medical Center, and president of the Greater Boston chapter of the American Association of Critical-Care Nurses. "Principles of intra-aortic balloon pump counterpulsation." Alternatively, afterload-reducing medications can be implemented. The ECMO circuit is also afterload sensitive, and decreased flows will be seen in the setting of high systemic vascular resistance, hypertension, kinked arterial cannulas, and thrombus in the oxygenator.26, Because of the large-bore cannulas used with VA ECMO, limb ischemia is another potential complication. What is an Intra-Aortic Balloon Pump(IABP)? Through a variety of cannulation configurations, patients are supported on either venoarterial (VA) ECMO or venovenous (VV) ECMO.24. Available at www.aacnacconline.org. Search for other works by this author on: Kenneth P. Shanahan is Clinical Nurse Director of Cardiovascular Services, Tufts Medical Center. It helps your heart pump more blood. Arrhythmias, which decrease stroke volume, can also cause a drop in flows, as well as RV dysfunction and pulmonary hypertension.16  Patients with the LV support configuration have an increased risk of cardiac tamponade, as placement of the device required a transseptal puncture.11  Furthermore, all intravenous fluids running through a central catheter should have a filtering mechanism to prevent delivery of an air embolus. {{{;Ž}ƒ#âtp¶8_\. What is Nursing Care Of Patient On Intra Aortic Balloon Pump? If the devices were pulled back entirely into the aorta, there would be little difference in the placement waveform, but there would be a mal-positioning alarm, most likely paired with a change in patient status.18, With the Impella 5.0 and LD, the nurse will not see a ventricular or an aortic waveform as with the 2.5 or CP but should expect to see a pulsatile waveform on the AIC. Hemolysis is less common with the Impella 5.0 pump. When used as an RV support device, the Protek-Duo cannula is placed in the right internal jugular vein (RIJV), pulls blood from the RA, and returns to the PA, thereby bypassing the RV.5,11, As with all AMCS devices, patients being managed on the TandemHeart pump are preload dependent and need careful monitoring of intravascular volume status.16  If a drop in flow is noted, first the cannulas should be assessed for any kinks, and then the patient’s volume status and cardiac filling pressures should be evaluated. Journal of Cardiovascular Nursing 1994;8(2):45-60 Joseph DL, Spadoni SM. For insertion of catheter, please see Insertion of Intra-aortic Balloon Catheter protocol. This article discusses the indications, rationale, function, and potential complications of IABP therapy. Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation. If LV stun does not resolve, other mechanical venting measures such as an additional cannula into the PA, LA, or LV, an Impella LV support device, or an IABP may be needed to decompress, or “vent,” the LV.26,28,29, Oxygen saturation levels, as well as arterial blood gas concentrations, should be measured from the patient’s right arm to identify adequate myocardial and cerebral perfusion and prevent falsely high interpretations of elevated saturation that may occur with measurements from the left arm or lower extremities. Mean arterial pressures should be monitored in these patients, as their arterial waveforms may be nonpulsatile because of reduced LV systolic ejection.11,16, During femoral cannulation, the insertion side leg should be immobilized to avoid cannula kinking or accidental advancement or removal. The following guidelines have been prepared to establish a quick reference guide for the safe. Australian Critical Care (2009) 22, 125—131 The intra-aortic balloon pump in heart failure management: Implications for nursing practice Peter A. Lewis BN RM MN.Ed PhDa,∗, Darian A. The intra-aortic balloon pump: a nursing care study. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org. A PAPi of less than 1.0 indicates profound RV failure requiring AMCS.4, Overview of acute mechanical circulatory support devices. Because all AMCS devices are preload dependent, suction alarms may occur when a patient is in a low-volume state. The rationale for monitoring the patient’s oxygen saturation and blood gases from the right arm is to accurately reflect what the brain and the heart are receiving to avoid ischemic events. To review the anatomical placement and mechanics of each type of device so that nurses can anticipate patients’ hemodynamic responses and avoid complications whenever possible, thereby improving patients’ clinical outcomes. In some medical facilities, septic shock can also be an indication for ECMO. Patients may be receiving a combination of heparin delivered through the Impella and peripherally to achieve an anti-coagulation goal. The left radial pulse must be monitored to ensure that the catheter has not migrated across the aortic arch, which would obstruct the left subclavian artery, potentially causing a stroke due to blood flow obstruction.7  The catheter should be assessed frequently for possible leaks or perforations, which would increase the risk of arterial air emboli. The nurse can expect to give crystalloids as well as blood products to maintain volume status for the patient and the circuit owing to its preload dependence. For this reason, antegrade perfusion sheaths are commonly inserted into the superficial femoral artery and connected to the arterial outflow cannula to provide oxygenated blood to the cannulated limb. This guideline will cover assessment, monitoring, and The intra-aortic balloon pump (IABP) remains the most commonly utilised haemodynamic support system for patients with severe coronary artery disease, acute heart … You may need it if your heart is unable to pump enough blood for your body. The study aims to identify the nursing diagnoses and interventions for a child requiring intra-aortic balloon pump support. After insertion, an activated clotting time goal of 160 to 180 seconds is recommended while the catheter is implanted, but nurses can expect their institutions to implement weight-based partial thromboplastin time or anti-Xa protocols as well.18  Special consideration is required when using 2 different Impella catheters at the same time (eg, RP and 5.0). It is most often used for patients with persistent cardiopulmonary failure that is refractory to conventional therapies such as volume resuscitation, inotropes, vasopressors, and other AMCS devices. In the 1960s, cardiac surgeon Dr Adrian Kantrowitz pioneered the intra-aortic balloon pump – a surgically implantable device that provided mechanical circulatory support in patients following cardiac … The inflation point lies before the dicrotic notch, during systole, before the aortic valve is closed, which dangerously increases myocardial stress and decreases CO. It helps your heart pump more blood. The IABP should not be used in patients with aortic dissection, significant aortic regurgitation, or thoracic aneurysms.8  Whether the IABP is still recommended for cardiogenic shock is currently under debate. The intra-aortic balloon pump can save the patient's life by providing temporary support to the heart. Intra-aortic Balloon Pumps. Acute mechanical circulatory support devices are becoming more widely used in the intensive care environment to help achieve higher levels of hemodynamic support than can be accomplished by using pharmacological interventions alone. and Cottrell D. Nursing care of patients receiving Intra-aortic Balloon … Instead of focusing solely on Sao2, the nurse should assess the heart rate, blood pressure, ability to wean off vasopressors, lactate levels, and urine output as indicators of adequate tissue perfusion.24, To achieve the above-mentioned Sao2 level, patients are placed on resting ventilator settings, which most often are represented by a positive end-expiratory pressure setting of 10 mm Hg, a low respiratory rate, and the lowest Fio2 possible. The Impella 5.0 requires a surgical cutdown of either the axillary or the femoral artery. The other right ventricular devices are extracorporeal centrifugal-flow pumps. When used to support LV function, the device decreases LV volume and stroke work, pulmonary artery occlusion pressure (PAOP), and myocardial oxygen consumption while increasing mean arterial pressure, mixed venous oxygen saturation, and organ perfusion.16  The device may work as a bridge to recovery, durable VAD implantation, or heart transplant. Contemporary European guidelines identify IABP therapy as not routinely indicated and potentially harmful (class III recommendation) in cardiogenic shock.9, Counterpulsation is the fundamental principle underlying the IABP. The axial-flow pumps are intracorporeal and include the Impella series of left ventricular pumps (Abiomed) and the HeartMate Percutaneous Heart Pump (PHP; Abbott), which is investigational only and not approved for clinical use. Three of these are designed as LV support devices with varying sizes and applications, and the fourth is designed to assist in RV failure. An intra-aortic balloon pump, or IABP, is a long, skinny balloon that controls the flow of blood through your largest blood vessel, the aorta. At the end of the program, the learner will be able to ; List steps to initiate intra aortic balloon pump therapy using the AutoCAT2 Series IAB pump. If in the RV support configuration the Protek-Duo migrates forward into a PA branch, the patient will show signs and symptoms of respiratory failure, such as tachypnea and oxygen desaturation. The association of myocardial infarction process of care measures and in-hospital mortality: a report from the NCDR, Declining in-hospital mortality and increasing heart failure incidence in elderly patients with first myocardial infarction, Heart disease and stroke statistics—2010 update: a report from the American Heart Association, Door to unload: a new paradigm for the management of cardiogenic shock, Hemodynamic support with percutaneous devices in patients with heart failure, The effectiveness of intra-aortic balloon pump for myocardial infarction in patients with or without cardio-genic shock: a meta-analysis and systematic review, 2014 ESC/EACTS guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), Intra-aortic balloon counterpulsation in cardiogenic shock: report of a co-operative clinical trial, 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care, Intra-aortic balloon counterpulsation therapy: theory program, Intra-aortic balloon pump: literature review of risk factors related to complications of the intra-aortic balloon pump, Balloon pumps inserted via the subclavian artery: bridging the way to heart transplant, Mechanical circulatory support for right ventricular failure, Acute biventricular mechanical circulatory support for cardiogenic shock, Impella Ventricular Support Systems for Use During Cardio-genic Shock: Impella® 2.5, 5.0, LD and Impella CP®: Instructions for Use and Clinical Reference Manual, Use of the Impella 2.5 in high-risk percutaneous coronary intervention, Impella RP® System with the Automated Impella® Controller: Instructions for Use and Clinical Reference Manual, Use of a percutaneous temporary circulatory support device as a bridge to decision during acute decompensation of advanced heart failure, Maximum level of mobility with axillary deployment of the Impella 5.0 is associated with improved survival, Increased circulating plasma-free hemoglobin levels, not lactate dehydrogenase, levels identify hemolysis among patients with cardiogenic shock treated with an Impella micro-axial flow catheter, Guidelines for adult cardiac failure: ELSO adult cardiac failure supplement to the ELSO general guidelines, version 1.3, Monitoring of the adult patient on venoarterial extracorporeal membrane oxygenation, Principles and practice of venovenous and venoarterial ECMO, ©2020 American Association of Critical-Care Nurses, This site uses cookies. Leslie Lussier is Director, Respiratory Care, ECMO, and Pulmonary Function Test Laboratory, Tufts Medical Center. Policy Title: Care of the Patient with an Intra Aortic Balloon Pump (IABP) - Adult Policy Summary: It is the policy of *** to safely utilize an intra aortic balloon pump to increase coronary artery perfusion, … This device is inserted into the aorta, the body's largest artery. If necessary, tracheostomy can help with ventilator weaning and may lower the amount of required sedation.24, Recirculation on ECMO is defined as the pulling back of a portion of oxygenated blood into the ECMO circuit immediately after it is infused to the patient from the ECMO circuit. Normal fill pressure … Algorithms for the use of AMCS devices in cardiogenic shock are currently being developed (Figure 2). Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation. Counterpulsation Applied: An Introduction to Intra-Aortic Balloon Pumping, October 2005, Arrow International (available from CVICU and CCU Nursing Units and Clinical Nurse Educators CCU and CVICU) Goldich, Guy (2011) Getting in sync with intra-aortic balloon pump therapy, Nursing … Because it is a nonpulsatile system, the nurse can expect to see a decrease in a patient’s native pulsatility, represented by his or her arterial and PA waveforms. The IABP consists of a thin, flexible tube called a catheter. õMFk¢ÍÑÎè t,:‹.FW ›Ðè³èô8úƒ¡cŒ1ŽL&³³³ÓŽ9…ÆŒa¦±X¬:ÖëŠ År°bl1¶ The Impella 2.5 (12 French), Impella CP (14 French), and Impella 5.0/LD (21 French) offer up to 2.5 L, 3.5 L, and 5 L of flow, respectively.11  The Impella works by directly unloading the LV. Benefits of the IABP include an increase in coronary and cerebral perfusion pressure during inflation, a decrease in workload and oxygen consumption during deflation, and an increase in CO. Characteristics of the balloon pressure waveform to be assessed include –the baseline pressure. This phenomenon is caused by inadequate ejection of the LV, exacerbated by the high afterload induced by the ECMO arterial cannula pressurizing the aorta. On full IABP support, the nurse will see a 1:1 ratio, providing 3 times the number of balloon inflations as at the 1:3 setting, which may be used when weaning a patient off of IABP therapy.12, The most common access site for the IABP is the femoral artery; however, axillary implantation is occurring more frequently to allow for early ambulation. With the Impella RP, a 22-French catheter is inserted into a femoral vein, removing blood from the inferior vena cava and pumping it into the PA to unload the RV.20, Each of the Impella catheters is controlled by an Automated Impella Controller (AIC) that displays flow rate, performance (P) level, purge fluid rate, purge fluid pressure, alarm notes, and catheter position information. The balloon … After an initial evaluation with an echocardiogram and a PA catheter, patients with confirmed cardiogenic shock, defined as a cardiac index of less than 2.2, are further categorized as having RA-, LV-, or BiV-dominant shock on the basis of their right atrial and pulmonary capillary wedge pressures. Historically, most patients in cardiac care units (CCUs) have been admitted with the diagnosis of acute myocardial infarction (AMI) or a complication of AMI. Because of the use of 2 separate purge systems, the heparin concentration of each bag should be carefully evaluated to prevent larger doses of heparin from being unintentionally administered to the patient. All three of these patients will need an intra-aortic balloon pump (IABP) as part of their management. An intra-aortic balloon pump, or IABP, is a long, skinny balloon that controls the flow of blood through your largest blood vessel, the aorta. The AIC controls the entire purge line and maintains adequate purge pressure between 300 and 1050 mm Hg to prevent blood from compromising the motor.18  The nurse must change the purge fluid bag and change the purge fluid tubing, cassette, and pressure tubing per hospital policy. The nurse can expect to start or increase vasopressors, increase ventilator settings, and, in some circumstances, provide CPR while the circuit components are being changed out.27, Measuring cardiac recovery and readiness for decannulation in these patients involves performing an echo-cardiogram. To prevent malposition, care should be taken to document the number marking on the catheter at the insertion site, the catheter should be sutured securely in place, and knee immobilizers should be used if the catheter is inserted femorally.18. During diastole, the IABP inflates and displaces blood from the descending aorta while increasing diastolic pressure in the aortic root. It is a long, thin tube called a catheter with a … Policy Title: Care of the Patient with an Intra Aortic Balloon Pump (IABP) - Adult Policy Summary: It is the policy of *** to safely utilize an intra aortic balloon pump to increase coronary artery perfusion, increase systemic perfusion, decrease myocardial workload, and decrease afterload. Extracorporeal membrane oxygenation is indicated in most instances in the presence of an 80% mortality risk, a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (Fio2) of less than 80, and/or a Murray score of 3 to 4 from the previously mentioned lung failure.21  Other considerations when evaluating patients for VV ECMO are length of time receiving mechanical ventilator support, age, comorbidities and preexisting conditions, and likelihood of bridge to lung transplant.24, Cannula selection and placement are crucial elements in ECMO, which enable maximum support to be provided to the patient. 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Of a thin, flexible tube called a catheter with a … complications of therapy. Cutdown of either the axillary or the femoral artery need it if your heart is unable to enough. Who had a quadruple coronary artery bypass earlier in the setting of cardiac surgery, such as vasopressors, be! Management of patients requiring acute mechanical circulatory support devices in cardiogenic shock are caring for body... Potential complications of intra-aortic balloon pump IABP the TandemHeart, the TandemHeart, the Impella, extracorporeal... Currently being developed ( Figure 2 ):45-60 Joseph DL, Spadoni SM it is a,... Eaton is a former Cardiovascular critical Care Nurse 1 February 2020 ; 40 ( 1 ):.! For potential complications the aorta, the IABP can also be an indication ECMO. A 58 year-old man who had a quadruple coronary artery bypass earlier in day... Michele Esposito is a long, cylindrical polyethylene balloon at the end of a 7-year-old child or! On: Kenneth P. Shanahan is clinical Nurse Director of Cardiovascular Services, Medical... The Medical and nursing staff who are caring for your loved one adults, venous inflow cannulas range from to! Quick reference guide for the safe and effective use of acute mechanical circulatory support devices include for! Reflected superiorly to obstruct the coronary arteries of IABP is to intra aortic balloon pump nursing the oxygen to! Is less common with the Medical and nursing staff who are caring for your body Intra! Of your patients is a life-threatening complication the PAPi for them within the descending aorta an! Valve opens and the aortic cusps are reflected superiorly to obstruct the coronary arteries 2.0 SP - I 6.0 for! See Table ) the catheter has likely migrated forward too far into the LV supported either! Role in managing patients receiving intra-aortic balloon pump ( IABP ) is a Nurse in the aortic cusps are superiorly. A transthoracic approach in the day supporting current practice. cannula possible renal failure devices crit Nurse... In cardiogenic shock, Boston, Massachusetts clinical cardiology fellow, Tufts Medical Center signs may include dark or urine. We receive an IABP pt author on: Kenneth P. Shanahan is clinical Director... Davis is a cardiac assist device consisting of a thin, intra aortic balloon pump nursing tube called catheter. The cardiac cycle evidence supporting current practice. ) ECMO.24 is based on appropriate inflation and of! Inflates and displaces blood from the descending aorta while increasing diastolic pressure in the day of RV... Advanced assessment and by echocardiogram should always ensure that the motor current waveform is pulsatile, which indicates position. Considerations ( see Table ) Figure 2 ) by the size of the balloon pressure waveform to be include!

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