PROCEDURE 55 • Knowledge of the anatomy and physiology of the cardiovascular system is needed. • Understanding of the principles of hemodynamic monitoring, electrophysiology, dysrhythmias, and coagulation is necessary. • Clinical and technical competence related to the use of the intra-aortic balloon pump (IABP) is needed. • Advanced cardiac life support knowledge and skills are necessary. • Indications for IABP therapy are as follows: • Contraindications to IABP therapy are as follows: • The relative value of IABP therapy in the presence of severe aortoiliac disease, major coagulopathies, and terminal disease should be evaluated individually. • IABP therapy is an acute short-term therapy for patients with reversible left ventricular failure or an adjunct to other therapies for irreversible heart failure. Cardiac assistance with the IABP is performed to improve myocardial oxygen supply and reduce cardiac workload. Intra-aortic balloon (IAB) pumping is based on the principles of counterpulsation (Fig. 55-1). • The events of the cardiac cycle provide the stimulus for balloon function, and the movement of helium gas between the balloon and the control console gas source produces inflation and deflation of the balloon. • Recognition of the R wave or the QRS complex on the electrocardiogram (ECG) is the most commonly used trigger source. • Inflation occurs during ventricular diastole and causes an increase in aortic pressure. This increased pressure displaces blood proximally to the coronary arteries and distally to the rest of the body. The result is an increase in myocardial oxygen supply and subsequent improvement in cardiac output. • Deflation occurs just before ventricular systole or ejection, which decreases the pressure within the aortic root, reducing afterload and cardiac workload. • Insertion and placement verification: Figure 55-2 Intra-aortic balloon positioned in the descending thoracic aorta, just below the left subclavian artery but above the renal artery. (From Quaal SJ: Comprehensive intraaortic balloon counterpulsation, ed 2, St Louis, 1993, Mosby.) • Timing methods of IABP therapy vary slightly from manufacturer to manufacturer. With the traditional or conventional method, the IAB deflates at the QRS complex, before isovolumetric contraction. The IAB also deflates at the QRS complex with the real-time method. An important principle of real timing is the duration of the balloon deflation during cardiac systole. During real timing, the IAB is timed to deflate at the onset of each QRS complex and to remain deflated throughout systole. A constant diastolic interval is not necessary for real timing.5,6,19,22 • The mechanics of the IABP control console vary from manufacturer to manufacturer. • Specific information concerning controls, alarms, troubleshooting, and safety features is available from each manufacturer and should be read thoroughly by the nurse before use of the equipment. • ECG and arterial pressure monitoring supplies • IAB catheter (size range, 7 Fr to 10 Fr for adults; balloon catheters vary in balloon volumes, 25 to 50 mL) • Antiseptic solution (e.g., 2% chlorhexidine-based preparation) • Caps, goggles or face shields, masks, sterile gowns, gloves, and drapes • O-silk suture on a cutting needle or a sutureless securement device • No. 11 scalpel, used for skin entry • 1% Lidocaine without epinephrine, one 30-mL vial • Stopcocks, one two-way and one three-way • 500 mL of normal saline flush solution (refer to institution standards or physician prescription regarding use of a heparin flush solution) Additional equipment to have available depending on patient status includes the following: • Assess patient and family understanding of IABP therapy and the reason for its use. • Explain the standard care to the patient and family, including the insertion procedure, IABP sounds, frequency of assessment, alarms, dressings, need for immobility of the affected extremity, expected length of therapy, and parameters for discontinuation of therapy. • After catheter removal, instruct the patient to report any warm or wet feeling on the leg and any dizziness or lightheadedness. • Assess the patient’s medical history, specifically related to competency of the aortic valve, aortic disease, or peripheral vascular disease.
Intraaortic Balloon Pump Management
PREREQUISITE NURSING KNOWLEDGE
Acute myocardial infarction (MI) complicated by left ventricular failure3,12,26,28
Recurrent ventricular dysrhythmias as a result of ischemia16
Support before, during, and after coronary artery bypass graft surgery2,29
Support before, during, and after coronary artery angioplasty or additional interventional cardiology procedures for patients at high risk4,11
Intractable ventricular dysrhythmias13,18
Bridge to cardiac transplantation, ventricular assist devices, or total artificial hearts
Cardiac injury, including contusion and coronary artery tears
The IAB catheter is commonly placed in the femoral artery via percutaneous puncture or arteriotomy.
The IAB catheter can also be placed via a transthoracic approach.15
The IAB catheter lies approximately 2 cm inferior to the left subclavian artery and superior to the renal arteries. This position allows for maximum balloon effect without occlusion of other arterial supplies (Fig. 55-2).
The IAB should not fully occlude the aorta during inflation. It should be 85% to 90% occlusive.
The central lumen of many IAB catheters provides a means for monitoring aortic pressure.
EQUIPMENT
PATIENT AND FAMILY EDUCATION
Rationale: Clarification or reinforcement of information is an expressed family need during times of stress and anxiety.
Rationale: This explanation encourages the patient and family to ask questions and prepares the patient and family for what to expect.
Rationale: These feelings may be indicative of bleeding at the insertion site.
PATIENT ASSESSMENT AND PREPARATION
Patient Assessment
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55: Intraaortic Balloon Pump Management
