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INTRA-AORTIC BALLOON PUMP Circulatory assist mechanical device for .the failing heart

WHAT IS I.A.B.P ? ** I.A.B.P….basically is a unique console specially designed to : - increase coronary artery perfusion - increase systemic perfusion - decrease myocardial workload - decrease afterload I.A.B.P THERAPY IS AN ACUTE SHORT TERM THERAPY PROVIDES TEMPORARY MECHANICAL CIRCULATORY ASSIST TO THE FAILING HEART BY UTILIZINGTHE PRINCIPLE OF COUNTERPULSATION

Counterpulsation

WHAT IS ? COUNTERPULSATION THE PRINCIPLE OF COUNTERPULSATION IS REFER TO THE ALTERNATING INFLATION AND DEFLATION OF THE INTRA-AORTIC BALLOON DURING DIASTOLE AND SYSTOLE RESPECTIVELY

.Intra-aortic balloon pump therapy ;)The pump outside the heart( When the heart does not have enough .1 oxygen due to blocked coronary arteries, or other medical problems, the heart must .work harder to provide the needed oxygen Intra-aortic balloon pump therapy helps .2 restore the balance between the supply of oxygen-rich blood the heart receives from the coronary arteries, and the amount of .oxygen the heart needs to pump

;This therapy involves two components One is a thin balloon which is.1 positioned within aorta after being .introduced through an artery Second component of balloon pump.2 therapy is the pump itself. The pump continually inflates and deflates the balloon within the aorta in time with .the heart beat

The intra-aortic balloon pump assists** the heart during both its rest phase .and its work phase In the rest phase, the balloon inflates,** increasing the supply of oxygen-rich .blood to the coronary arteries In the work phase, the balloon** deflates, decreasing the workload on .your heart The decrease in workload results in a** decrease in the amount of oxygen the .heart needs to pump

.The normal work/rest cycle of the heart As blood is pumped, the heart is at work. ** During the work phase, the heart pumps oxygen-rich blood into the aorta and out to the .far reaches of the body This task requires a large amount of oxygen. At** the end of each work phase the heart has used up a large portion of the oxygen it has been .given As chambers fill, the heart is at rest phase,** preparing to pump more blood. During this phase the heart muscle is able to relax. While it is resting, it is receiving a fresh supply of oxygen-rich blood through the coronary .arteries

.How the intra-aortic balloon assists the heart When the balloon deflates, the heart's workload is** reduced. Just before the heart gets ready to work, .the balloon within the aorta deflates This deflation results in a drop in pressure in the** aorta, so that when the heart pumps it doesn't have to work against high pressure. Instead, the heart's workload is actually reduced, and blood is pumped .throughout the body more easily When the balloon inflates, the heart receives more** oxygen. When the heart is in its rest phase, and receiving its fresh supply of blood, the balloon .placed within the aorta is inflated by the pump This process pushes more oxygen-rich blood through** the coronary artery supply network and into the heart's muscle tissue, providing the tired heart with .extra energy for its work phase

Inflation of the balloon during diastole =** augmentation of the aortic diastolic pressure which increases coronary .) blood flow ) DPTI Deflation of the balloon occurs just prior** to the onset of systole and reduces impedance to left ventricular ejection .) )TTI This results in less myocardial work,** decreased myocardial oxygen consumption and increased cardiac .output

.PHYSIOLOGY EFFECT OF I.A.B.P : AUGMENTATION augmentation of the diastole pressure : INCREASE IN coronary perfusion mean arterial pressure cardiac output myocardial oxygen supply : DECREASE in Aortic End-Diastolic pressure heart rate afterload systemic vascular resistance left ventricular End-Diastolic pressure myocardial oxygen consumption -

;Increased Aortic diastolic pressure MAP Early transmitral flow Ejection fraction )cardiac output ( Coronary perfusion Cerebral & renal perfusion Myocardial O2 supply Diastolic coronary flow

;Decreased Aortic systolic pressure LVEDP Myocardial O2 consumption Lactate production Afterload Heart rate Systemic vascular resistance

Cases that may consider by expert requiring IABP : therapy Unstable angina Altered mental status Heart rate > 110bpm Dysarrthmias SBP < 90mmHg MAP < 70mmHg with Vasopressor support Cardiac index < 2.4 PAWP > 18mmHg Decreased SVO2 Inadequate peripheral perfusion Urine output < 0.5ml/kg/hour

Indication and contraindication

; INDICATON Refractory unstable angina.1 Cardiogenic shock / septic shock.2 Refractory left ventricular failure.3 Impending infarction.4 Complication of M.I.5 Cardiac contusion.6 ;Prophylactic support.7 coronary angiography /angioplasty thrombolysis high risk intervention procedure ; Bridging device.8 cardiac transplant total mechanical assistance -

: CONTRAINDICATION : ABSULUTE *** aortic valve insuffiency dissection of the aneurysm to the aortic * thoracic * : RELATIVE *** endstage cardiomyopathies atherosclerosis endstage terminal disease ) abdominal aortic aneurysm ) not resected peripheral vascular disease -

CONTRAINDICATION :Mechanical defects*** valvular disease / insufficiency ruptured papillary muscle ventricular septal defect left ventricular aneurysm : Surgical indication*** post surgery myocardial dysfunction inability to wean from C.P.B prophylactic support -

Set up of IABP Insertion of IAB catheter

Malaysia : Bed side CVICU staff SFH : Cath lab staff Assist in insertion of IAB either bedside or in CVL Technician set up IABP machine

Equipment require pre : insertion

IABP console )Helium gas tank)240psi ECG & Arterial pressure monitoring set IAB catheter set & insertion kits Skin prep requirement .Sterile dressing , drapes & gown Glove,cap,mask or goggle ) Suture ) cutting needle / silk Scalper blade Local anesthesia LA 1%/2% way stopcock connection 2/3 10/20/50ml leurlock plug syringes 50ml slip tip syringe Heparinised saline Hemodynamic transducer monitoring kits Medication as per doctors order sedation/analgesic Inotrops )IVF)NSS/D5NS etc .17

Fluoroscopy Portable CXR Emergency trolley Lead and apron Special stretcher

Prepare patient : explanation to pt’s and family Validate Consent

Ensure pt’s hooked on monitor* *assist doctor : - invasive procedure *indwelling catheter Ventilated cases lease with RT

Responsible as a nursing provider in IABP management and care

Establish ECG input to the IABP console** Obtain ECG configuration with optimal** R‘ wave amplitude‘ Or – indirect ECG input can be obtained** via bedside ECG to IABP console : Setting a trigger** R‘ wave‘ QRS complex arterial pressure waveform may be used as a trigger for balloon inflation and( )deflation NB:Pt‘s with PPM-set trigger to reject the pacemaker artifact .Obtained base data and investigation prior procedure** Ensure patient‘s condition allow to proceed with the** insertion of IAB catheter Notify doctor if any abnormality from the data** collection prior insertion and obtain written order .for IAB insertion

Insertion of IAB catheter team : - doctor - scrub nurse -circulating nurse -technician

Catheter insertion approach : *percutaneously ) common ) * cut down * via transthoracic placement ))during cardiac surgery

)Pre-insertion consideration:)IAB KITs Prior insertion of IAB catheter keep the IAB** cath in its package until absolutely ready to insert the balloon and to completely drawn the vacuum before the insertion, to ensure balloon .clear the sheath **)Complete IABP console)OK function test** ready set of pressure transducer correct ECG & related cables )helium tank)240psi Complete prep trolley for IAB insertion **

.Prior to removal of IAB from tray.1 connect the one way valve to the male luer on the . short drive line tube attached to the IAB Slowly aspirate a full syringe of air.2 make sure the one way valve remain connected to IAB until the balloon is properly positioned in . the patient Remove the cath from the tray, keeping it in line with.3 the IAB membrane grasp the cath close to the tray & pull it straight . out keep the cath level with the tray DO NOT LIFT or BEND the cath during removal )Remove stylet from central lumen )if applicable Flush the central lumen with Heparinised saline solution.4

For sheath insertion only : * Remove Peel-Away hemostsasis device prior to IAB catheter insertion. .* Push tabs to break,then peel away

:IAB sizing recommendation 30cc Height ”0’6< BSA

40cc < 162cm ”0’6-”4’5 < 1.8m2

50cc 162-182cm ”4’5 > > 1.8m2

>182cm

TRIGGERING To achieve optimal effect of counterpulsation,** inflation and deflation need to be correctly .timed to the patient’s cardiac cycle This is accomplished by either using the patient’s** ECG signal, the patient’s arterial waveform or an .intrinsic pump rate The most common method of triggering the IAB is** from the R wave of the patient’s ECG signal. Mainly balloon inflation is set automatically to start in the middle of the T wave and to deflate .prior to the ending QRS complex Tachyarrhythmias, cardiac pacemaker function** and poor ECG signals may cause difficulties in obtaining synchronization when the ECG mode is .used In such cases the arterial waveform for triggering may be used

TIMING and WEANING It is important that the inflation of the.1 IAB occurs at the beginning of diastole, noted on the dicrotic notch on the .arterial waveform Deflation of the balloon should occur.2 immediately prior to the arterial .upstroke Balloon synchronization starts usually at a.3 .beat ratio of 1:2 This ratio facilitates comparison between.4 the patient’s own ventricular beats and augmented beats to determine ideal IABP .timing Errors in timing of the IABP may result in.5 different waveform characteristics and a various number of physiologic effects

;Weaning consideration If the patient‘s 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 Consider discontinue heparin therapy 4-** .6hours before IAB cath removal

IABP support maybe discontinued if the patient clinical picture :present the following

Absent of low cardiac output syndrome )Urine output > 30ml/hr )>0.5ml/kg/hr Minimal inotopics support HR < 100bpm Absence of lethal/unstable Dysarrthmias MAP >70mmHg PAWP < 18mmHg CI > 2.4 Spo2 60-80% Capillary refill < 2sec .Angina free .7

Removal of balloon catheter

Done without an operative approach Can be done quickly & safely Explained procedure to patient Prep area & requirement Disconnect the balloon from the console permitting the IAB cath to vent to atmosphere pt BP will collapse, the balloon membrane for) )withdrawal Remove all dressing & suture prior to attempt to .withdrawn the IAB cath Post removal, continue observe hemodynamic status, check distal pulses & assess if risk of .complication

Secure hemostasis direct firm pressure at site 30-45min beside pressure at site,firm digital pressure to the femoral artery immediately above insertion site then apply pressure dressing .apply sand bag pressure for at lease 4-6hr .Notify doctor for risk of complication

Clinical factor increase IABP complication; * peripheral vascular disease * old age * female gender * Diabetic cases * Hypertension * prolonged support * large cath size > 9.5fr * body surface area < 1.8m2

* cardiac index < 2.2L/min/m2

Management for IABP trouble shooting

Theory of IABP Refer to lecture theory for IABP