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ICID > Clinical Management > Cardiovascular > Pages > Intra-aorticBalloonPump-PatientManagement  

Pages: Intra-aorticBalloonPump-PatientManagement

Version HistoryVersion History

Name

Intra-aorticBalloonPump-PatientManagement 

Title

Intra-aortic Balloon Pump - Patient Management 

Description

 

Scheduling Start Date

 

Scheduling End Date

10/01/2017 07:00 

Page Not Required

No 

16 Revision

1.0

Contact

 

Contact E-Mail Address

maria.ford@salisbury.nhs.uk 

Contact Name

Maria Ford 

plcIndications

1.1  Background

The Intra-Aortic Balloon Pump (IABP) is a circulatory assist device that is used to support the left ventricle. It is used in patients with a wide range of disorders that cause a low cardiac output and include:

  • Haemodynamic support during and after Percutaneous Coronary Intervention (PCI)

  • Unstable angina

  • Cardiogenic shock

  • Pre operatively in high risk patients

  • Mechanical complications post myocardial infarction

The IABP is inserted percutaneously through the femoral artery and positioned in the descending thoracic aorta. The catheter tip lies distal to the left subclavian artery and proximal to the renal arteries. On chest x-ray, the tip should be visible between the 2nd and 3rd intercostal space.

 Figure 1: Balloon pump set up

The size of the IABP is dependent on patient’s height to prevent occlusion of the renal and subclavian arteries. Inflation and deflation of the balloon catheter is timed to the cardiac cycle.  The balloon is connected to a console that regulates the inflation or deflation of the balloon with the passage of helium. Inflation of IABP occurs just after the closure of the aortic valve causing an increase in diastolic arterial pressure and an increase in cardiac output.

Figure 2: Balloon inflation

Deflation of the IABP occurs in systole causing a decrease in aortic end diastolic pressure, ventricle wall tension and increase in stroke volume.

Figure 3: Balloon deflation

The physiological effects are:

  • Increases coronary artery perfusion

  • Increases myocardial oxygen supply

  • Decreases myocardial oxygen demand

  • Decreases myocardial work by reducing afterload

  • Increases blood pressure

  • Decreases pulmonary artery pressure

Helium is used to inflate the balloon as it is easily dissolved in blood and prevents the risk of air emboli if the catheter ruptures. When a patient is on an intra-aortic balloon pump the nurse should expect to see the following waveform, figure 4.

Figure 4: Normal balloon inflation

When balloon-assisted, the diastolic pressure should always be the highest pressure recorded on the waveform. This will ensure that the coronary arteries receive the maximum blood flow. The balloon-assisted systolic pressure should be lower than the patients non-assisted, systolic pressure due to the reduction in afterload.

Arterial pressure monitoring

The central lumen of the IABP catheter allows monitoring of the arterial pressure in the descending aorta during the cardiac cycle. When connected to a transducer it will display a waveform that the nurse will be expected to interpret.

For further information about care of the arterial line please refer to the “Arterial Line Policy”.

IABP triggering

The trigger is the way the IABP identifies the beginning of the cardiac cycle. There are 5 ways triggering may be achieved. 

  • ECG mode: Using the R wave on the ECG 

  • Pressure: Using the arterial pressure waveform. In irregular rhythms, the pressure trigger mode is not recommended

  • Pacer V (ventricular)/AV(atrioventricular): Uses ventricular spike to trigger an event, is not an appropriate trigger for demand pacing

  • Pacer A (atrial): Used when the patient has an atrial pacemaker. In this mode the R wave on the ECG is the trigger, the atrial pacer spikes are enhanced and rejected. Never used for patients who have a ventricular pacemaker. 

  • Internal: Allows a synchronous trigger set at 80 beats/min. The internal mode should never be used if a patient is generating a cardiac output. 

1.2 Aim/purpose

The aim of the policy is to ensure that safe and effective care is delivered to patients who have an intra-aortic balloon pump. This will be achieved by:

  • Ensuring that appropriate training is provided for all personnel involved in the management of the IABP

  • Ensuring that the device is managed and removed safely in accordance with evidenced based practice 

  • To ensure that practice is audited across the Trust and that local incident data relating to IABP’s are collected & reviewed. 

1.3 Patient/client group

All patients who have an intra-aortic balloon pump.

1.4 Exceptions/ contraindications

  • Severe aortic regurgitation

  • Abdominal or aortic aneurysm

  • Aortic dissection

  • Severe calcific aorta-iliac disease

  • Severe peripheral vascular disease

  • Previous fem-pop bypass

1.5 Definition of terms

Afterload

The amount of pressure the left ventricle must work against to pump blood into the systemic circulation

Preload

This is determined by the amount of blood remaining in the left ventricle at the end of diastole

Augmentation

The ability of the balloon to be fully expand and contain the full amount of helium for the catheter. During normal pumping this is maintained on full to prevent blood clots forming. 

Counter pulsation

Counter pulsation is when aortic blood is displaced with the inflation and deflation of the balloon catheter. This is timed to the cardiac cycle.

Dicrotic notch

The dicrotic notch reflects the slight backflow of blood in the aorta that follows closure of the aortic valve and pulmonary valve (semi lunar). It represents the end of ventricular systole and beginning of diastole.

Contractility The ability of the cardiac cells to contract. This depends upon how much the muscle fibres are stretched at the end of diastole

plcClinicalMangement

2.1 Staff & equipment

Staff Training 

All patients with IABP’s should be cared for in clinical areas that are familiar with the needs of the patient. Nursing staff caring for these patients must have received training and be able to demonstrate that they are competent in the management of the patient. Documentation of level of competency in relation to IABP’s should be included in all ward/unit induction programs and staff training portfolios. 

Pre-requisite for caring for the patient 

Caring for the patient 

  • The practitioner must be supported to complete the ABG competency, appendix 2

  • The practitioner must be supported to complete the IABP competency, appendix 3

  • The practitioner must have received training from the cardiology physiologist and/or company representative in the care of the patient with an IABP

Ward location

Following insertion the patient will be transferred to a level 2 facility where a minimum 1 to 2 nurse to patient ratio can be secured. The Department of Health guidelines (2000) define level 2 as:

“Patients requiring more detailed observation or intervention, including support for a single failing organ system or post-operative care and those ‘stepping down’ from higher levels of care.”

Tisbury Ward and Radnor Ward are able to provide level 2 care.

The Department of Health guidelines (2000) define level 3 as:

“Patients requiring advanced respiratory support alone or basic respiratory support, together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.”

Radnor Ward is the designated level 3 facility within the Trust and will accept patient’s with an IABP who require ventilation. 

Staffing levels 

The patient requiring an IABP to support cardiac function may also have multisystem instability and/or failure. The intensive nature of the nursing intervention therefore requires:

  • The nurse to patient ratio for a patient with an IABP is 1:1

  • A ratio of 2:1 may be required at the discretion of the charge nurse

  • The nurse caring for the patient must have completed the requisite training and be able to safely manage the patient and troubleshoot the console 

  • The nurse assigned to relieve for breaks must be trained to care for the patient on the IABP

  • The nurse who relieves for meal breaks must have completed the requisite training and be able to safely manage and troubleshoot the console in the nurse's absence 

Equipment 

2.2 Method/procedure

For the insertion procedures

For setting up the IABP

For IABP removal

Nursing management 

The aim of nursing management and intervention is to:

  • Evaluate the patient’s response to therapy in relation to haemodynamic status, control of arrhythmias, systemic vascular perfusion and relief of cardiac symptoms

  • To monitor the patient for the early signs of complications and intervene to prevent harm

  • To ensure that the IABP is functioning by confirming that the machine is delivering the correct timing

  • To ensure that the nurse is able to undertake appropriate troubleshooting of all alarm situations and safe operation 

 

Nursing intervention

Cardiovascular 

  • Monitor temperature, pulse, systolic, diastolic and mean arterial blood pressure hourly

  • Observe and record the IABP waveform

  • Ensure ECG leads are secure

  • Monitor and treat arrhythmia’s

  • Maintain therapeutic anticoagulation

  • Monitor radial and pedal pulses hourly

Respiratory

  • Monitor respiratory rate and pulse oximetry hourly

  • Provide supplementary oxygen as required

  • Encourage deep breathing exercises

Renal 

  • Catheterise and monitor urine output hourly

  • Monitor renal function daily

Gastrointestinal 

  • Assist and monitor patients dietary and food intake

  • Use of nutritional supplements if required

  • Refer to dietician as needed

  • Monitor bowels and give laxatives as required

Skin 

  • Educate the patient about the need to be elevated no more than 30 degrees and to keep the affected leg straight

  • Observe pressure areas

  • Use the SKIN bundle and turn patient every 2- 4 hours. Use a minimum of three members of staff to ensure that the balloon is not moved

  • Ensure that the insertion site is visible whilst maintaining patient dignity

  • Check IABP entry site hourly and observe for bleeding and /or haematoma formation

  • Monitor limb perfusion hourly

CNS

  • Fully inform patient and family about what is happening

  • Keep noise levels to a minimum

  • Cluster care to allow for periods of uninterrupted sleep

  • Monitor pain score hourly and ensure adequate pain control

Documentation

  • The procedure must be fully documented in the patient notes 

  • The IABP Observation Chart, appendix 4, should be used for every patient with an IABP. 

  • Following insertion observations should be recorded on the Trusts TPR chart. Observations should be carried out every 15 minutes for the first hour and then hourly until the line is removed. 

  • Following removal observations should be recorded on the Trusts TPR or ITU chart every 15 minutes for the first hour, hourly for 3 hours and 4 hourly until discharge.

Clinical support 

There will be a cardiology consultant and physiologist available for advice throughput the 24 hour period. 

 

Monday to Friday 

08:00 to 17:00

Monday to Friday

17:00 to 08:00

Weekends and bank holidays 

Cardiology consultant

Extension 4258

Via switchboard

Via switchboard

Cardiology physiologist 

Via switchboard

Via switchboard

Via switchboard

Troubleshooting - IABP pump

Problem

Cause

Action

No Trigger

IABP has lost the ECG trigger

Reconnect ECG leads

IABP disconnected

Extension tubing has become disconnected

Reconnect the extension tubing. Press IABP fill for 3 seconds then press assist/standby to start pumping

Rapid gas loss

Leak, kink or hole in the tubing 

Check the patients leg is not bent up, check all connections and check tubing, if flecks of blood appear in the tubing the IABP may have ruptured- stop pumping and inform cardiologist immediately

Check IABP catheter

Means the catheter is kinked

Examine catheter for signs of kinks and ensure patients leg is kept straight

Low helium

Helium level slow

Inform cardiac technician to change helium tank

Low battery

Not plugged into the main supply

Plug into wall socket

IABP failure 

IABP console fails to function as a result of technical malfunction or presence of blood in the condenser

Contact cardiologist and technician immediately

Leak in IABP circuit

Loose connection, high rate of helium diffusion from the balloon or ruptured balloon

Check connections. If blood is evident in the line stop the pump and contact the cardiologist immediately. 

Augmentation set below limit 

Augmentation outside of set parameters 

Check patients vital signs, review alarm parameters, check the transducer is in line with the patient. If concerned contact cardiologist

Prolonged time in standby

  •  Taking too long to troubleshoot alarms

  •  Error in recommencing therapy

  • Do not recommence intra-aortic balloon pumping if the balloon has been stopped for 20 minutes

  • Contact the cardiologist immediately

In the event of a cardiac arrest

  •  The IABP can be left in mode of ECG or pressure as it will synchronise to the rate and rhythm of chest compressions

  •  If put into standby mode can be left in this mode for NO MORE than 30 minutes

  • The IABP is completely isolated from the patient and is safe to defibrillate

Troubleshooting - IABP Waveform 

Problem

Waveform

Physiological effects

Nursing actions

Early inflation

The balloon inflates during systole and when the aortic valve is closed i.e. before the dicrotic notch

Hanlon-Pena & Quaal (2011)

 

  •  Increases myocardial workload

  • Decreases stroke volume

  • Decreases cardiac output

Contact the Cardiac Physiologist on Ext 4258 between 08.00 and 5.15pm or via switch board out of those hours

Early deflation

With early deflation, a U shape appears and peak systolic pressure is less than or equal to assisted peak systolic pressure. 

 

  • Decreased coronary artery perfusion

  • Decreased afterload reduction  

Contact the Cardiac Physiologist on Ext 4258 between 08.00 and 5.15pm or via switch board out of those hours

Late inflation

The balloon inflates after the closed aortic valve. The dicrotic notch precedes the inflation point.

 

  • Reduction in coronary artery perfusion pressure

Contact the Cardiac Physiologist on Ext 4258 between 08.00 and 5.15pm or via switch board out of those hours

Late deflation

The balloon has been inflated too long or inflates at the beginning of ventricular ejection. The left ventricle has to eject blood against the resistance of the inflated balloon.

 

  • Increases afterload

  • Increases myocardial oxygen consumption

  • Increases cardiac workload

  • Increases preload

Contact the Cardiac Physiologist on Ext 4258 between 08.00 and 5.15pm or via switch board out of those hours

 2.3 Potential complications / risk management

Complication

Cause

Nursing assessing/action

Limb ischaemia 

Femoral artery obstruction

  • Thrombus formation

  • Balloon migration up the aortic arch reducing blood supply to the  left arm

  • Document hourly pedal pulses

  • Document hourly radial pulses 

  • Document limb temperature

  • Document limb colour 

Inform medical team immediately if there is a change to limb perfusion 

Bleeding from the insertion site

  • Secondary to coagulopathy 

  • Secondary to vessel damage during insertion

  • Secondary to patient movement

  • Retro-peritoneal bleeding

  • Hourly cardiovascular observations 

  • Keep site exposed whilst maintaining patient dignity

  • Observe the insertion site anteriorly 

  • Observe for bleeding posteriorly

  • Observe posteriorly for bruising to the flanks (Grey Turner's sign)

  • Prevent catheter movement

Inform medical team immediately if there is significant uncontrolled bleeding

Thromboembolism

  • Caused by the presence of the balloon 

  • Higher risk if there is a lower inflation ratio or if pump stops

  • Anticoagulation as per hospital policy

  • Check clotting studies as per hospital policy

Thrombocytopenia

  • Mechanical damage to platelets

  • Anticoagulation therapy 

  • Observe patient for bruising, oozing and/or bleeding

  • Monitor platelet count

  • Replace where indicated

Balloon catheter rupture and gas loss 

  • Contact with sharp object

  • Balloon membrane fatigue

  • Contact with a calcified plaque 

  • Backflow of blood into the tubing

  • Immediate response required if console alarms “gas leak”, “low augmentation” or  “blood detect”

Inform medical team immediately

Aortic dissection

  • Increased risk in patients with a friable aorta i.e. those with connective tissue disorders including Marfan’s disease

Observe patient for the following signs and symptoms:

  • Back pain

  •  Abdominal pain

  • Cardiovascular instability

Inform medical team immediately

Compartment syndrome

  •   Temporary or partial limb ischaemia

Observe limb for 

  • Swelling

  • Loss of sensation and/or function

  • Pain

  • Measure and record calf girth

Inform medical team immediately

Infection
  • During insertion procedure secondary to a failure to maintain site asepsis

  • Following insertion secondary to a failure to maintain site asepsis

  • Secondary to site contamination from incontinence

  • Hourly observations 

  • Check septic markers daily 

  • Aseptic technique for all line interventions

  • Check and record VIP score daily 

  • Use semi-occlusive transparent dressings and change when soiled 

  • Consider bowel management system if the patient has diarrhoea

Inform medical team immediately if you suspect a line infection 

Renal failure
  • Decreased urine output after the insertion of IABP can occur if the balloon moves distally occluding the renal arteries and reducing renal perfusion

  • Catheterise

  • Hourly urine output

  • Check renal function 

Inform medical team immediately if urine output decreases

 

plcPatientInformation

The nurse should ensure that the patient understands the following:

  • Educate the patient about the need to avoid sitting up more than 30 degrees 

  • Educate the patient about the need to keep the affected leg straight

plcAudit

4.1 Audit Indicators

Aspect of care

% Compliance 

Exception

Definition

  1. The nurse caring for the patient has completed a minimum of 7.5 hours of theoretical training on:

a. Arterial lines

b. IABP

100%

None

Arterial line competency training log

IABP competency training log

On line eLearning certificate

2. The nurse caring for the patient has complete a minimum of 7.5 hours of radial arterial line practical training on Radnor Ward

100%

None

Arterial line competency training log

3. The nurse caring for the patient has complete a minimum of 7.5 hours of IABP practical training on Tisbury Ward

100%

None

IABP competency document

4. The member of staff caring for the patient has completed the “arterial line competency” document within 6 months of training

100%

None

IABP competency document

5. The member of staff caring for the patient has completed the “IABP competency” document within 6 months of training

100%

None

IABP competency document

6. A copy of the arterial line competency statement  has been placed in the personnel file

100%

None

Personnel file

7. A copy of the IABP competency statement  has been placed in the personnel file

100%

None

Personnel file

8. The patient was cared for in a level 2 facility

100%

None

Healthcare record

9. A minimum of 1:2 nurse to patient ratio was achieved

100%

When a 1:1 ratio has been required

Healthcare record

Safety briefing

Nursing evaluation

10. All patient complications are documented and investigated via the Trust’s adverse event reporting process

100%

None

Incident reporting

Healthcare record

 

4.2  Audit design

 

See appendix 5 for audit data collection tool

plcEvidenceBase

 
  1. Hanlon-Pena, P and Quaal, S.  (2011) Intra-aortic balloon pump timing: review of evidence supporting clinical practice American Journal of Critical CareVolume 20, no 4, pp323 - 333

  2. Marquet (2013) Learning resources http://ca.maquet.com/clinician-information/e-learning-programs/

  3. The Intensive Care Society (2009) Levels of Critical Care for Adult Patients London.

plcAppendices

Appendix 1 Trust Study Day   Appendix 1
Appendix 2 ABG Competency  Appendix 2
Appendix 3 IABP Competency   Appendix 3
Appendix 4 IABP Observation Chart Appendix 4
Appendix 5 Date Collection Tool Appendix 5

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plcSummary

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Content Type: Guidance
Version: 1.0 
Created at 26/11/2014 03:17  by S15499807\Administrator 
Last modified at 26/11/2014 03:17  by S15499807\Administrator