ICID > Clinical Management > Cardiovascular > Intra-aortic Balloon Pump - Patient Management  
 

Intra-aortic Balloon Pump - Patient Management 

  •  
  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    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

    2. Clinical Management

    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

     


    3. Patient Information

    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


    4. Audit

    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

    5. Evidence Base

     
    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.


    6. Appendices

    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


    Document Owner Maria Ford 
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