Before tThe intra-aortic balloon pump (IABP) became a successful piece of technology, it was first introduced by Harken in 1958 in hopes of treating left heart failure (IABPumpers, 2006). Harken thought that by removing a certain amount of blood from both femoral arteries during systole, and rapidly replacing it during diastole, he could augment the cardiac output and increase coronary perfusion. However, this pumping system led to extreme hemolysis and turbulence with failure to increase coronary blood flow (IABPumpers, 2006).
Soon after, Moulopoulus from Cleveland Clinic developed the first successful IABP in the 1960’s. This newly developed IABP was timed to inflate and deflate according to the phases of the cardiac cycle, and was first used in a clinical practice in 1968 by the Kantrowiz’s group (IABPumpers, 2006). Initially the placement of the IABP was done through surgical grafting due to the large size of the catheter, but as this technology improved through the years, the catheters became small enough to be placed non-surgically at patient’s bedside (IABPumpers, 2006).
Now, with more than 70,000 balloon catheters inserted each year in the U. S, IABP therapy is known to be the mostas a common treatment for cardiogenic shock (Vales, Kanei, Ephrem, & Misra, 2011). Purpose of Technology The most important purpose of the IABP therapy is to increase cardiac output (Vales, Kanei, Ephrem, & Misra, 2011). As stated previously, tThe IABP is timed to inflate and deflate according to phases of the individual’s cardiac cycle (IABPumpers, 2006). Inflation of the balloon occurs at diastole, which displaces the blood from the aorta to the coronary arteries and the vital organs.
Deflation occurs just before systole and left ventricular ejection. This deflation along with the blood displacement during diastole leads to decreased afterload and pressure in the aorta, which ultimately results in decreased myocardial demand (Sole, Klein, & Moseley, 2009). Hemodynamically speaking, the overall goal is to reduce myocardial work and left ventricular afterload as well as improving coronary and systemic blood flow (Vales, Kanei, Ephrem, & Misra, 2011).
Indications and Contraindications The IABP is no different than other forms of medical technology, in which there are situations where it is an optimal option, as well as where the use is detrimental. For instance, the balloon pump can be considered an ideal treatment for left ventricular shock resulting from an acute myocardial infarction (MI). Other conditions in which the IABP is useful for include, unstable angina related to medical therapy, post MI irritability, failure to wean off of cardiopulmonary bypass, as well as those with low output syndrome and to stabilize high risk patients who are undergoing general anesthesia (Western Sydney Health Services, 2004).
Overall, the IABP should only be utilized in those patients with the possibility of recovery of the left ventricle, or those awaiting a heart transplant. On the contrary, there are situations in which the IABP would not be the optimal treatment. These would fall under the category of contraindications and are as follows: aortic dissection, patients with severe peripheral vascular disease and irreversible brain damage and severe aortic valvular insufficiency (Western Sydney Health Services, 2004). Steps Before, During and After Use
Nursing care of the IABP is absolutely critical to the success of treatment for the patient and includes care of the pump in addition to assessing the patient before, during and after use from a cardiovascular and haemodynamic perspective (O’Donovan, 2011). Prior to the insertion of IABP, the nurse is responsible for obtaining witnessing consent for the procedure, educating the patient about the procedure and specific limitations and risks, as well as performing a full hemodynamic and physical assessment including close observation of the patient’s peripheral circulation (O’Donovan, 2011).
After consent is obtained, the patient is fully educated, and assessments are completed, the nurse begins to prepare for the procedure by shaving the patient’s groins, preparing all necessary equipment, lying the patient flat if tolerated, attaching cables to the machine and ensuring that it is fully operational and ready for use (Insertion of intra-aortic balloon catheter, 2005).
Once the patient is properly cleaned and draped according to facility policy, the process begins with insertion of the guide-wire through the access needle, followed by insertion of the sheath through the femoral artery (Insertion of intra-aortic balloon catheter, 2005). The next step is preparing the balloon catheter for insertion and passing the balloon over the guide-wire and through the sheath, where the tip is then positioned in the descending thoracic aorta, two centimeters below the left subclavian artery (Insertion of intra-aortic balloon catheter, 2005).
Once in place, blood is aspirated from the central lumen to ensure that the tip is not subintimal and has not caused a dissection (Nickson, 2010). Once the site is dressed and appropriate pressure lines and various cables are attached, the next step involves selecting what trigger ration is best tolerated, performing a chest x-ray to confirm proper placement of the balloon catheter, and finally suturing the catheter into place (Insertion of intra-aortic balloon catheter, 2005). Immediately following post-procedure, the nurse’s focus is on performing assessments and comparing to post-procedure results.
Hourly required nursing tasks include ensuring that the head of the bed is at an angle less than 30 degrees and confirmation of correct machine settings such as timing, trigger, and proper balloon inflation (O’Donovan, 2011). In addition, the nurse must also perform hourly assessments of the peripheral pulses and circulation comparing them to pre-insertion results, as well as monitor the insertion site for bleeding or hematoma formation (O’Donovan, 2011). Lastly, the nurse must draw blood hourly and assess full blood count and anticoagulation labs to observe for decreases in hemoglobin and platelet count.
This could signify the possibility of hemorrhage (O’Donovan, 2011). Once the patient’s condition is considered to be stable, tThe doctor determines whether or not the patient is ready to be weaned off and removed from the machine. During the process of weaning and removal, the nurse’s role is to assess the patient for signs and symptoms of intolerance or heart failure, which include dyspnea, tachycardia, and hypotension (O’Donovan, 2011). Post-removal, the nurse’s job is to continue close observation of the patient for any recurrences of signs or symptoms signifying heart failure or deterioration in health condition (O’Donovan, 2011).
In addition, the nurse continues to observe the insertion site for bleeding and obtains labs to assess the patient’s risk for hemorrhage (O’Donovan, 2011). Due to the long-term vascular complications associated with the use of intra-aortic balloon pumps, the patient’s peripheral vascular assessment should be monitored continually for several days post-removal (Reid & Cottrell, 2005). Limitations All sources of technology have their benefits as well as their limitations. In pediatric care, there are limitations to the development of the balloon pump including size constraints in the pathophysiology of failure (Cheng et al. 2009).
Other limitations related to pediatric patients include inadequate hemodynamics related to the increase in elasticity in a child’s heart muscle, as well as the presence of technical difficulties related to the insertion of the pump (Cheng et al. , 2009). Regarding care forIn adults, there is one main limitation discussed in literature, which statesis that it is necessary to have a certain amount of function in the left ventricle in order for IABP to effectively support the heart (Cheng et al. , 2009). Troubleshooting
Although the IABP has maintained a high success rate, there are a few things that can go wrong, causing the pump to malfunction and become ineffective. The first problem that can occur is called a “no trigger” (Williams, 2005). This means that the pump is unable to time the inflation and deflation of the balloon correctly due to an inability to read a pressure or trace the electrocardiogram (ECG). The nurse should check the ECG leads and pressure cable to ensure they are connected. If connected, it may be necessary for the nurse to replace the leads to get a better reading (Williams, 2005).
Another problem that can occur is the intra-aortic balloon catheter tubing can become disconnected. This causes the pump to stop working. In this case, the nurse should reconnect the tubing, press IAB on the pump, fill for three seconds, and then press assist/standby to restart the pump (Williams, 2005). One less common malfunction that may occur is a rapid gas loss due to a leak or hole in the tubing or balloon itself. The nurse would observe spots of blood in the tubing if this should occur (Williams, 2005). Another way of identifying this malfunction is if the pump is filling more frequently than necessary.
The nurse’s action would be to stop the pump and immediately call the attending physician. The catheter will need to be taken out to search for leaks and replaced with a new IAB catheter (Williams, 2005). Low Helium is one malfunction possible with an IABP. This occurs when the supply of helium is less than 24 fills (Williams, 2005). This is a sign that the helium cylinder needs to be replaced. The nurse will need to make certain that the O ring is in place when replacing the cylinder to guarantee a good seal is achieved (Williams, 2005).
IABP failure is one of the more serious malfunctions that can occur. This means that the IABP is no longer pumping (usually from an electrical problem or blood collecting in the condensers) (Williams, 2005). Should this happen, the nurse will need to call the physician immediately. The IAB console should be disconnected and a new console obtained (only if the balloon is still in tact). The nurse needs to make sure the machine is not labeled as a defective machine. Now, if the patient’s hemodynamic status is good, the patient may have the catheter removed (Williams, 2005).
The last malfunction to be addressed is when the augmentation is below the limit set. If concern arises due to the drop, the physician should be contacted immediately. Otherwise, the alarm set should be assessed, and the nurse should consider lowering the alarm line based on the patient’s progress (Williams, 2005). Documentation A patient with an IABP is to be closely examinedmonitored by the nursing staff. Assessments should be maintained per hospital protocol. Assessments should also include a close observation of the insertion site for infection, hemorrhage and heart failure (Williams, 2005).
While assessing the patient, it is also necessary to assess the external tubing to ensure that no kinks, condensation, or blood are present. In addition, daily chest x-rays are to be completed to monitor the positioning of the catheter (Williams, 2005). Special documentation for the patient with an IABP pump should include hemodynamic recordings (blood pressure, cardiac output, stroke volume, systemic vascular resistance, wedge pressure, right atrium pressure), circulation observations, IABP ratio and level augmentation, and urine output to watch for migration of the IAB catheter (Williams, 2005).
This special documentation is to be done hourly to ensure close monitoring is being achieved and any malfunctions or complications are picked up quickly (Williams, 2005). Approaches to Prevent Complications The use of an IABP can lead to a variety of complications during use as well as post-removal. There are approaches to consider which decrease the occurrences of these complications. Only tThis can be done through thorough unremitting assessments to monitor for signs and symptoms of these complications. Some of the most critical are circulatory compromise, hemorrhage and heart failure.
One important approach is to complete hourly assessments of peripheral pulses and circulation of sites distal to the insertion site. It is then important to compare these assessments to pre-insertion results to monitor for any changes (O’Donovan, 2011). This will help to observe fordetect any circulatory compromise. The nurse must also monitor the insertion site for bleeding or hematoma formation, as well as draw blood hourly and assess full blood count and anticoagulation labs to observe for decreases in hemoglobin and platelet count (O’Donovan, 2011).
These interventions will help to monitor for any possibility of hemorrhage. Another important approach is to continue to assess for signs and symptoms of intolerance of the procedure or heart failure, which include dyspnea, tachycardia and hypotension (O’Donovan, 2011). Overall, patients need to be continuously assessed and observed by the nurse before, during and after the IABP procedure to monitor for any changes in circulatory function. Evidence Supporting IABP Many believe the use of an IABP is more controversialdangerous for patients than it has worth.
There are complications that do need to be considered before, during and after use of this balloon pump. However, even with the possibility of certain complications arising, the IABP does successfully reduce myocardial work load and left ventricular afterload, as well as improve coronary and systemic blood flow (Vales, Kanei, Ephrem, & Misra, 2011). Lewis, Ward, & Courtney (2009)In one study, it is proven suggest that experience with this machine makes for better outcomes.
Hospitals with high use of IABP demonstrate a significantly lower mortality rate compared to hospitals that demonstrate limited IABP use (Lewis, Ward, & Courtney, 2009). This finding indicates that above all else, in use of an IABP, experience and education is key. Nurses must have education on equipment use, expected outcomes or complications, as well as how to successfully monitor weaning patients to provide the best chance of gaining full heart function after removal of the IABP. This can be provided through continuous research to improve function, patient response and patient outcomes with use of the IABP.