CLINICAL SUPPORT SERVICES MANAGING IABP THERAPY … · | Clinical Support Services | Managing Intra-Aortic Balloon Pump Therapy - CS300 IABP | 1 | MNAGINGA INTRA-AORTIC BALLOON THERAPY

CLINICAL SUPPORT SERVICESMANAGING IABP THERAPY - CS300™ IABP

CS300 IABP COLOR DISPLAY AND kEYPAD CONTROLS

1 | | Clinical Support Services | Managing Intra-Aortic Balloon Pump Therapy - CS300 IABP |

MANAGING INTRA-AORTIC BALLOON THERAPY

Course Description:

This six hour program is designed for the experienced

healthcare professional directly involved with the care of

the patient requiring intra-aortic balloon pump therapy.

Participants should have experience with hemodynamic

monitoring and 6 months critical care experience.

Previous experience with intra-aortic balloon pump

therapy is preferred.

This program is comprised of 3 modules consisting

of theoretical, technical, and clinical considerations

for a patient requiring IABP therapy. The theoretical

module will briefly review cardiac physiology and the

theory of intra-aortic balloon pumping. The technical

module will discuss percutaneous insertion and removal

of the intra-aortic-balloon catheter followed by a

detailed explanation of the MAQUET IABP, highlighting

troubleshooting in the clinical setting. Case studies

will be utilized to further reinforce troubleshooting

techniques. The clinical module provides a discussion

of clinical considerations for patients requiring IABP

therapy. A skills workshop utilizing the system trainer

and Abbreviated Operator’s Guide will be provided.

Behavioral Objectives:

At the conclusion of this program, the participants will

be able to:n Define the two physiological effects achieved by

the mechanics of inflation and deflation of the IAB

as it relates to the cardiac cycle illustrated by an

augmented arterial pressure waveform.n Identify four indications and three contraindications

for IABP therapy.n Identify the potential complications associated with

IABP therapy.n Demonstrate the set up, operation, and

troubleshooting of the MAQUET IABP utilizing the

system trainer for practice and the abbreviated

operators guide for reference.

| 2 | Managing Intra-Aortic Balloon Pump Therapy - CS300 IABP | Clinical Support Services |

COURSE SCHEDULE

8:00-8:10

Introduction

Review Program

8:10-9:30

MODULE I - Theoretical Aspects

Review Cardiac Mechanics

Measurement of Cardiac Performance

Left Ventricular Failure

Theory of IABP

Factors Affecting Diastolic Augmentation/Timing Errors

Indications/Contraindications

9:30-9:40

Break

9:45-10:45

MODULE II IAB -

Catheter and Technical Introduction to IABP

IAB Catheter Insertion

Technical Features of the IABP

10:45 – 11:00

Break

11:00 -12:00

Troubleshooting Alarm and Advisory Messages

Hands On

12:00 – 12:30

Lunch

12:30 – 1:15

Additional Hands on

1:15 – 1:45

MODULE III - Clinical Considerations

Side Effects/Potential Complications

Care Management/Case Studies

1:45 – 2:00

Open Discussion

Program Evaluation


| 3 | | CLINICAL SUPPORT SERVICES | MANAgINg INTRA-AORTIC BALLOON PUMP ThERAPy - CS300

MODULE I THEORETICAL ASPECTS Of IABP


ATRIALSYSTOLE

VENTRICULARFILLING

ISOVOLUMETRICRELAXATION

ISOVOLUMETRICCONTRACTION

VENTRICULAREJECTION PHASE

I. REVIEw PHYSIOLOGY Of CARDIAC MECHANICS

A. CARDIAC CYCLE

1. Atrial Systole

2. Isovolumetric Contraction

3. Ventricular Ejection

a. Slow Ejection

b. Rapid Ejection

c. Slow Ejection

4. Isovolumetric Relaxation

5. Ventricular Filling

a. Rapid Filling

b. Slow Filling


ATRIALSYSTOLE

SEMI-LUNARVALVE OPENS100

120

80

60

40

10

0

ATRIALSYSTOLE

VENTRICULARSYSTOLE

DIASTOLE

AV VALVECLOSES

AV VALVEOPENS

SEMI-LUNARVALVE CLOSES

VENTRICULARPRESSURE

APPX. TIME (sec.) 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8

ELECTROCARDIOGRAM

PR

ES

SU

RE

(m

mH

g)

ARTERIALPRESSURE

VENTRICULAREJECTION PHASE

VENTRICULARFILLING

ISOVOLUMETRICCONTRACTION

ISOVOLUMETRICRELAXATION

P

R

T

Q S

B. PRESSURE wAVES

1. Ventricular Waveform

a. Pressure

b. Volume

2. Arterial

a. Radial/Brachial

b. Aortic


B. PRESSURE wAVES (continued)

NORMAL ARTERIAL wAVEfORM

SYSTOLIC PRESSURE

RAPID VENTRICULAREJECTION PHASE(75% SV Ejected)

NORMAL ARTERIAL WAVEFORM

AORTIC VALVE OPENS AORTIC END DIASTOLIC PRESSURE

DICROTIC NOTCH ■ Aortic Valve Closes ■ Diastole Begins

RUN-OFF PHASE(25% SV Ejected)

I. REVIEw PHYSIOLOGY Of CARDIAC MECHANICS (continued)


160

100 200 300 400

120

ST

RO

KE

VO

LU

ME

– m

l

END – DIASTOLIC VOLUME

CARDIACFAILURE

CARDIACRESERVE

80

40

C. MYOCARDIAL OXYGEN SUPPLY AND DEMAND

SUPPLY

1. Coronary artery anatomy

2. Diastolic pressure

3. Diastolic time

4. O2 extraction

a. Hemglobin

b. PaO2

D. fRANk-STARLING LAw Of HEART

Ventricular function curve. As the end-diastolic volume increases, so does the force of ventricular contraction. Thus the stroke volume becomes greater up to a critical point after which stroke volume decreases. [Cardiac failure]

DEMAND

1. Heart Rate

2. Afterload

3. Preload

4. Contractility

MVO2


LV fAILURE

Pumping Efficiency

Baroreceptors Activate

Activation of Renin-Angiotensin-Aldosterone-ADH

Pulmonary Edema

AnaerobicMetabolism

Lactic AcidProduction

Tissue Acidosis

Tissue Anoxia

DEATH

LV Volume & Pressure

HR

Release of Catecholamines

Afterload (SVR)

Na+ & H2O Reabsorption

O2 Demand

Preload (LVEDP)

Preload (LVEDP) Afterload (SVR)

Pulmonary Artery Pressure

HR

C.O.

C.O.

O2 Supply

Contractility

O2 Demand

Glomerular Filtration Pressure

Oxygenation

BP

C.O.

VASOCONSTRICTION

HYPERVOLEMIA

TISSUE HYPOXIA

Supply

Demand

Supply

Demand

MVO2

MVO2

Supply

Demand

MVO2

I. REVIEw PHYSIOLOGY Of CARDIAC MECHANICS (continued)


II. THEORY Of IABP THERAPY

A. COUNTERPULSATION

1. Balloon Structure and Position

2. Increased Coronary Perfusion

a. Inflation

b. Augmentation of Diastolic Pressure

3. Decreased Left Ventricular Workload

a. Deflation

b. Afterload Reduction

4. Physiological Pressure Wave Changes

a. Dicrotic Notch

b. Diastole: Augmentation

c. Decreased End-Diastolic Pressure

d. Systole: Decreased Assisted Systolic Pressure

Inflate Deflate


A. COUNTERPULSATION (continued)

mmHg

120

100

CD

A

A One Complete Cardiac CycleB Unassisted Aortic End Diastolic PressureC Unassisted Systolic PressureD Diastolic AugmentationE Assisted Aortic End Diastolic PressureF Reduced Systolic Pressure

B

E

F

80

REDUCEDMYOCARDIAL O2

DEMAND

INCREASED CORONARYARTERY PERFUSION

II. THEORY Of IABP THERAPY (continued)


ARTERIAL wAVEfORM VARIATIONS DURING IABP THERAPY

1:1 IABP fREQUENCY

1:2 IABP fREQUENCY

1:3 IABP fREQUENCY

DIASTOLIC AUGMENTATION

ASSISTED AORTIC ENDDIASTOLIC PRESSURE

ASSISTED SYSTOLEASSISTED SYSTOLE

mmHg

120

140

100

80


ASSISTED AORTIC ENDDIASTOLIC PRESSURE

ASSISTED SYSTOLE

UNASSISTED SYSTOLE

mmHg

120

140

100

80 UNASSISTED AORTIC ENDDIASTOLIC PRESSURE


UNASSISTED AORTIC END DIASTOLIC PRESSURE

ASSISTED AORTIC END DIASTOLIC PRESSURE

ASSISTED SYSTOLE

UNASSISTED SYSTOLE

mmHg

100

120

60

80

UNASSISTED SYSTOLE



B. EffECTS Of IABP

1. Primary

a. Supply

b. Demand

2. Secondary

a. CO/CI

b. HR

c. PAD-PCWP

d. SVR

e. B/P-SYSTOLIC

DIASTOLIC

MAP


3. Systemic

a. Neuro

b. Renal

c. Vascular

d. Respiratory


C. fACTORS AffECTING DIASTOLIC AUGMENTATION

1. Patient Hemodynamics

a. Heart Rate

b. Stroke Volume

c. Mean Arterial Pressure

d. System Vascular Resistance

2. Intra-Aortic Balloon

a. IAB in Sheath

b. IAB Not Unfolded

c. IAB Position

d. Kink in IAB Catheter

e. IAB Leak

f. Low Helium Concentration

3. IABP

a. Timing

b. Position of IAB Augmentation Control



D. TIMING ERRORS

1. Early Inflation

Inflation of the IAB prior to aortic valve closure

waveform Characteristics:

n Inflation of IAB prior to dicrotic notch

n Diastolic augmentation encroaches onto

systole (may be unable to distinguish)

Physiologic Effects:

n Potential premature closure of aortic valve

n Potential increase in LVEDV and LVEDP or

PCWP

n Increased left ventricular wall stress or afterload

n Aortic Regurgitation

n Increased MVO2 demand

2. Late Inflation

Inflation of the IAB markedly after closure

of the aortic valve


n Inflation of the IAB after the dicrotic notch

n Absence of sharp V

n Sub-optimal diastolic augmentation


n Sub-optimal coronary artery perfusion

UNASSISTEDSYSTOLE

DIASTOLICAUGMENTATION

ASSISTEDSYSTOLE

ASSISTED AORTICEND DIASTOLIC

PRESSURE

UNASSISTEDSYSTOLE DIASTOLIC

AUGMENTATIONASSISTEDSYSTOLE

DICROTICNOTCH


PRESSURE

EARLY INfLATION

LATE INfLATION


EARLY DEfLATION

LATE DEfLATION

3. Early Deflation

Premature deflation of the IAB during the diastolic

phase


n Deflation of IAB is seen as a sharp drop following

diastolic augmentation

n Sub-optimal diastolic augmentation

n Assisted aortic end diastolic pressure may be

equal to or less than the unassisted aortic end

diastolic pressure

n Assisted systolic pressure may rise


n Sub-optimal coronary perfusion

n Potential for retrograde coronary and carotid

blood flow

n Angina may occur as a result of retrograde

coronary blood flow

n Sub-optimal afterload reduction

n Increased MVO2 demand

4. Late Deflation


n Assisted aortic end-diastolic pressure may be

equal to the unassisted aortic end diastolic

pressure

n Rate of rise of assisted systole is prolonged

n Diastolic augmentation may appear widened


n Afterload reduction is essentially absent

n Increased MVO2 consumption due to the left

ventricle ejecting against a greater resistance

and a prolonged isovolumetric contraction phase

n IAB may impede left ventricular ejection and

increase the afterload


ASSISTEDSYSTOLE


PRESSURE

UNASSISTED AORTICEND DIASTOLIC

PRESSURE

PROLONGED RATE OF RISEOF ASSISTED SYSTOLE


UNASSISTEDSYSTOLE

WIDENEDAPPEARANCE


PRESSURE



E. INDICATIONS

1. Refractory Unstable Angina

2. Impending Infarction

3. Acute MI

4. Refractory Ventricular Failure

5. Complications of Acute MI [i.e. acute MR or

VSD, or papillary muscle rupture]

6. Cardiogenic Shock

7. Support for diagnostic, percutaneous

revascularization, and interventional procedures

8. Ischemia related intractable ventricular

arrhythmias

9. Septic Shock

10. Intraoperative pulsatile flow generation

11. Weaning from bypass

12. Cardiac support for non-cardiac surgery

13. Prophylactic support in preparation for

cardiac surgery

14. Post surgical myocardial dysfunction/low

cardiac output syndrome

15. Myocardial contusion

16. Mechanical bridge to other assist devices

17. Cardiac support following correction of

anatomical defects

f. CONTRAINDICATIONS

1. Severe aortic insufficiency

2. Abdominal or aortic aneurysm

3. Severe calcific aorta-iliac disease or

peripheral vascular disease

4. Sheathless insertion with severe obesity,

scarring of the groin, or other

contraindications to percutaneous insertion

Please Refer to the Instructions for Use Prior to Insertion of the IAB

MODULE II TECHNICAL ASPECTS


I. INTRA-AORTIC BALLOON CATHETER

A. DESIGNED fOR SHEATHLESS OR SHEATHED INSERTION

Fiberoptic IAB Catheter

Conventional IAB Catheter


Infusion Bag 500ml Sterile IV Solution Maintained at300 mmHg

Arterial Recipient Set

To Arterial Pressure Input on IAB Pump

Continuous FlushingDevice

Three-Way Stopcock

Maximum 8ft(2.5 Meters)Pressure Tubing

To Luer Connection on Catheter Extender

Stopcock

Transducer

PRESSURE MONITORING THROUGH IAB CATHETER

PRECAUTIONSn Use a standard flushing apparatus for arterial

pressure monitoring with the inner lumen. Careful

technique should be used in the set up and flushing

of the arterial pressure monitoring apparatus to

minimize the risk of an embolus entering the aorta

where it could potentially enter the carotid or

coronary arteries.n Aspirate and discard a 3cc volume of blood from the

inner lumen prior to attaching a flushing apparatus to

the female luer hub.n Ensure that all air bubbles are removed from the

inner lumen and flushing apparatus. In addition, tap

the Y-fitting to remove all air bubbles.n Prior to fast flushing, stop IAB pumping to reduce

the risk of an embolus entering the aortic arch should

an embolus be ejected from the inner lumen.n For optimal signal quality the inner lumen should not

be used for blood sampling.n Always aspirate 3cc initially if the inner lumen aortic

pressure signal becomes damped. If you meet

resistance during aspiration, consider the inner

lumen to be occluded. Discontinue the use of the

inner lumen by placing a luer cap on the female luer

hub.n The use of in-line filters or other devices can

potentially alter the appearance of the arterial

pressure waveform.n Do not over-tighten connections.

B. CLINICAL CONSIDERATIONS fOR CENTRAL

AORTIC PRESSURE MONITORING

PRECAUTION n For optimal signal quality, use no more than 8 feet

(2.5 meters) maximum of pressure tubing between

the transducer and female luer hub of the Y-fitting.

When monitoring pressure through the inner lumen,

use a standard arterial pressure monitoring apparatus

connected to a three-way stopcock. Connect the

three-way stopcock to the female luer hub of the

inner lumen. A 3cc/hour continuous flow through the

inner lumen is recommended. The anticoagulation

dosage should be in accordance with standard

hospital practice for arterial pressure lines and may

be modified, on physician discretion, for patients

receiving anticoagulation therapy. Per hospital policy,

a fast forward flush may be performed hourly to help

maintain patency of the inner lumen.


RECOMMENDATIONS fOR ACHIEVING OPTIMAL

PRESSURE SIGNAL QUALITY

1. Use no more than 8ft (2.5m) of a low compliance

pressure tubing such as that supplied by MAQUET

in the IAB Insertion Kit between the transducer

and Y-fitting of the catheter.

2. Once the catheter is in place, aspirate and

discard 3cc of blood from the inner lumen and

then immediately perform a manual flush using

a syringe filled with 3cc to 5cc of flush solution.

This will minimize the chances of stagnant blood

clotting in the inner lumen.

3. Apply only gentle force to the syringe when

aspirating the inner lumen.

4. Do not use a R.O.S.E. (Resonance Over Shoot

Eliminator) or other damping device.

5. Remove air from flush bag prior to pressurizing.

6. Prime the pressure set-up using gravity flush.

7. Maintain 300 mmHg of pressure on the flush

solution and elevate it above the transducer.

8. Whenever the inner lumen of the IAB becomes

filled with blood (such as after aspiration), the

flush valve should be activated for a minimum of

15 seconds in addition to the time it takes to clear

the pressure tubing of blood.

9. Ensure that all air bubbles are removed from the

inner lumen and flushing apparatus.

10. Use room temperature flush solution.

B. CLINICAL CONSIDERATIONS fOR CENTRAL

AORTIC PRESSURE MONITORING (continued)


II. TECHNICAL COMPONENTS Of THE CS300 IABP


A. REAR PANEL

1. Fiberoptic Module

a. IAB Sensor Input

b. Vent Key

c. To bedside monitor

2. Safety Disk/Condensate Removal System

a. DC Input

b. IAB Fill Port

c. Drain Port

3. Helium Supply

a. Pressure Gauge

b. Manual Fill Port

4. Patient Connections

a. ECG

b. Pressure

c. Monitor Input

n ECG

n Pressure

d. ECG/Pressure Output

5. Data Communications Outputs

a. RS-232

b. Phone Line

c. Diagnostic Output

6. Power Cord/Mains

7. System Timer

II. TECHNICAL COMPONENTS Of THE CS300 IABP (continued)


1. Alarm and Advisory Messages

2. ECG

a. Lead

b. Gain

3. Pressure Source

4. IAB Fill Mode

5. Slow Gas Alarm Status

6. Operation Mode

7. IAB Status Indicator

8. Trigger

9. Heart Rate Display

10. Pressure Display

11. Augmentation Alarm

12. Battery Indicator

13. Helium Indicator

B. MONITOR CS300


C. CS300 IABP kEY PAD CONTROLS

5. Trigger Source Key

a. ECG

b. Pressure

c. Pacer V/AV

d. Pacer A

e. Internal

6. IAB Frequency

7. IAB Augmentation

8. IAB Inflation Controls

9. IAB Deflation Controls

1. Operation Mode Keys

a. AUTO

b. Semi-Auto

c. Manual

2. Zero Pressure Key

3. START key and Indicator

4. STANDBY Key and Indicator



1. Alarm Mute Key

2. IAB Fill Key

3. Help Key Indicator

4. Menu Guide

a. Ref Line

b. Aug. Alarm

c. ECG/AP Sources

d. Pump Options

e. User Preferences

5. Inflation Interval Key

6. Freeze Display Key

7. Print Strip Key

D. CS300 kEY PAD CONTROL PANEL


1. ECG

E. RECORDER

2. Pressure

3. Balloon Pressure Waveform



f. SYSTEM BATTERY

1. Charge Status

2. Portable Operation

G. DOPPLER STORAGE


The inflation marker shows the period of inflation. Vertical timing marks located

below the arterial waveform are also available to aid with initial timing.

INfLATION MARkERS

A unique automatic timing algorithm allows effective balloon pumping even during atrial fibrillation.

Press the Inflation Interval key to observe the period of inflation while pumping. Vertical markers

located below the arterial waveform and the highlighted portion indicate the period of balloon inflation.



III. TROUBLESHOOTING

A. HIGH PRIORITY ALARMS

All Modes

Augmentation Below Limit Set*

No Trigger

IAB Disconnected

Check IAB Catheter

Leak in IAB Circuit

Rapid Gas Loss

Blood Detected

Autofill Failure

Autofill Failure – No Helium

High Pressure Drive

Low Vacuum

AUTO Operation Mode

Poor Signals Persist

Semi Auto or Manual Mode

ECG Detected*

No Pressure Trigger

Trigger Interference

Check Pacer Timing

Autofill Required

Other:

Safety Disk Test Fails

B. MEDIUM PRIORITY ALARMS

All Modes

IAB Optical Sensor Failure

Low Battery

Low Battery

AUTO Operation Mode

Poor Signal Quality

No Pressure Source Available

C. LOw PRIORITY ALARM

AUTO Operation Mode

Unable to Update Timing

D. TECHNICAL ALARMS

Electrical Test Fails Code #

System Failure

No Patient Status Available

E. INfORMATIONAL MESSAGES

All Modes

A.P. Optical Sensing Module Failure

Unable to Calibrate IAB Optical Sensor

IAB Optical Sensor Calibration Expired

No Trigger

Prolonged Time In Standby

Autofilling

Auto Zeroing

Autofilling and Zeroing

Function Not Available

Low Helium

Battery in Use [EXT]

Battery In Use

System Test OK

System Trainer

Maintenance Required Code #

Slow Gas Loss Alarm is OFF

Leak In IAB Circuit – Overridden

Blood Detected – Overridden

AUTO Operation Mode

Function Unavailable in Auto Operation Mode

* Pumping NOT suspended


E. INfORMATIONAL MESSAGES (continued)

AUTO or SemiAuto Operation Mode

Auto R-Wave Deflate

R-Wave Deflate

SemiAuto

Irregular Pressure Trigger

SemiAuto or Manual:

Verify Proper Timing

IAB Not Filled

Manual Fill IAB

Auto Operation Mode is Disabled

Gas Loss and Catheter Alarms Disabled

Manual Mode

Manual Timing Selected – See Help

Other

Install Safety Disk

Unplug Disk Outlet

Plug Disk Outlet

Leak Testing Safety Disk

f. PATIENT CONDITIONS

1. Atrial Fibrillation

2. Ectopics

3. Cardiac Arrest

4. Cardioversion/Defibrillation

G. CHANGING HELIUM TANk

H. SAfETY DISk LEAk TEST

I. MANUAL fILL

J. MANUAL TIMING

III. TROUBLESHOOTING (continued)


IV. NORMAL BALLOON PRESSURE wAVEfORM

PEAK INFLATION(POSITIVE OVERSHOOT)

PLATEAU (FULL INFLATION OF IAB)

IABDEFLATION

IABINFLATION

ZERO BASELINE RETURN TO ZERO BASELINE

PEAK DEFLATION(NEGATIVE OVERSHOOT)


VARIATIONS IN BALLOON PRESSURE wAVEfORMS

1. HEART RATE

BRADYCARDIAIncreased duration of plateau due to longer diastolic phase

TACHYCARDIADecreased duration of plateau due to shortened diastolic phase

2. RHYTHM

Varying R-R intervals result in irregular plateau durations

3. BLOOD PRESSURE

HYPERTENSIONIncreased height or amplitude of the waveform

HYPOTENSIONDecreased height oramplitude of the waveform


4. GAS LOSS

Leak in the closed system causing the balloon pressure waveform to fall below zero baseline. This may be due to a loose connection, a leak in the IAB catheter, H2O condensation in the external tubing, or a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane.

5. CATHETER kINk

Rounded balloon pressure waveform, loss of plateau resulting from a kink or obstruction of shuttle gas. This may be caused by a kink in the catheter tubing, improper IAB catheter position, sheath not being pulled back to allow inflation of the IAB, the IAB is too large for the aorta, the IAB is not fully unwrapped, or H2O condensation in the external tubing.

6. SUSTAINED INfLATION

Theoretical possibility if the IAB remains inflated longer than 2 seconds. The intra-aortic balloon pump will activate the System Failure alarm and deflate the IAB.

MAQUET IABP PERfORMANCE CHECkLIST – CS300

Name: Date:

Hospital Policy and Procedure Review: Date: Initials:

Basic Intra-Aortic Balloon Pump Course: Date: Initials:

Technical Seminar/Advanced Troubleshooting: Date(s): / Initials:

Challenge Exam (if applicable): Date: Score: (P/f)

DIRECTIONS fOR INSTRUCTORPlace your initials next to the skills the participant is able to perform. Leave blank the skills requiring repeat performance. Clarify learning needs if necessary in the comment section. The “Clinical Setting” column is an optional checklist for use by a preceptor or resource person for reinforcement of skills acquired on system trainer.

SkILLS SYSTEM TRAINER CLINICAL SETTING

INITIAL SET UP

Establish Power: Main power switch & IABP On/Off switch ON

Open helium tank and verify helium pressure

Establish ECG and Pressure connections

If Using a Sensor IAB:n Ensure the IAB Sensor Cable is connected to the sensor module and clipped to helium extender tubing

If Using a Conventional IAB/Transducer:n Open transducer to airn Press zero pressure key for 2 secondsn Close transducer

CONfIRM OPERATION MODE – AUTO

INITIATE PUMPING

Attach IAB catheter & appropriate extender to safety disk

Press the Start key

If Using a Sensor IAB:n Observe the “Autofilling & Zeroing” messagen Verify optimal diastolic augmentation

If Using a Conventional IAB/Transducer:n Observe the “Autofilling” messagen Verify optimal diastolic augmentation

VERIfY AUG. ALARM

Verify Aug. Alarm setting is approximately 10mmHg less than the patient’s augmented diastolic pressure

Adjust, if necessary by pressing Aug. Alarm key and using the up and down arrow keys, in the navigation circle, to change value displayed on the screen

ASSESS HEMODYNAMIC BENEfITS

Ensure optimal augmentation

Ensure optimal afterload reduction

If desired, IAB deflation can be fine tuned using the IAB deflation control

RECORD PRESSURES: ASSISTED & UNASSISTED

Press Print Strip key to record waveforms

Use Printer Menu in User Preferences to change printer settings

AUTO OPERATION MODE

Describe ECG and pressure source selection

Describe Trigger source selection

Describe automatic timing and Cardiosync 2 with R-Trac

SEMI-AUTO OPERATION MODE

Describe ECG and pressure source selection

Describe Trigger source selection

Describe automatic timing and Cardiosync 2 with R-Trac

PRESSURE SOURCE - Describes understanding of how pressure source is originated and calibrated

Fiberoptics

Conventional IAB/Transducer

TROUBLESHOOTING SYSTEM TRAINER CLINICAL SETTING

DEMONSTRATES ABILITY TO IDENTIfY VARIABLE TRIGGER SELECTION CRITERIA & APPROPRIATE USE Of EACH TRIGGER

Atrial Fibrillation

Demand Ventricular Pacemaker, Rate 60

AV sequential pacemaker, demand mode

Unobtainable ECG signal, regular rhythm, BP 100/50

Cardiac arrest with good chest compressions

Sinus Tachycardia

Sinus Rhythm with frequent PVC’S

Fixed rate AV sequential pacemaker

Atrial pacemaker - 100% paced

EVALUATES SITUATIONS THAT MAY CAUSE AN IAB CATHETER ALARM & DESCRIBES APPROPRIATE INTERVENTION

Kink in the catheter or tubing

Patient sitting straight up in bed

IAB has not exited the sheath

IDENTIfIES & RECOMMENDS APPROPRIATE ACTION fOR POTENTIAL LOSS Of HELIUM (“GAS LOSS”)

Blood in the IAB catheter shuttle gas tubing

IAB catheter disconnected from the console

DISCUSSES THE fOLLOwING ALARM & INfORMATIONAL MESSAGES

Poor Signal Quality

Poor Signals Persist

No Pressure Source Available

Unable to Update Timing

IAB Optical Sensor Failure

AP Optical Sensing Module Failure

Unable to Calibrate IAB Optical Sensor

IAB Optical Sensor Calibration Expired

SkILLS SYSTEM TRAINER CLINICAL SETTING

DISCUSSES THE HEMODYNAMIC RELATIONSHIP BETwEEN THE PATIENT & IABP THERAPY IN REGARD TO DIASTOLIC AUGMENTATION

Increased heart rate

Decrease in patient stroke volume

Ectopy

Increase in patient BP

Decreased SVR

DEMONSTRATES APPROPRIATE INTERVENTION fOR THE fOLLOwING ERRORS IN TIMING & VERBALIZES POTENTIAL CLINICAL IMPLICATIONS

Early inflation

Late inflation

Early deflation

Late deflation

PORTABLE OPERATION

Initiates and terminates portable operation

Identifies location of battery charge light

INTERfACE CABLES (If APPLICABLE)

Identifies location and use of ECG and/or pressure interface cables

Describes proper use of ECG interface cable in the presence of pacemakers

LOw LEVEL OUTPUT CABLE (If APPLICABLE)

Identifies location and use of low level output cable

Instructor Signature Instructor Initials

Instructor Signature Instructor Initials

Comments

MODULE IIICLINICAL CONSIDERATIONS


I. SIDE EffECTS AND COMPLICATIONS

ASSESSMENT PREVENTION TREATMENT OPTIONS

1. Limb Ischemia n Check distal pulses, color, temp. and capillary filling Q30 min. x 2 hrs, then Q2 hrs.

n Monitor differential toe temperatures.

n Use smallest sheath/catheter sizes indicated.

n Risk factors: female, diabetics, peripheral vascular diseases.

n Select limb with best pulse.

n Remove sheath and observe for bleeding.

n Subcutaneous Xylocaine injection for arterial spasm.

n Change insertion site to opposite limb.n Bypass graft femoral artery.

2. Excessive bleeding from insertion site

n Observation - anteriorly and posteriorly for blood or hematoma.

n Careful insertion technique.n Monitor anticoagulation

therapy.n Prevent catheter movement at

insertion site.

n Apply pressure. Assure distal flow.n Surgical repair.

3. Thrombocytopenia n Daily platelet count. n Avoid excessive heparin. n Replace platelets as needed.

4. Immobility of balloon catheter.

n The IAB should not remain inactive (i.e. not inflating and deflating) for more than 30 min. because of potential for thrombus formation.

n Observation of IAB status indicator movement.

n Observation of augmentation.

n Maintain adequate trigger.n Observe movement of IAB

Status indicator.n If unable to inflate the IAB with

the IABP, inflate and deflate the IAB by hand, using a syringe and stopcock once every 3-5 min.

n Notify the physician if the IAB is immobile for > 30 min.

5. Balloon leak n Observe tubing for blood with or without the presence of a blood detect, low augmentation, and/or gas loss or IAB catheter alarm.

n Do not remove the IAB from its tray until it is ready to be inserted.

n If blood is observed in the pneumatic tubing, disconnect the balloon from the IABP and notify the physician immediately.

6. Infection n Observation of insertion site.n Blood cultures for symptoms of

infection.

n Sterile technique during insertion and dressing changes as per infection control policy.

n Antibiotics.

7. Aortic Dissection n Assess for pain between shoulder blades.

n Daily hematocrit.n If suspected, aortogram may be

indicated.

n Insertion of IAB over guide wire with fluoroscopic control.

n Balloon removal.n Surgical repair.

8. Compartment syndrome may develop after IAB removed.

n Observation of limb for swelling and/or hardness.

n Measure calf girth.n Monitor interstitial pressure.

n Use the smallest catheter/ sheath appropriate.

n Maintain adequate colloid osmotic pressure.

n Fasciotomy if necessary.


II. wEANING AND REMOVAL

A. fREQUENCY

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SYSTEM POTENTIAL PROBLEMS NURSING INTERVENTIONS

Cardiac Left Ventricular Failure Monitor Vital Signs q15-30" until stableBlood Pressure MAP, Syst, DA, AOEDPHeart RatePAPPCWP/LAPCardiac Output/Cardiac IndexCVPSVR (Systemic Vascular Resistance)Maintain Optimal Diastolic Augmentation and Afterload ReductionMaintain Clarity of ECG Pattern Serving as TriggerRhythm Strips PRN12 Lead ECGs QD and PRNCardiac EnzymesCheck Pacer Function

CAUTION n In the event of Asystole, assure balloon movement by placing Trigger on ECG, Arterial Pres-

sure or Internal (bear in mind a Mean Arterial Pressure of about 50 mmHg is required to visualize augmentation).

Respiratory Pulmonary EdemaPulmonary EmboliAtelectasisPneumoniaPleural Effusions

Monitor ABGs closely PRNObserve Chest X-ray QDn Lung fieldsn Balloon positionProvide appropriate ventilatory supportStandard respiratory care on intubated patient with sterile suctioning techniquePost-extubation, modified respiratory therapy is utilizedDeep breathing, coughing, chest physiotherapy and naso-tracheal suctioning may be usedElevate HOB 30°Turning (if hemodynamically stable) cautiously

NeurologicalPsychiatric

Altered Level of ConsciousnessPsychosisOver SedationCerebral Embolization

Neurological assessment q2h/PRN(Pupils, LOC, motor function)Appropriate sedationNormalization of environment (TV and radio, if appropriate)Uninterrupted rest periods are essential to these patientsEmotional support regarding fears and anxieties should be provided to patient and family

Renal Prerenal FailureAcute Renal FailureUrinary Tract InfectionOcclusion of Renal Artery

Observe urine output q1hNotify physician if < 30cc or > 200 cc/hr. In absence of diuretics or fluid challengeStrict Intake and OutputObserve patient’s fluid volume status - Intake and OutputDaily Serum K+, BUN, Creatinine or Blood chemistries qd/PRNDaily weightUrine Specific Gravity q8hUrine Electrolytes and Osmolarity qdNote appearance of urineWatch for sings of urinary tract infectionCheck position of IAB catheter on chest film

IV. NURSING CARE Of THE PATIENT ON AN IABP


IV. NURSING CARE Of THE PATIENT ON AN IABP (continued)

SYSTEM POTENTIAL PROBLEMS NURSING INTERVENTIONS

Vascular Peripheral IschemiaThrombocytopeniaPeripheral EmbolismBleeding from Anticoagulation

Check peripheral pulse (q15" x 1 hr, then q2h post-insertionPedal, Posterior Tibial, PoplitealObserve color and temperature of involved leg q2hMaintain anticoagulation protocol:HeparinAspirinRheomacrodexObserve coagulation studies: PT, PTT, Platelets, Hgb and HctObserve for side effects of anticoagulation therapy: petechiae, ecchymosis, excessive bleeding from catheter insertion sitesAvoid flexing the patient’s hip and knee of involved leg due to IAB catheterApply anti-embolism stockings to non-involved leg

Immunologic Wound InfectionSystemic Sepsis

Monitor temperatureObserve WBCMaintain antibioticsChange IAB dressing qd - strict sterile techniqueMaintain “Best Practice” for all hemodynamic lines and observe for drainageCulture appropriate sites including blood, urine and sputum if specific signs and sym-ptoms of infection process are present.

Gastro-intestinal NutritionalStress UlcerationParalytic Ileus

May have diet as tolerated (clear liquid/soft)Hyperalimentation or tube feedings may be necessary with prolonged intubationMeasure abdominal girth q8hAssess bowel sounds q8hObserve for abdominal distention. Use stool softeners and fracture bedpan as appropriatePortable KUB X-ray may be required without interrupting IABPNaso-Gastric tube if appropriateNaso-Gastric drainage q8h for occult bloodProvide appropriate antacid regimen

Musculoskeletal ThrombosisDecubitus UlcerFoot Drop

ROM - Active and Passive to uninvolved legDorsiflexion of foot on involved legTurn (log roll) q1-2h – cautiously if hemodynamically stableApply air mattress and utilize heel and elbow protectorsUse footboard or high top tennis shoes to prevent foot drop

Patient and Family Teaching

Family anxietyLate Distal EmboliLate Aortic Dissection

Reinforce simple explanation to patient and familyDischarge planning – communication of progress to nursing floorObserve for and instruct in manifestations of late peripheral ischemia or emboli

Cardiac Assist Device

Mechanical Function of IABP Note and record settings according to hospital policyObtain optimal diastolic augmentation and optimal afterload reduction PRNNotify physician of difficultyPrevent inflation of IABP during Ventricular EjectionMaintain adequate ECG and arterial traceChange Helium tank PRNNote IAB autofill q2h/refill PRNWatch for signs of balloon leak: frequent loss of augmentation, blood in extender tubingIf IAB catheter is immobile for greater than 30 minutes, notify physician for appropriate intervention


V. CRITICAL PATHwAY Of THE IABP PATIENT

INSERTION PUMPING wEANING REMOVAL

Blood Work H&H, pt, ptt Platelet count, WBC Prior to removal, obtain: H&H, pt, ptt, platelet count

Diagnostic Procedures

FluoroscopyPortable CXR

Routine CXR qd, radiopaque tip at 2nd to 3rd ICS

Treatments Shave and prep both potential insertion sites.

Monitor insertion site frequently.Arterial line care per policy.Dressing change per policy.

Pressure applied and site dressed per policy.

Activity Maintain bed rest:Do not raise HOB > 45°.Do not flex or bend the leg in which the IAB was inserted.Assist the patient with log rolling and positioning.

Bed rest per policy.OOB as tolerated.

Nutrition Will depend on the patient’s condition and the indication for IAB insertion.

Nursing Interventions

Assess patient and monitor hemodynamic alterations per ICU routine.Administer IV fluids, vasodilator and/or inotropic agents per orders.Assess patient for pain or discomfort and medicate per physician order.Assess vascular status (color, sensation and movement) as well as pulse quality (pedal, posterior tibial, popliteal, femoral, and radial bilaterally).

NOTE: diminished left radial pulse may indicate IAB migration.Maintain anticoagulation protocol per physician order and observe for side effects.Encourage deep breathing.Assist the patient with turning and positioning at least q2h.Observe for urine output.

NOTE: urine output < 30cc/hr may be an indication that the IAB is occluding the renal arteries.Assure IAB movement, verify IABP controls in accordance with hospital policies.

NOTE: IAB should not remain immobile for > 30 minutes in situ.

NOTE: change of pedal pulses in affected leg could be a sign of limb ischemia.

Patient Teaching

Educate the patient and family members on IABP therapy utilizing the patient education brochure.Explain each phase of the IABP process. Instruct patient to:n Apply pressure to insertion site if they should cough or sneezen Report any chest pain or heavinessn Report any pain, numbness or tingling in their arms or legs

Expected Outcomes

Patient and family will have adequate knowledge base of IABP therapy.Relief of patient and family anxiety.The patient will experience clinical improvement from the IAB by:n Increasing the supply of myocardial oxygenn Decreasing the demand for myocardial oxygenThis will be evidenced by:n Increased cardiac outputn Increased MAPn Decreased PAP/PCWPn Decreased chest painSmooth progression through IABP therapy.Patient hemodynamically stable.

The foregoing is intended to serve as a guideline for the development of a critical pathway. It is not a recommendation

from MAQUET.


INSERTION PUMPING wEANING REMOVAL

Description of Phases A balloon is positioned in your aorta after being introduced through an artery.

The IABP shuttles gas from the console to the balloon and is timed with your heart beat.

Decreasing the amount of assistance your heart needs from the IABP.

Removing the balloon from your artery.

Teaching Most insertions of the IAB can be completed in approx. 15 minutes. The insertion site will be numbed prior to insertion. During the insertion, you may feel some pressure at the insertion site.

The IABP is helping your heart but not beating for it. Pumping will stop every 2 hours for a short period of time. This is normal.

The amount of time it takes to wean varies for each patient.

Removal is typically done at the bedside and only takes a few minutes to complete.

Activity Bed Restn To ensure that the IAB remains in the proper position, you should not sit up or

attempt to get out of bed.n The leg in which the IAB is inserted should not be bent or flexed.

Your nurse will assist you with turning and changing your position.Take deep breaths frequently.

Once the IAB is removed, you will remain in bed for a specific length of time depending on what your physician has ordered. This is usually 6-8 hours.

Nursing Interventions Your condition will be monitored according to ICU routine.The nurse will assess your vital signs, which include:n Heart rate and rhythm, blood pressure, respirations, pulse checks and other

measurements as your condition warrants.The insertion site will be checked frequently by your nurse.The dressing will be changed on a regular basis.Your nurse will give you pain medication. Please report any of the following:n Chest pain or heaviness, pain, numbness or tingling in your arms or legs.

Report any wetness at the insertion site.

Diagnostic Procedures Fluoroscopy (X-ray guidance) may be utilized during insertion. Chest X ray will be done to verify placement of the IAB.

Routine chest X-rays will be obtained during IABP therapy.

Nutrition Your diet will depend on your condition and the reason the IAB was inserted.

Lab Tests Blood tests will be obtained prior to the insertion.

Blood tests will be obtained as your condition warrants it.

The foregoing is intended to serve as a guideline for developing a clinical progression for IABP Therapy. It is not a

recommendation from MAQUET.

The clinical progression is an outline of what to expect for patients and families who require Intra-Aortic Balloon

Pump Therapy. The process will vary for each patient.

VI. CLINICAL PROGRESSION - IABP THERAPY


VII. CONSIDERATIONS fOR TRANSPORT

A. PURPOSE Of TRANSPORT PROGRAM

B. PLANNING THE TRANSPORT PROGRAM

1. Retrieval vs. Referral

2. Coordinator of Transport Team

C. TRANSPORT TEAM

1. Physician

2. Nurse, IABP Technician

D. TRANSPORT PROGRAM CONSIDERATIONS

1. Team Leader

2. Liabilities

3. Communication and Response Procedure

4. Consent Form and Patient Chart

5. Family Education

6. Patient Management During Transport

E. VEHICLE USED fOR TRANSPORT

1. Ambulance

a. power supply

b. equipment on board

c. ramp

d. response time

2. Aircraft

a. power supply

b. equipment on board

f. EQUIPMENT CONSIDERATIONS

1. IABP Supplies

2. Drugs

3. Infusion Pumps

4. Respiratory Care

G. POST TRANSPORT CONSIDERATIONS

1. Equipment Check

2. Follow-up


CITATIONS

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Christenson JT, Licker M, Kalangos A. The role of intra-aortic counterpulsation in high-risk OPCAB surgery: a prospective randomized study. Journal of Cardiovascular Surgery 2003 Jul-Aug;18(4):286-94.

Christenson JT, Cohen M, Ferguson JJ III, et al. Trends in intra-aortic balloon counterpulsation complications and outcomes in cardiac surgery. Annals of Thoracic Surgery 2002 Oct;74(4):1086-91.

Christenson JT, Simonet F, Schmuziger M. Economic impact of preoperative intra-aortic balloon pump therapy in high-risk coronary patients. Annals of Thoracic Surgery 2000 Aug;70:510-5.

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Christenson JT, Simonet F, Badel P, Schmuziger M. Evaluation of preoperative intra-aortic balloon pump support in high risk coronary patients. European Journal of Cardiothoracic Surgery 1997 Jun;11(6):1097-1103; discussion 1104.

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Hasdai D, Califf RM, Thompson TD, et al. Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction. Journal of the American College of Cardiology 2000 Jan; 35(1):136-43.

Hasdai D, Holmes DR Jr, Califf RM, et al. Cardiogenic shock complicating acute myocardial infarction: predictors of death. American Heart Journal 1999 Jul;138(1 Pt 1):21-31.

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Hochman JS, Sleeper LA, Godfrey E, et al. Should we emergently revascularize Occluded Coronaries for cardiogenic shock: an international randomized trial of emergency PTCA/CABg-trial design. American Heart Journal 1999 Feb;127(2):313-21.

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Mishra S, Chu WW, Torguson R, et al. Role of prophylactic intra-aortic balloon pump in high-risk patients undergoing percutaneous coronary intervention. American Journal of Cardiology 2006 Sep 1;98(5):608-12. Epub 2006 Jun 30.

Ohman EM. Counterpulsation and thrombolysis together improve survival after cardiogenic shock – the TACTICS results. Presented at the 22nd Congress of European Society of Cardiology on August 27, 2000 in Amsterdam, the Netherlands.

Quaal SJ. Comprehensive Intra-aortic Balloon Pumping. CV Mosby Company St. Louis 2nd Edition 1993.

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Sanborn TA, Sleeper LA, Bates ER, et al. Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the ShOCK Trial Registry. Should we emergently revascularize Occluded Coronaries for cardiogenic shock? Journal of the American College of Cardiology 2000 Sep;36(3 Suppl A):1123-9.

Stone GW, Ohman EM, Miller MF, et al. Contemporary utilization and outcomes of intra-aortic balloon counterpulsation in acute myocardial infarction. Journal of the American College of Cardiology 2003 Jun 4;41(11):1940-45. Comment in: Journal of the American College of Cardiology 2003 Jun 4;41(11):1946-7.

Suzuki T, Okabe M, Handa M, et al. Usefulness of preoperative intra-aortic balloon pump therapy during off-pump coronary artery bypass grafting in high-risk patients. Annals of Thoracic Surgery 2004 Jun;77(6):2056-9; discussion 2059-60.

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Indications

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Arafa OE, Geiran OR, Anderson K, et al. Intra-aortic balloon pumping after predominantly right ventricular failure after heart transplantation. Annals of Thoracic Surgery 2000;70:1587–93.

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Bates ER, Stomel RJ, Hochman JS, Ohman EM. The use of intra-aortic balloon counterpulsation as an adjunct to reperfusion therapy in cardiogenic shock. International Journal of Cardiology 1998;65(Suppl 1):S37–42.

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Briguori C, Sarais C, Pagnotta P, et al. Elective versus provisional intra-aortic balloon pumping in high-risk percutaneous transluminal coronary angioplasty. American Heart Journal 2003;145:700–707.

Califf, R.M.; Ohman, E.M., Reocclusion after thrombolytic therapy and percutaneous transluminal coronary angioplasty. Cardiac Assists 1990 March; 5(2).

David JS, Gueugniaud PY, Hepp A, et al. Severe heart failure secondary to 5-fluorouracil and low doses of folinic acid: Usefulness of an intra-aortic balloon pump. Critical Care Medicine 2000;28:3358–60.

Demas C, Flancbaum L, Scott G. The intra-aortic balloon pump as an adjunctive therapy for severe myocardial contusion. American Journal of Emergency Medicine 1987;5:499–502.

Dietl CA, Berkheimer MD, Woods EL, et al. Efficacy and cost effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less. Annals of Thoracic Surgery 1996;62:401-409.

Emmerman CL, Pinchak AC, Hagen JF. hemodynamic effects of the intra-aortic balloon pump during experimental cardiac arrest. American Journal of Emergency Medicine 1989 July;7:373 383.

Emery RW, Eales F, Joyce LD. Mechanical circulatory assistance after heart transplantation. Annals of Thoracic Surgery 1991; 51:43 7.

Ferguson JJ, Cohen M, Freedman RJ Jr, et al. The current practice of intra-aortic balloon counterpulsation: Results from the Benchmark Registry. Journal of the American College of Cardiology 2001;38:1456–1462.

Freedman RJ Jr. Myoconservation in cardiogenic shock The use of intra-aortic balloon pumping and other treatment modalities. Cardiac Assists 1992 January;6(2).

Freedman RJ Jr. The intra-aortic balloon pump system: Current roles and future directions. Journal of Applied Cardiology 1991;6:313 318.

George BS. Thrombolysis and intra-aortic balloon pumping following acute myocardial infarction Experience in four TAMI studies. Cardiac Assists 1988 October;4(3).

Georgen RF, Dietrick JA, Pifarre R. Placement of intra-aortic balloon pump allows definitive biliary surgery in patients with severe cardiac disease. Surgery 1989 September;106(4):808 814.

Goodwin M, Hartman J, McKeever L, et al. Safety of intra-aortic balloon counterpulsation in patients with acute myocardial infarction receiving streptokinase intravenously. The American Journal of Cardiology 1989; 64:937 938.

Grotz RL, Yeston NS. Intra-aortic balloon counterpulsation in high risk cardiac patients undergoing non cardiac surgery. Surgery 1989 July;106(1):1 5.

Gunnar RM, Bourdillon PDV, Dixon DW. guidelines for the early management of patients with acute myocardial infarction. American College of Cardiology 1990 August;16(2):249 292.

Gurbel PA, Anderson RD, MacCord CS, et al. Arterial diastolic pressure augmentation by intra-aortic balloon counterpulsation enhances the onset of coronary artery reperfusion by thrombolytic therapy, Circulation 1994; 89(1):361 365.

Gutfinger DE, Ott RA, Miller M, et al. Aggressive preoperative use of intra-aortic balloon pump in elderly patients undergoing coronary artery bypass grafting. Annals of Thoracic Surgery 1999;67:610–613.

Hochman JS, Buller CE, Sleeper LA, et al. Cardiogenic shock complicating acute myocardial infarction-etiologies, management and outcome: a report from the ShOCK


Indications (continued)

Trial Registry. Should we emergently revascularize Occluded Coronaries for cardiogenic shock? Journal of the American College of Cardiology 2000 Sep;36(3 Suppl A):1063-70.

Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. New England Journal of Medicine 1999 Aug; 341(9):625-34.

Hochman JS, Boland J, Sleeper LA, et al. Current spectrum of cardiogenic shock and effect of early revascularization on mortality. Results of an international registry. Circulation 1995 Feb 1;91(3):873-881. Comment in: Circulation. 1995 Sep 1;92(5):1349-50.

Ishihara M, Sato H, Tateishi H, et al. Intra-aortic balloon pumping as the postangioplasty strategy in acute myocardial infarction. American Heart Journal August 1991;122(2):385 389.

Kahn JK, Rutherford BD, McConahay DR. Supported “high risk” coronary angioplasty using intraaortic balloon pump counterpulsation. Journal of the American College of Cardiology 1990 April;15:1151 5.

Kern MJ, Aguirre F, Bach R, et al. Augmentation of coronary blood flow by intra-aortic balloon pumping in patients after coronary angioplasty. Circulation 1993 Feb;87(2):500 511.

Kern MJ, Aguirre FV, Tatineni S, et al. Enhanced coronary blood flow velocity during intra-aortic balloon counterpulsation in critically ill patients. Journal of the American College of Cardiology 1993 Feb;21(2):359 368.

Kern MJ. Intra-aortic balloon pumping post angioplasty - Documentation of increased coronary blood flow. Cardiac Assists 1992 June;6:1 5.

Kern MJ. Intra-aortic balloon counterpulsation. Coronary Artery Disease August 1991;2(6):649 660.

Lane AS, Woodward AC, Goldman MR. Massive propranolol overdose poorly responsive to pharmacologic therapy: Use of the intra-aortic balloon pump. Annals of Emergency Medicine 1987 Dec;16(12):1381 1383.

Lazar HL, Yang XM, Rivers S, et al. Role of percutaneous bypass in reducing infarct size after revascularization for acute coronary insufficiency. Circulation 1991;84(Suppl III):III 416 III 421.

Mangano DT, Browner WS, Hollenberg M. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The New England Journal of Medicine 1990 Dec 27; 323(26):1781 8.

Marra C, de Santo LS, Amarelli C, et al. Coronary bypass grafting in patients with severe left ventricular dysfunction: A prospective randomized study in timing of perioperative intra-aortic balloon pump support. International Journal of Artificial Organs 2002;25:141–6.

Masaki E, Takinami M, Kurata Y, et al. Anesthetic management of high-risk cardiac patients undergoing noncardiac surgery under the support of intra-aortic balloon pump. Journal of Clinical Anesthesia 1999;11:342–5.

McNamara NS, Wharton WP, La Rochelle T, Deboard D. Use of intra-aortic counterpulsation in patients with acute myocardial infarction who present to community hospitals. Critical Pathways in Cardiology 2002;1:159–179.

Mercer D, Doris P, Salerno TA. Intra-aortic balloon counterpulsation in septic shock. The Canadian Journal of Surgery 1981 Nov;24(6):643 645.

Ohman EM, George BS, White CJ, et al. Use of aortic counterpulsation to improve sustained coronary artery patency during acute myocardial infarction. Results of a randomized trial. Circulation 1994 Aug;90(2):792 799.

Ohman EM, Califf RM, George BS, et al. The use of intra-aortic balloon pumping as an adjunct to reperfusion therapy in acute myocardial infarction. American Heart Journal 1991 Mar;121(3):895-901.

Reiss N, el-Banayosy A, Posival H, et al. Transport of hemodynamically unstable patients by a mobile mechanical circulatory support team. Artificial Organs 1996;20:959–63.

Ryan TJ, Antman EM, Brooks N, et al. 1999 Update: ACC/AhA guidelines for the management of patients with acute myocardial infarction: Executive summary and recommendations: A report of the American College of Cardiology/American heart Association Task Force on Practice guidelines (Committee on Management of Acute Myocardial Infarction). Circulation 1999;100:1016–1030.

Schreiber TL, Kodali UR, O’Neill WW, et al. Comparison of acute results of prophylactic intra-aortic balloon pumping with cardiopulmonary support for percutaneous transluminal coronary angioplasty (PTCA). Catheterization and Cardiovascular Diagnosis 1998;45:115–119.

Schreiber TL, Miller DH, Zola B. Management of myocardial infarction shock: Current status. American Heart Journal 1989 Feb;117(2):435 443.


Indications (continued)

Siu SC, Kowalchuk GJ, Welty FK, et al. Intra-aortic counterpulsation support in the high risk cardiac patient undergoing urgent noncardiac surgery. Chest 1991 Jun;99(6):1342 1345.

Stomel RJ, Rasak M, Bates ER. Treatment strategies for acute myocardial infarction complicated by cardiogenic shock in a community hospital. Chest 1994;105(4):997 1002.

Complications

Arceo A, Urban P, Dorsaz PA, et al. In-hospital complications of percutaneous intra-aortic balloon counterpulsation. Angiology 2003;54:577–85.

Barnett MG, Swartz MT, Peterson GJ, et al. Vascular complications from intra-aortic balloons: Risk analysis. Journal of Vascular Surgery 1994 Jan;19(1):81 89.

Brodell GK, Tuzcu EM, Weiss SJ. Intra-aortic balloon pump rupture and entrapment. Cleveland Clinic Journal of Medicine 1989 Oct;56(7):740 742.

Cohen M, Ferguson JJ, Freedman RJ Jr, et al. Comparison of outcomes after 8 vs. 9.5 French size intra-aortic balloon counterpulsation catheters based on 9,332 patients in the prospective Benchmark Registry. Catheterization and Cardiovascular Interventions 2002;56(2):200–206.

Eltchaninoff H, Dimas AP, Whitlow PL. Complications associated with percutaneous placement and use of intra-aortic balloon counterpulsation. American Journal of Cardiology 1993 Feb;71:328 332.

Funk M, Gleason J, Foell D. Lower limb ischemia related to use of the intra-aortic balloon pump. Heart and Lung 1989;18:542 552.

Goran SF. Vascular complications of the patient undergoing intra-aortic balloon pumping. Critical Care Nursing Clinics of North America 1989 Sep;1(3):459 467.

Gottlieb SO, Brinker JA, Borken AM, et al. Identification of patients at high risk for complications of intra-aortic balloon counterpulsation: A multivariate risk factor analysis. American Journal of Cardiology 1984; 53:1135 1139.

Kantrowitz A, Wasfie T, Freed PS, et al. Intra-aortic balloon pumping 1967 through 1982: Analysis of complications in 733 patients. American Journal of Cardiology 1986;57(11):976 983.

Kvilekval KH, Mason RA, Newton GB, et al. Complications of percutaneous intra-aortic balloon pump. Use in patients with peripheral vascular disease. Archives of Surgery 1991 May;126:621 623.

Lazar JM, Ziady GM, Dummer SJ, et al. Outcome and complications of prolonged intra-aortic balloon counterpulsation in cardiac patients. American Journal of Cardiology 1992,Apr;69:955 958.

Robicsek F, Holleman JH, Roush TS, et al. Peri-operative intra-aortic balloon assist, decreasing complications to the minimum. Thoracic and Cardiovascular Surgeon 2003;51:115–125.

Schecter D, Murali S, Uretsky BF. Vascular entrapment of intra-aortic balloon after short term balloon counterpulsation. Catheterization and Cardiovascular Diagnosis 1991;22:174 176.

Stahl KD, Tortolani AJ, Nelson RL, et al, Intra-aortic balloon rupture. ASAIO Journal 1988;XXXIV:496 499.

Velez CA, Kahn JK. Compartment syndrome from balloon pump. Catheterization and Cardiovascular Interventions 2000;51:217–219.

Insertion

Gorton ME, Soltanzadeh H. Easy removal of surgically placed intra-aortic balloon pump catheter. Annals of Thoracic Surgery 1991;51:325 6.

Heebler RF. Simplified technique for open placement and removal of intra-aortic balloon. Annals of Thoracic Surgery 1989;48:134 6.

Nash IS, Lorell BH, Fishman RF, et al. A new technique for sheathless percutaneous intra-aortic balloon catheter insertion. Catheterization and Cardiovascular Interventions 1991 May;23(1):57 60.

Phillips SJ, Tannenbaum M, Zeff RH, et al. Sheathless insertion of the percutaneous intra-aortic balloon pump: An alternate method. Annals of Thoracic Surgery 1992; 53:162.

Shahian DM, Jewell ER. Intra-aortic balloon pump placement through dacron aortofemoral grafts. Journal of Vascular Surgery 1988 Jun;7:795 7.

Pediatrics

Anella J, McCloskey A, Vieweg C. Nursing dynamics of pediatric intra-aortic balloon pumping. Critical Care Nurse 1990 Apr;10(4):24 28.

del Nido PJ, Benson LN, Bohn D, et al. Successful use of intra-aortic balloon pumping in a 2 kilogram infant. Annals of Thoracic Surgery 1988 Nov;46:574 576.


Pediatrics (continued)

Dunn JM. The use of intra-aortic balloon pumping in pediatric patients. Cardiac Assists 1989 June; 5(1).

Nawa S, Sugawara E, Murakami T, et al. Efficacy of intra-aortic balloon pumping for failing fontan circulation. Chest 1988 Mar;93(3):599 603.

Pinkney KA, Minich LL, Tani LY, et al. Current results with intra-aortic balloon pumping in infants and children. Annals of Thoracic Surgery 2002;73:887–91.

Veasy LG, Blalock RC, Orth J. Intra-aortic balloon pumping in infants and children. Circulation 1983;68(5):1095 1100.

Webster H, Veasy LG. Intra-aortic balloon pumping in children. Heart and Lung 1985;14(6):548-555.

Transport

Bellinger RL, Califf RM, Mark DB. helicopter transport of patients during acute myocardial infarction. American Journal of Cardiology 1988 Apr;61:718 722.

Gottlieb SO, Chew PH, Chandra N. Portable intra-aortic balloon counterpulsation: Clinical experience and guidelines for use. Catheterization and Cardiovascular Diagnosis 1986;12:18 22.

Kramer RP Jr. helicopter transported intra-aortic balloon pumping: advanced technology made airborne. Cardiac Assists 1988 Jun;4(2).

Mertlich G, Quaal SJ. Air transport of the patient requiring intra-aortic balloon pumping. Critical Care Nursing Clinics of North America 1989 Sep;1(3):443 458.

Nursing Care

Bavin TK, Self MA. Weaning from intra-aortic balloon pump support. American Journal of Nursing 1991 Oct;91(10): 54 59.

Patacky MG, Garvin BJ, Schwirian PM. Intra-aortic balloon pumping and stress in the coronary care unit. Heart and Lung 1985 Mar;14(2):142-8.

Quaal SJ, guest ed. Critical Care Clinics of North America. Philadelphia WB Saunders 1996 Dec;8(4).

Shoulders O. Managing the challenge of IABP therapy. Critical Care Nurse 1991 Feb;11(2):60 76.

Weinberg LA. Buying time with an intra-aortic balloon pump. Nursing 1988 Sep;18(9):44 49.

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CLINICAL SUPPORT SERVICES MANAGING IABP THERAPY … · | Clinical Support Services | Managing Intra-Aortic Balloon Pump Therapy - CS300 IABP | 1 | MNAGINGA INTRA-AORTIC BALLOON THERAPY