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Rev Latino-am Enfermagem 2009 setembro-outubro; 17(5):658-63Artigo Original www.eerp.usp.br/rlae

COM PLICATIONS OF INTR A-AO RTIC BALLOON INA COHORT OF HOSPITALIZEDPATIENTS: IMPLIC ATIO NS FOR NURSING CARE^Renata Bacelar Silva de Assis^Karina Azzolin^

Marta Boaz"*Eneida Rejane Rabelo^Assis RBS, Azzolin K, Boaz M, Rabelo ER. Compl icat ions of in tra-aort ic bal loon in a cohort of hospital izedpatients: implications for nursing care. Rev Latino-am Enfermagem 2009 setembro-outubro; 17(5):658-63.Objectives: To describe compiications associated to the use of intra-aortic balloon pum ps (IABP), and theirrelationship with dwe lling time , presen ce of risk factors/comorbidities, and nursing records. Methods:Retrospective cohort study, in which medical records were analyzed through the completion of specificallydesigned forms. Results: In total, 104patients were included, with mean age 6511 years, 52% men; 26(25%) of them presented va scular complications, more frequently ischemia (25%); peripheral vascular diseasewas the risk factor/como rbidlty more frequen tly related to complications (56.3%; p= .003). Nursing recordsshowed that the useof catheter was recorded in 30 cases (29%), and the patient's clinicai situation after itsremoval in 28 cases (27%). Conclusion: This study show ed that the frequency of complications reiated to IABPis high. Conside ring risk factor/como rbidity factors, peripheral vascular disease was significantly associated tocomplications. Nursing records were sub-optimal.DESCRIPTORS: coho rt studies; intra-aortic balloon pum ping; nursing care

COM PLICACIONES DEL BALN INTRAA R TICO EN UNA COHORTE DE PACIENTESHOSPITALIZADOS: IMPLICACIONES PARA LA ASISTENCIA DE ENFERMERAEste estudio tuvo como objetivos describir las complicaciones provenientes de la utilizacin del baln intraartico(BIA), relacionndolas con el t iempo depermanencia, con la presencia de factores de r iesgo/enfermedadesconcomitantes y con ios registros de enfermen'a. Se uti i iz como mtodo la cohorte histrica, con anlisis defichas por medio del l lenado de un instrumento construido especificamente para el estudio. Despus de laevaluacin de 104pacientes, edad promedio 6511, 52%sexo masculino, los resultados mostraron que 26(25%) presentaron complicaciones vasculares, siendo la isquemia (25%) la ms incidente; entre los factoresde riesgo/enfermedades concomitantes, el que ms se relacion con complicaciones fue la enfermedad vascularperifrica (56,3%, p=0,003). En lo quese refiere a las evaluaciones de enfermeria, 30 (29%) presentabanregistro del uso del catter, y 28 (27%) relataban el estado clinico del paciente despus de su retirada. Seconcluye que este estudio demostr queel indice decomplicaciones es todavia alto cuando relacionado al BIA.Entre los factores de r iesgo/enfermedades concomitantes, la enferme dad vascular perifrica fuesignificativamente relacionada concomplicaciones. Los registros de los enfermeros no fueron exhautivos.DESCRIPTORES: estudios de cohortes; contrapuisador intraartico; atencin de enfermeria

COMPLICAOES DO BALO INTRA -A RTICO EM UMA COORTE DE PAC IENTESHOS PITALIZADO S: IMPLICAES PARA A ASSISTNCIA DE ENFERMAGEMEste estudo teve com o objetivos descrever as compiicaes decorrentes da utilizao do baleo intra-artico(BIA), relacionando-as com o tempo de permanencia, com a presena de fatores de r isco/comorbidades eco m os registros deenfermagem. Uti l izou-se como mtodo a coorte histrica, comanlise deprontuarios pormeio de preenchimento de instrumen to espec ifico para o estudo. Aps avaliao de 104 pacientes, idademdia 6511, 52%sexo masculino, os resultados mostraram que 26 (25%) apresentaram compiicaesvasculares, sendo a isquemia (25%) a mais incidente; entre os fatores de r isco/comorbidades, o que mais serelacionou comcompiicaes foi a doena vascular perifrica (56,3%, p = 0,003). Quanto as evolues deenfermagem, 30 (29%) apresentavam registro do uso do catter, e 28 (27%) relatavam o estado clinico dopaciente aps a sua retirada. Conduise queeste estudo demonstrou queo indice decompiicaes ainda altoquando relacionado ao BIA. Dentre os fatores de r isco/comorbidades, a doena vascular perifrica foisignificativamente reiacionada com compiicaes. Os registros dosenfermeiros foram subtimos.DESCRITORES: estudos de coortes; balo intra-artico; cuidado s de enfermagem

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Rev Latino-am Enfermagem 2009 s etem bro-o utubro ; 17( 5):65 8-63 Complications of intra-aortic balloon in a cohort of hospitalized patients...www.eerp.usp.br/rlae Ass is RBS, Azzol in K, Boaz M, Rab elo ER.

INTRODUCTION

use of intra-aortic bailoon pump (IABP)iias been increasing year by year, as a iiemodynamicsuppo r t r esou rce fo r ca rd iac pa t i en ts w i th i e f tven t r i cu ia r dys func t i on . Th e use of ti i is device isincreasingly frequent in iieart surgeries, as weii as iniiemodynamic units'^*. Its main goais inciude: greateroxygen fiow to tine myocardium, reduced wori

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Complications of intra-aortic balloon in a cohort of hospitalized patients... Rev Latino-am Enfermagem 2009 setem bro- outub ro; 17( 5):65 8-63Assis RBS, Azzolin K, BoazM, Rabelo ER. www .eerp. usp. br/riae

variables were expressed as total n and its relativepe rcen tages , and con t i nuous va r i ab les we redescribed as mean standard deviation and 25 and7 5 % pe rc en t i l e s , depend ing on the i r n o rma ldistribution or not. The chl-square test was used forcategorical data comparisons. Quantitative variableswere analyzed using Student 's t, Spearman's andWilcoxon's test, depending on whether they wereparametric or not.

Table 2 - Patient complications related to IABP use(n = 26 ) , 200 1 -2 005 , a t a spec ia l ized ca rd io logyhospital. Porto Alegre, RS, 2006

IABP-related com plications n (%)*IschemiaVascular obstructionHemorrhageAmputationInfection

26 (25)13(12.5)2(1.9)

1 (1 )1 ( 1 )

Categorical variabies expressed as n (%)

RESULTSClinical and demographic characteristics

This research included 104 files of patientssubmitted to IABP. Thirty files were excluded becausethey did not contain records on IABP placement time.The patients' mean age was 6511 years, and 51.9%were men. The mean dwelling time in hours was 28(12-57 .5) . R isk facto rs , comorb id i t ies and use o fanticoagulation therapy are shown in Table 1.

Table 1 - Descr ipt ion of demog raphic and c l in icalcharacteristics of patients (n = 104) with IABP, 20 01 -2005, at a specialized cardiology hospital. Porto Alegre,RS, 2006

Clinical and dem ographic c haracteristics n (%)Age (years)'Gender (male)Median time with IABP in hours^Peripheral vascular diseaseObesityDiabetesSystemic arterial hypertensionSmokingUse of anticoagulation therapy

64.910.754 (52)

28 (12-57.6)16(15.4)10 (9.6)

38 (36.5)62 (59.6)45 (43.3)67 (64.4)

mean standard deviation; ^ median and 25 and 75% percentiies.

IABP-related compl icat ionsTable 2 illustrates IABP-related complications.

T w e n t y - s i x ( 2 5 % ) p a t i e n t s p r e s e n t e d v a s c u l a rcomplications like limb ischemia, followed by vascularobstruct ion. A smal l number of other compl icat ionswere found, such as hemorrhage and infection. Nocases of dissection and/or rupture of the aorta werefound . The mos t seve re comp l i ca t i on was the

Complications related to presence of risk factors and/or comorbid i t ies

Of all comorbidities under analysis, peripheralvascular d isease was more frequently re lated wi thvascular complications and was found in 9 (34.6%)patients. Sixty-seven patients received anticoagulationtherapy, of whom 42 (63%) d isplayed signi f icant lyless complications than the other 25 (37%) patientswho did not receive this therapy (p

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Rev Latino-am Enfermagem 2009 s etem bro-o utub ro; 17{5 ):658 -63 Complications of intra-aortic balloon in a cohort of hospitalized patients...www.eerp.usp.br/rlae Ass is RBS, Azzoi in K, Boaz M, Rabelo ER.

f i les under analysis, only 30 (28.8%) contained theevolution, describing the catheter use, and 28 (26.9%)reported on the patient's conditions after its removal.These data are demonstrated in Table 4.

Table 4 - Description of IABP patient files (n = 104),2001-2005, at a specialized cardiology hospital. PortoAlegre, RS, 2006

Criteria under analysis n (%)Physical limb exam 68 (65.4)Evolution of complications by other professionals 27 (26)Nursing evolution during use of IABP 30 (28.8)Nursing evolution after use of IABP 28 (26.9)Patients without records 33( 31.7 )'Categorical variables expressed as n (%).

DISCUSSIONDue to the high incidence of complications

and the need for careful assessment by the IABPpatient care team, the researchers investigated thisreality at a special ized cardiology hospital. In to ta l ,104 patient fi les were evaluated, of which 26 (25%)presented vascular complications - more than currentliterature data. All of these presented limb ischemia;only one presented a severe and irreversible lesion,including the need for amputation of the affected limb;no cases of aorta dissection of rupture were found. Aretrospective cohort study that aimed to assess IABP-related vascular compl icat ions demonstrated 11.1%of complications, with ischemia as the most frequentvascular complication and women as the most affectedgender''. An American study reported incidence levelsrang ing be tween 7 .2 and 47 % of vascu la rcomplications in cases of IABP use*^'. In 2000, a studyof 1,174 patients who used IABP demonstrated 15%of complications. In this sample, 27% of patients haddiabetes mellitus, 52% arterial hypertension and only8%, per iphera l vascu la r d isease. The compar isonbetween those research data and this more recentstudy showed that the present sample consisted ofmore severe pat ients in terms of the presence ofcomorbidities. The higher percentage of complicationsis also attributed to the fact that the place of study isa referral institution in cardiology and receives a largenumber of severe patients, which may entail a greaterpotential for the development of complications.

appearance of vascular complications and peripheralvascular d isease, IABP dwel l ing t ime and use ofanticoagulation therapy or not. It was identified that15.4% of patients suffered from peripheral vasculardisease; 36% did not receive anticoagulation therapy;and dwelling time was longer in 100% of patients withcom p l i ca t i ons . These f i nd ings unde r l i ne c u r ren tl i t e ra tu re abou t the assoc ia t i on be tween somecomorbidities and the emergence of complications.

In this study, as opposed to other sources'"''*,f e m a l e p a t i e n t s r e v e a l e d f e w e r r i s k s o fcompl icat ions than men. A study publ ished in 2000demonstrated, using mult ivar iate analysis, that thefemale gender , per iphera l vascu la r d isease andh igh body mass i ndex (BMI ) we re i ndependen tpredictors for the appearance of compl icat ions***.This study, on the opposite, showed no correlationb e t w e e n o b e s i t y a n d f e m a l e g e n d e r a n d t h ep r e s e n c e o f c o m p l i c a t i o n s , h i g h l i g h t i n g o n l yperipheral vascular disease as the comorbidity thatpredicts adverse vascular events. Moreover, as dataana lys is was based on secondary sources, therecords d id no t con ta in the pa t ien ts ' we igh t andheight for the sake of BMI calculations, but merelyrecords of obesi ty. European retrospective cohorts tud ies ca r r i ed ou t i n 2000 and 2005 a l soe m p h a s i z e th e a s s o c i a t i o n b e t w e e n p e r i p h e r a lvascu la r d isease and the use o f an t icoagu la t ionthe rapy as r i sk fac to rs fo r the occu r rence o fcomp l i ca t i ons ; op in ions d i f fe r , howeve r , on therelat ion between gender and adverse events*^' ' ' ' .

In a l l 104 cases under analysis, catheteri n s e r t i o n w a s p e r c u t a n e o u s . O t h e r t e c h n i q u e s ,including artery exposure (d issect ion), have beenappointed as predictors of further complications, suchas d issect ion and rup ture o f the aor ta , in tensehemorrhages and patient death'^"' ' .

In this study, nursing records on the presenceof IABP were unsatisfactory as to the description ofper fus ion cond i t ions, sk in co lo r and presence o fperipheral pulses in the limb the IABP was insertedin. No articles were found in literature that assessednursing records and the use of IABP. However, articlesin European, As ian and Nor th Amer ican journa lshighlight the importance of nursing care for patientssubmitted to this mechanical support device. Researchemphasizes that nurses should be trained as to theindications, benefits, risks and potential complications

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Complications of intra-aortic balloon In a cohort of hospitalized patients... Rev Latino-am Enfermagem 2009 sete mb ro-ou tubro ; 17C5):658-63Assis RBS, Azzol in K , Boaz M, Rablo ER. www.eerp.usp.br/rlaedur i ng and a f te r the ca the te r i nser t i on i snecessary'^'^*. The deficient nursing records may berelated to the access of technical and administrativeduties, as well as to the high number of patients underthe professionals' responsibility, besides the fact thatthe institution has not ful ly implemented the nursingprocess and its routine. Despite a certain degree ofconsensus about the fact that the nursing process cancontribute to a more autonomous and evidence-basedpractice, in nursing, few institutions actually adopt allof i ts steps'^ ' ' . To under l ine the importance of thenursing process, a systemic review carried out in 2007identified 14 studies that proved the better quality ofnursing documentation/assessments when the nursingdiagnosis was applied*^^'. The systemization of thenu r s i ng p r oc es s s uppo r t s t he dev e l opm en t o finterdiscipl inary and humanized care methodologies,serv ing as a work p rocess . Care methods ,independently of their denominations, represent oneof the most impor tant conquests in nurs ing carenowadays'^^'.

The team's actions in terms of constant andsystemat ic pat ient assessment are h ighl ighted asimpor tan t fac to rs fo r the ear l y de tec t i on o fcomplications and for planning interventions, as earlierstudies indicate deficient recording of signs, symptomsand etiologies of nursing diagnoses'^^'. The excessivenumber of patients and the whole complexity involvedcan often interfere in care, impairing the identificationof complications in earlier stages. Patients with IABPare considered critical. Hence, nurses should be awareo f po t en t i a l p r ob l em s and , t h r oug h adequa t eas s es s m en t , i den t i f y pa t i en t s a t g r ea t e r r i s k .Strategies like follow-up during catheter insertion andper fus ion moni tor ing of pat ients ' ex t remi t ies andhemodynamic state, using a protocol with increasingassessment i n te r va l s , guaran tee care* " ' . In th i scontext, training on the theme and recycling on careassociated with the creation of specific nursing careprotocols would const i tu te impor tant s t rategies toguide professionals in their daily practice'^^'.

FINAL CONSIDERATIONS

The mos t f r equent compl i ca t i ons amongIABP patients were vascular, including l imb ischemia( 25% ) and v as c u l a r obs t r uc t i on ( 12 . 5% ) . W henrelated to catheter dwel l ing t ime, i t was evidencedthat pat ients who used i t for more than 37 hoursp r es en t ed s i gn i f i c an t l y m o r e c om p l i c a t i ons t ha tpatients wi th a median usage t ime of 24 hours. Asf o r r i s k f ac t o r s as s oc i a t ed w i t h c om p l i c a t i ons ,higher incidence levels were found in male patientsand wi th a history of per ipheral vascular disease.W i t h r e g a r d t o n u r s i n g r e c o r d s , o n l y 2 8 . 8 %described the use of IABP.

Despite the large technological evolution inthis area, complication rates remain high, mainly ofv as c u l a r c om p l i c a t i ons . N ev e r t he l es s , t heimprovement in cardiac output as a resul t of thistreatment is undeniable. In this scenario, the relationbetween the risks and benefits of the method shouldbe assessed aga ins t the background o f fac to rsassociated with possible future complications.

T he m a i n r i s k s f o r I ABP pa t i en t s a r eb l e e d i n g , b a l l o o n r u p t u r e , i n f e c t i o n a n d s k i nbreakdown. The occurrence of these compl icat ionscan be minimized by per iodical c l inical assessment,in addi t ion to the moni tor ing of laboratory resul tsf o r h e m a t o c r i t a n d h e m o g l o b i n , p l a t e l e t a n dc o a g u l a t i o n m a r k e r s . B e s i d e s , b a c k , f l a n k o rabdominal pain complaints should be assessed andrecorded, and d is ta l pulse character is t i cs shouldbe observed. Control of body temperature, as wel las redness, warmth, swel l ing or dra inage at theinser t ion s i te is mandatory . F inal ly , in tervent ionst o r e d u c e p r e s s u r e a r e a s a n d h y d r a t i o n a n dnutr i t ion control survei l lance are important aspectsin the dai ly assessment of these patients '^^ ' . Someother s t rategies, such as the fu l l implantat ion ofthe nursing process and the use of pulse evaluat ionprotocols can add benefi ts to this treatment.

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Rev Latino-am Enfermagem 2009 setembro-outubro; 17(5):658-63www.eerp,usp.br/rlae Complications of intra-aortic balloon In a cohort of hospitalized patients...Assis RBS, Azzolin K, Boaz M, Rabeio ER.revascularization: analysis of 911 cases. Eur J CardiothoracSurg 2002 December; (21):741-7.5. Molnar HM. Intra Aortic Ballon Pump: Nursing ImplicatiosFor Patients With An Iliac Artery Approach. Am J Crit Care1998 Ju ly ; 7(4):300-5.6. Sanfelippo PM, Baker NH, Ewy HG, Moore PJ, Thomas JW,Brahos GJ, et .a l . Vascular Complications Associated withthe use of Intra Aortic Ballon Pump. Tex Heart Inst J 19873 u n e ;1 4 (2 ) : 1 7 8 -8 2 .7. Elahi MM, Chetty GK, Kirke R, Azeem T, Hartshorne R, SpytTJ . Complications Related to Ihtra Aortic Ballon Pump inCardiac Su rgery : a Decade Later. Eur 3 Vase Endovasc Surg2005 February ; (29):591-4.8. Sirbu H, Busch T, Aleksic I, Friedrich M, Dalichau H.Ischaemic complications with intra-aortic balloon counter-pulsation: incidence and management. Department of Thoracicand Card iovascu la r Su rge ry , Georg -Augus t Un ive rs i ty ,Go t t ingen , Germany . Ca rd iovasc Su rg 2000 January ;8 ( 1 ) : 6 6 - 7 1 .9. Mueller DK, Stout M, Blakeman BM. Morbidity an Mortalityof Intra-aortic Ballon Pumps Placed Through the Aortic Arch.Chest 1998 Ju ly ; 114( l ) :85-8.10. Diaz CL, Arroyo L, Blanco BB. Pacientes com baln de

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