Intra Aortic Ballon

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This is the html version of the file http://www.icufaqs.org/IABPFAQ.doc .

oogle automaticall! generates html versions of documents as we crawl the we".

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Intra$Aortic Balloon Pump %eview &/'(

)ello all * here+s the latest topic FAQ. As usual, please remem"er that these documents

are not meant to replace reference te-ts, and the! are certainl! not meant to "e the last

word on an!thing The idea here is to present information that passes on the e-perienceof a preceptor to the newer I0 nurse, gathered over 1too man!2 !ears of I0

e-perience at the 1trenches2 level. I do tr! to fill in the gaps with reference sources,

usuall! from the we", and I+ll list them at the end.

I+ve tried to organi3e the questions so that different topics are clearl! separated, so that

people can quic4l! find the answers that the! need. As usual, please feel free to write all

over this document, point out mista4es 5there are pro"a"l! lots6, and add questions,

criticisms, etc.
http://www.icufaqs.org/IABPFAQ.dochttp://www.icufaqs.org/IABPFAQ.doc


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#$ 7hat is an intra$aortic "alloon pump8

9$ 7h! is an IABP inserted8

Inflation: perfusing tight lesions..

9$# 7hat is diastolic augmentation8

9$9 )ow much volume does the "alloon hold8

9$ 7h! do the! use helium8

9$; 7hat are tight lesions8

9$< 7hat is sta"le angina8 0nsta"le angina8

9$( 7hat is =>?@P8 7hat if =>?@P doesn+t wor48

9$ )ow do I 4now if the "alloon is wor4ing8


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9$ 7hat if the "alloon goes in, and the!+re still having s!mptoms8

9$& 7hat are C$waves8 7h! do the! come and go8

Deflation: treating cardiogenic shoc4.

9$#' 7hat is cardiogenic shoc48

9$## 7hat is afterload8

9$#9 7hat is 1afterload reduction28

9$# 7h! can+t we Eust use pressors8

9$#; )ow can I tell if the "alloon is wor4ing8

9$#< 7hat happens to the CP, P7, urine output8

9$#( )ow do I 4now if the patient is "alloon dependent8

9$# 7hat is the 1chemical "alloon28


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$ )ow is a "alloon inserted8 7ho does the procedure8

;$ 7hat is "alloon timing8

Inflation timing

.

;$# 7h! does the "alloon inflate at the dicrotic notch8

;$9 7h! do we use the arterial wave for timing8

;$ But there+s also the 1"alloon pressure waveform2. 7hat is that for8

;$; 7hat is a dicrotic notch, and wh! do the! call it dicrotic8

;$< 7hat is diastolic augmentation8

;$( )ow does inflation help8


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;$ 7hat are all those initials pointing to the different parts of the timing waveforms8

;$ )ow do I ma4e sure m! inflation timing is right8

Deflation timing

;$& 7hat is the 1point of isovolumetric contraction28

;$#' 7hat is 1m!ocardial stro4e wor428

;$## )ow does deflation help8

;$#9 )ow do I ma4e sure m! deflation timing is right8

;$# 7hich wa! do I turn the 4no"s on the console8

Timing Pro"lems

;$#; I 4now that there are two "ig "ad timing errors * what are the!, wh! are the! so


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"ad, and how do I ma4e sure I don+t ma4e them8

;$#< 7hat is earl! inflation8

;$#( 7hat is late deflation8

;$# Are there 1good2 timing errors8

;$# an the G "e used for timing8

;$#& 7hat if the patient is "eing paced8

;$9' 7hat if the patient is having ectop!8 @r A$fi"8

;$9# 7hat is 1triggering28

;$99 7hat is 1trigger mode28

;$9 )ow often do I need to chec4 m! "alloon timing8


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($ 7hich "alloon console do we use8

($# 7hat is the purpose of the 1"alloon pressure waveform28

($9 )ow often should I chec4 it8

($ an I assume that the "alloon pressure waveform is o4a! if m! arterial$line timing

waveforms are o4a! too8

($; 7hen do I have to worr!8

($< 7hat should I do if something is seems wrong with the "alloon pressure waveform8

($( )ow is the entire setup connected to the patient and the "edside monitor8

($ 7hat is the 1root line28

($ 7h! does the root line transducer need to "e air$filtered8


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($& 7h! do we mar4 the root line 1?o Fast Flush28

($#' 7h! can+t I draw "loods from the root line8

($## an I ever8

($#9 There seem to "e eight arterial "lood pressure waves coming from this patient.

7hich one do I "elieve8

($# 7h! do I need to transduce all of them8

($#; )ow do I chec4 the helium level8 )ow do I change the helium

tan48

($#< 7hat is purging8 Hhould I purge the "alloon8

($#( 7hat do I do if the console quits8

($# 7h! can+t I run the console with the gas alarms off8

($# )ow do I reset the console if it alarms8

($#& 7hat do I do if the console sa!s 1gas lea428

($9' @r 14in4ed line28

($9' @r 1no trigger28


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($9# 7hat if I have to travel with the patient8

($99 7hat if there+s a lot of water in the "alloon line8

($9 Hhould I ever turn the console off8

($9; 7hen should I call the "alloon tech for help8

($9< )ow do I page the "alloon tech8

($9( )ow do I 4now if the helium is getting low8 )ow do I change the helium tan48

$ 7hat a"out documentation8

$# 7hich pressures do we document8

$9 )ow do I document pulses8

$ Hhould I paste in the PC% strips8


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$; 7hat a"out the weaning ratio8

$< 7hat goes on the flow sheet, and what goes in m! note8

$ 7hat is "alloon weaning8

$# Is there a weaning protocol8

$9 7hen should we start weaning the "alloon8 7hat is 1stunned

m!ocardium28

$ )ow do I 4now the patient is tolerating the "alloon wean8

$; )ow do I 4now if the!+re not8

$< Hhould I stop weaning if the patient is having trou"le8


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$( )ow long can a "alloon sta! in8

$ 7ho pulls the "alloon8

$ 7hen should I turn off the heparin "efore a "alloon gets pulled8

$& 7hat should I worr! a"out after the "alloon gets pulled8

Intra$aortic Balloon Pump %efresher FAQ

#$ 7hat is an intra$aortic "alloon pump8


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An intra$aortic "alloon pump is a device that "asicall! does two good things for a heart introu"le. These two effects correspond to the two movements that the "alloon ma4es,

namel!: inflation and deflation. The "alloon itself loo4s li4e a wire coat$hanger with a

transparent plastic hotdog on the end, which inflates and deflates in careful timing with

certain parts of the cardiac c!cle of s!stole and diastole. The "alloon is inserted into the

femoral arter!, threaded up, and the tip is placed so that it sits Eust "elow the aortic arch

* this is usuall! done in the cath la" under fluoro, "ut can "e done at the "edside in an

emergenc!.

Inflated, on the left


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http://www.nvicv.nl/=P%I/images/IABP9.Epg

The "alloon is 1driven2 to inflate and deflate "! this device, the console. The helium doesthe inflation lives in a small 5ver! small6 tan4, and the timing of the movements is

controlled in careful s!nch with the rate and rh!thm of the heart. It has to "e C%J

precise, for reasons we+ll get into.
http://www.nvicv.nl/LPRIC/images/IABP2.jpghttp://www.nvicv.nl/LPRIC/images/IABP2.jpg


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http://www.tmc.edu/thi/ia"pKconsole.Epg

9$ 7h! is an IABP inserted8

Two reasons: first, to help perfuse the coronar! arteries, when the! are nearl! closed "!

tight lesions. If !ou tr! to visuali3e the cardiac c!cle, thin4 of the heart during diastole:

the cham"er walls open up, and on the left side of the heart, the valve leading from the

=C to the aorta * the aortic valve * flips shut. The aorta has Eust "een filled "! the

previous s!stolic contraction, and now with the aortic valve closed, it re"ounds a little,

li4e a garden hose with a pulse of water going through it * the walls stretch a "it with

each s!stole, and then spring "ac4 a "it, creating a small "ac4wards pressure towards

the heart. The openings leading to the coronar! arteries are actuall! in the wall of the

aorta, Eust a"ove the aortic valve, and the arteries fill passivel! during diastole. The

"alloon is timed to inflate at the end of diastole, creating a forci"le pressure "ac4wards

along the aortic arch, pushing "lood activel! through the coronar! arteries.

The second reason is for the management of acute cardiogenic shoc4. This is what the

deflation movement does.
http://www.tmc.edu/thi/iabp_console.jpghttp://www.tmc.edu/thi/iabp_console.jpg


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Inflation: perfusing tight lesions, treating ischemia that won+t go awa!.

9$# 7hat is diastolic augmentation8

Because this occurs during the diastolic part of the c!cle, and "ecause it 1augments2 the

normal coronar! "lood flow, this is called 1diastolic augmentation2.

9$9 )ow much volume does the "alloon hold8

The "alloon itself can hold different volumes, "ut usuall! is set to an inflation volume of

;'cc.


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9$ 7h! do the! use helium8

1The advantage of helium is its lower densit! and therefore a "etter rapid diffusioncoefficient.2 7hat I thin4 this means is that helium, "eing ver! light, and not ver! dense,

is easier to push and pull in and out of the "alloon through the line tu"ing. I+m not sure

what happens if the helium gets into the patient * I remem"er "eing told that it+s

ph!siologicall! inert * ma!"e the patient tal4s funn!8

?B: Balloon Tech ar! sa!s that the 1rapid diffusion coefficient2 means that the helium

will dissolve ver! quic4l! in the "lood if the "alloon were to lea4 some into the circulation.

)opefull! not a whole lot of helium: if the "alloon were to rupture, a "olus of helium

would act Eust li4e an! other gas/air em"olus in the circulation * for an! sign of "alloon

rupture 5li4e "lood in the "alloon line6, the console must "e shut down immediatel!, and

the "alloon removed.


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9$; 7hat are tight lesions8

Tight lesions are the narrow spots along the lumens of the coronar! arteries that ma4e

for all the trou"le * if the!+re nearl! closed, sa! L&


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part of the heart8 Prett! important vessel, this

http://www.hgcardio.com/preplad.Epg

9$< 7hat is sta"le angina8 0nsta"le angina8

Hta"le angina is the ischemic chest pain that a patient gets earl! in the development of

their coronar! lesions * the! get the pain under sta"le, predicta"le conditions, li4e

clim"ing a flight of stairs. 0nsta"le angina is the pain the patients get as the coronar!

lesions get tighter. This angina can stri4e spontaneousl!, without an! e-ertion, and

represents worsening AD.
http://www.hgcardio.com/preplad.jpghttp://www.hgcardio.com/preplad.jpg


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?ow * which 4ind of G changes are !ou going to see in episodes li4e this8

This 4ind8 7hat is this 4ind8

http://www.tveatch.org/e4gs/e4g&.Epg
http://www.tveatch.org/ekgs/ekg89.jpghttp://www.tveatch.org/ekgs/ekg89.jpg


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)ow a"out this 4ind8 7hich is this8 Is !our treatment going to "e the same for thesetwo8 Different8

9$( 7hat is =>?@P8 7hat if =>?@P doesn+t wor48

=>?@P are the initials that some people use to remem"er the maneuvers to ma4e for

cardiac ischemia: =asi- 5assuming the!+re 1wet26, >orphine, ?itrates, @-!gen, and

Position 5sit them up if the!+re short of "reath * unless the!+re h!potensive6. If =>?@P

doesn+t wor4, then !ou have to thin4 a"out putting in a "alloon pump to forci"l! perfuse

the coronaries.


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9$ )ow do I 4now if the "alloon is wor4ing8

Jou 4now that the "alloon is wor4ing if the patient+s chest pain goes awa! Jou also want

to loo4 at their G to see if their ischemic changes, if an!, have resolved * remem"er,

some dia"etic patients, and we see lots of them $ don+t have chest pain with ischemia,

so !ou have to "e careful. There are 1anginal equivalents2 * meaning, the patient

"ecomes ischemic, "ut instead of having pain, does something else * "rea4s into a

sweat ma!"e, "ecomes short of "reath

9$ 7hat if the "alloon goes in, and the!+re still having s!mptoms8

If the ischemia isn+t controlled with IABP insertion, the! pro"a"l! need to go for an


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emergent AB or stent procedure, since something is pro"a"l! a"out to infarct.

9$& 7hat are C$waves8 7h! do the! come and go8

C$waves are a sign of ischemia * the! can show up as part of a P7 waveform, and in

this conte-t it means that the patient has developed 1ischemic >%2 * mitral regurgitation.

The idea is that the ischemia has affected the papillar! muscles that control the mitral

valve.

That+s these gu!s.

The!+ve stopped wor4ing properl!, and the valve starts lea4ing. Jou can use the

presence of C$waves as an indicator that the patient is still in ischemic trou"le *

sometimes this is useful if a patient is intu"ated and can+t tell !ou the!+re having pain, or


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in people who don+t have pain, li4e dia"etics with neuropath! sometimes. The goal

would "e the same as treating someone with ischemic changes on their #9$lead * !ou

want to see the v$waves go awa!. =oo4 for the o-!genation to worsen with v$waves,

since the valve is letting "lood flow "ac4wards towards the lungs * loo4 for it to improve

once the valve is wor4ing again.

http://www."ios"cc.net/"#''cardio/images/F9#K'A.Epg

Acute "ac4flow of "lood into the lungs what+s the other name for that8

This is the definition of a 1flash2. Jou hear lot of people sa! * 1>r. Ho$and$Ho flashed

toda!.2 * meaning what, e-actl!8 People throw terms around with no clear idea of what

the! meandid he have ischemic >%8 Did he plug8 Be precise
http://www.biosbcc.net/b100cardio/images/FG21_07A.jpghttp://www.biosbcc.net/b100cardio/images/FG21_07A.jpg


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Deflation: treating cardiogenic shoc4:

9$#' 7hat is cardiogenic shoc48

1ardiogenic2 means that the shoc4 state is "eing caused "! heart failure: the pump isn+t

pumping. 7h! not8


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This is actuall! a prett! good image * the !ellow "it representing infarcted area is in Eust

the right area for producing cardiogenic shoc4. 7h!8

http://www.aspirin.ca/nglish/ardiovascularDisease/)eartAttac4.asp
http://www.aspirin.ca/English/CardiovascularDisease/HeartAttack.asphttp://www.aspirin.ca/English/CardiovascularDisease/HeartAttack.asp


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%emem"er that there are three parts of a "lood pressure, and the common 4inds ofshoc4 are caused "! "ad things happening to one of those: pump, volume, and arterial

squee3e. 7hich one is this8

9$## 7hat is afterload8

Afterload is the resistance that the heart is loo4ing at, as it tries to pump "lood out into

the entire arterial s!stem.

5Preload is the volume arriving in the =C, measured as the wedge pressure. 7hat

num"er would tell !ou the preload of the %C86


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%emem"er that the arterial "ed as a whole can squee3e, and loosen. If the arterial

squee3e is high, then the heart has a harder time pushing "lood into the tight vessels *

so looser is "etter ?ot too loose Afterload corresponds to the HC% num"er * normal is

around #''', septic would "e low, and cardiogenic would "e high. %emem"er * high is

tight, low is loose.

HC% rises in cardiogenic shoc4, the arteries tighten, tr!ing to 4eep "lood pressure up

is this a good thing8

http://en.wi4ipedia.org/wi4i/Image:rafi4K"lut4reislauf.Epg

9$#9 7hat is afterload reduction8

Hince a high afterload ma4es it harder for the =C to empt! itself, it adds to the wor4 that
http://en.wikipedia.org/wiki/Image:Grafik_blutkreislauf.jpghttp://en.wikipedia.org/wiki/Image:Grafik_blutkreislauf.jpg


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the failing heart has to do * "ad Ho the goal is to lower the afterload * to dilate the

arterial 1"ed2 $ to lower the HC%. Jou can do this with drugs, li4e ?T or nipride, "ut if

the patient has a s!stolic pressure of &' * pro"a"l! not a good idea

Ho now comes the IABP. The "alloon, deflating Eust at the "eginning of s!stole, creates

an area of lower pressure in the aorta * which helps the =C empt! itself, and ta4es a lot

of the wor4load off it * mechanical afterload reduction. Almost ever!one with cardiogenic

shoc4 died of it "efore the IABP came along for this purpose.

9$# 7h! can+t we Eust use pressors8

7ell * !ou could, and sometimes !ou have to, even with the "alloon pump wor4ing. But

do !ou reall! want to add a pressor to failing heart muscle8 Pro"a"l! not * !ou want to

avoid things that ma4e the heart wor4 harder, things that increase 1>C'92 * m!ocardial

o-!gen consumption. Do"utamine $ the "eta pressor $ would "e the drug of choice. Jou

sure !ou want to use it8

7hat a"out the other pressors8 %emem"er, the alpha receptors are in the arteries, and

pressor$i3ing the arteries in this situation would "e "ad * it increases afterload

resistance, and those arteries are pro"a"l! alread! quite tightened up * that+s the refle-

response the "od! uses to tr! to maintain "lood pressure if cardiac output falls. These


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people alread! have "ad peripheral perfusion * the!+re so tight that the! ma! not have

detecta"le pulses * add an alpha pressor and the! might lose their fingers

?ow * see8 This is the mirror, the opposite of the refle- response that the "od! uses to

compensate in sepsis, in which the patient has a loose arterial "ed, and the

compensation is reall! elevated cardiac output. HC% in sepsis would "e high or low8

=ow * correct. Hee that8 Two refle- responses availa"le for two different situations.

Ho $ what might happen if the "alloon insertion went 1dirt!28

9$#; )ow can I tell if the "alloon is wor4ing8

Himple: if the "alloon goes in for chest pain/ischemia, !ou loo4 for the patient+s pain and

G changes to go awa!. Those nast! v$waves should go awa! too, if the! were there

"efore, and >% going awa! should improve o-!genation quic4l!. 10n$flash2


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If the "alloon goes in for cardiogenic shoc4, then "lood pressure should improve as the

cardiac output comes up. The HC% should come down, and !ou should "e a"le to wean

some on the do"utamine.

9$#< 7hat should happen to the urine output, and the wedge pressure8

The P7 should go down for two reasons * the "alloon should improve the "lood

suppl! to a hurting =C and help it pump "etter * empt! itself "etter. Afterload reduction

from deflation should help P7 go down "ecause of the mechanical advantage the

"alloon gives to the =C. 7ith "etter cardiac output, urine output should improve *

remem"er that some"od! needs to chec4 the N$ra! to ma4e sure the the tip of the

"alloon is in the right position * too low and it can o"struct the renal arteries, which tends

to "e "ad for the 4idne!s.

9$#( )ow do I 4now if the patient is "alloon dependent8

1Balloon dependent2 descri"es a patient who is cardiogenic, and whose heart depends

on the mechanical assistance from the IABP to 4eep "lood pressure up. Pause the IABP


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* their BP falls. This patient is o"viousl! not read! to wean from the "alloon !et. A patient

with a "ig >I producing cardiogenic shoc4 ma! recover enough function in a"out a

wee4+s time to wean.

9$# 7hat is the 1chemical "alloon28

The phrase 1chemical "alloon2 refers to using a com"ination of vasoactive drugs to

mimic the effect of the IABP * usuall! this is tried in an outside hospital to sta"ili3e a

patient "efore the! can "e moved somewhere that a "alloon can "e placed. Do"utamine

is used to increase cardiac output, and IC ?T or sometimes nipride is ver! carefull!

added to decrease afterload resistance * remem"er that nipride dilates the arterial "ed,

and do"utamine can too This is a ver! tric4! road to go down, and is o"viousl!

dangerous, since the do"utamine can produce tach!arrh!thmias, and the nipride can

produce reall! stupendous h!potension. ?ever forget to ta4e ridiculous care usingnipride, running it alone, never flushing the line, etc.

$ )ow is a "alloon inserted8 7ho does the procedure8


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An IABP is inserted "! an interventional cardiologist, usuall! in the cath la" under

fluoroscop!, using much the same technique as an! central line placement. Cer! rarel!

the "alloon is put in at the "edside, "ut this is usuall! in a near$code situation * it+s "een

man! !ears since I+ve seen this done. areful placement is needed to avoid placing the

"alloon too high or low, and the patient must have an -$ra! to confirm proper placement

of the "alloon tip. This can "e read "! the "alloon techs, "ut has to "e confirmed "! a4nowledgea"le doc.

;$ 7hat is "alloon timing8

Timing is ever!thing in life, and the IABP is no e-ception. If !ou thin4 a"out it even for a

moment, !ou+ll reali3e that if the "alloon is still inflated in the aorta, when the heart is

tr!ing to pump "lood into that aorta * well, that would "e a "ad thing. Ho the timing of

"oth inflation and deflation must "e carefull! loo4ed after. This is the responsi"ilit! of thenurse caring for the patient. Jou can not avoid this * !ou can not rel! on the timing set

"! the "alloon techs, "ecause timing needs can change frequentl!. If !ou feel

uncomforta"le with timing, that+s pro"a"l! a good thing, "ecause that means !ou care

a"out !our practice. J I+ll tr! to cover this as "est I can * and we ma! "e getting a

simulator into the unit that we can connect to a console. Then I+ll run the staff "! it on the

night shift until ever!one is more comforta"le with this. >eanwhile, !ou should feel free

to call the "alloon techs at night, or call the %?s in the 0 or the cardiothoracic I0

for advice.

@ne more word a"out timing "efore going into the details: remem"er that there are

1safe2 positions for each timing 4no", or slider. @n our machine, turning the 4no"s

inwards, towards the center of the console, puts them in a position where the timing can


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not hurt the patient. It won+t help them either, "ut at least no damage will "e done. 7hen

I trained on the old console, the! taught us to remem"er that it+s li4e during a storm:

1safe inside2, and 1dangerous outside2 * the old consoles had two timing sliders instead

of 4no"s, "ut the idea was the same: moving the sliders inwards was alwa!s safe if !ou

were worried, and moving the sliders outwards was moving first into treatment, and then

if !ou went too far, danger. Ho if !ou+re not sure where !ou are with the timing, turn the4no"s inwards * left$hand 4no" towards the right, cloc4wise * right$hand 4no" towards

the left, countercloc4wise, alwa!s towards the center of the console. Then wor4 the left

4no" carefull! "ac4 towards the dicrotic notch to set inflation, and then wor4 the right

4no" to the right to set deflation.

Timing Basics

%ight Finall! got a scanner. 5All strips come from documentation "! the Datascope

orporation, and are used with permission6. @4a!, here+s a nice strip of a "alloon that+s

Eust a"out perfectl! timed, with the console set at a ratio of #:9 * meaning, it+s

1"allooning2 ever! other "eat. =et+s see if I can remem"er how to do arrows


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# 9 # 9

www.datascope.com/ca/pdf/preinserviceKselfKstud!Kguide.pdf 0sed "! permission.

@4a!, what have we got here8 First off, see the groups of three8 Three pea4s8 =oo4 forthe groups to help !ou orient !ourself. ?ow $ ever!"od! see the first arrow on the top

left, pointing at 1PHP28 ?um"er #8 That+s the patient+s pea4 s!stolic "lood pressure.

?ow loo4 at the ne-t arrow down, 1APHP2, num"er . Hee how the pea4 that it+s pointing

to is lower than the first one8 Jou can see the same thing happening clearl! in the "eats

that follow * this is important * see how the second arterial pea4 is lower than the first

one8 5The reall! high waveform in the middle, num"er 9, is the "alloon doing its thing,

"ut we+ll get to that in a minute.6 The first waveform, the PHP, is the 1patient+s s!stolic

pressure2, and num"er , after the "alloon wave, is the 1assisted patient+s s!stolic

pressure2, which reflects 1unloading2.

7h! is this such a good thing8 =et+s remem"er that in cardiogenic shoc4, the heart is

tr!ing to pump against a reall! tight arterial s!stem * it tightens up to tr! to maintain
http://var/www/apps/conversion/tmp/scratch_3/www.datascope.com%2Fca%2Fpdf%2Fpreinservice_self_study_guide.pdfhttp://var/www/apps/conversion/tmp/scratch_3/www.datascope.com%2Fca%2Fpdf%2Fpreinservice_self_study_guide.pdfhttp://var/www/apps/conversion/tmp/scratch_3/www.datascope.com%2Fca%2Fpdf%2Fpreinservice_self_study_guide.pdf


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"lood pressure when the heart loses pumping power. Is this a good thing8 It ought to "e

* it+s the onl! thing the "od! can do in this situation. But does a wea4ened =C enEo!

pumping against a reall! tight set of arterial vessels8 ?o it does not %emem"er, this is

what 1afterload2 means * the resistance that the =C is facing as it tries to pump "lood out

into the arteries. An!"od! 4now what num"er we use to measure afterload8 7ho said

HC%8 Cer! good )igher is tighter, lower is looser, and if !our patient+s heart is failing,looser is "etter. Ho the first goal of proper timing is to ma4e sure that the assisted s!stole

is lower than the patient+s own s!stole.

This is where the difference in arterial pressures comes in * the "alloon, "! deflating,

lowers the arterial pressure in the aorta * that+s part of the 1assist2. The other part of the

assist is that the deflation helps the =C empt! itself * more on that "elow.

After the dicrotic notch * this is the point at which the "alloon inflates * see the

waveform shoot upwards8 ?um"er 98 This is the pressure generated in the aorta as the

"alloon inflates, and since this inflation is happening during * which phase of

contraction8 * diastole * this reall! high part of the wave is called the 1augmenteddiastolic2 pressure. 5@n the diagram it sa!s 1PDP2 * I have no idea what the! mean.6

Hince this is the highest pressure generated in !our patient+s arteries, !our transducer

setup is going to displa! this num"er as the patient+s own s!stolic * which it ain+t. 7e

follow the >AP in this situation an!how. But it is perfusion pressure * that inflation

pressure does help perfuse tissues, so ma!"e it doesn+t matter so much, as long as !ou

4now the difference. I usuall! write 1augmented diastolic2 over m! hourl! BP chec4s on

the flow sheet to indicate what the transduced s!stolic num"er reall! means.

?ow loo4 at the place where the pressure in the aorta is lowest, at the end of "alloon

deflation * this is called the BADP: the 1Ballooned Aortic nd$Diastolic Pressure2. Ha!

that three times fast. This point should alwa!s "e lower than the patient+s own diastolic

pressure * which on the diagram is the "ottom arrow on the left. Hee how the one is


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lower than the other8 This is the second goal of proper timing * to lower the diastolic

resistance in the arteries. Both pressure components are lowered, decreasing the HC%.

?ow ta4e a loo4 at the group of three pea4s on the right side of the diagram. This should

"e the pattern !ou want to get with proper timing. 7ith the machine set at a ratio of #:9,

!ou should see the assisted s!stole lower than the patient+s, and the BADP lower than

the patient+s diastolic. Hee the pattern8 H!stolic pea4s lower, diastolic "ottoms lower.

Jou+ll see people standing, scrutini3ing the monitor, sa!ing, 1@4a!, this should "e lower

than that, and this should "e lower than that.2

Inflation Timing

;$# 7h! does the "alloon inflate at the dicrotic notch8

The "alloon is supposed to inflate towards the end of diastole. Ho $ the walls of the heart

open up, the cham"ers fill, and the aortic valve flips shut. It turns out that the anatomical

openings $ the ostea $ leading to the coronar! arteries are in the wall of the aorta, Eust

a"ove the valve, and at the end of diastole the aorta re"ounds a little "it, and the


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coronaries perfuse * passivel!. ?ow, if !our ischemic patient needed more than Eust

passive perfusion * what could !ou do8 Inflate the "alloon. )ow do !ou 4now when to

inflate8 It turns out that the dicrotic notch, coming at the end of diastole, indicates e-actl!

the event we want * the closure of the aortic valve. @nce the valve is closed, the "alloon

inflates, and "lood is forci"l! pushed "ac4wards along the aortic arch, and into the

coronar! arteries under pressure, improving perfusion.

;$9 7h! do we use the arterial wave for timing8

Himple: we use the arterial wave to loo4 for the dicrotic notch, to use as the mar4er for

inflating the "alloon. 0se the inflation 4no" to move the inflation wave leftwards, until it

meets the dicrotic notch.

# 9 # 9 # 9


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Arrows again. This time, the arrows from a"ove are pointing to the dicrotic notches. The

arrows from "elow are pointing to the inflation waves of the "alloon. 5The inflation wave

is a lot smaller in this picture than it usuall! is. Bad diastolic augmentation6 Is it

an!where near where it ought to "e8 At the notch8 ?o * it needs to "e moved leftwards.

>ove it to the left with the inflation 4no", turning awa! from the center of the console. If

!ou do it slowl!, !ou+ll see the inflation wave actuall! move over until it intersects with the

dicrotic notch. Don+t go too far Bingo an !ou see how the arrows coming later in the

strip point to the same things8 The augmentation should improve as !ou fi- the inflation

timing.

;$ But there+s also the 1"alloon pressure waveform2. 7hat+s that for8

The arterial wave comes from the patient, so it doesn+t tell !ou an!thing a"out the

"alloon itself. The "alloon pressure wave tells !ou if the "alloon is inflating or deflating

properl!. 0suall! in m! e-perience if the "alloon is timing well and producing a good$

loo4ing waveform, then the "alloon waveform is ta4ing care of itself. Jou are still

responsi"le for 4nowing what the wave is supposed to loo4 li4e, and !ou should 4eep a

cop! of the IABP waveform card to chec4. )ere+s an e-ample of a properl! timed

waveform:


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;$; 7hat is a dicrotic notch, and wh! do the! call it dicrotic8

The notch indicates closure of the aortic valve, and comes at the end of diastole, as the

pressure falls. 7h! is it called dicrotic8

;$< 7hat is diastolic augmentation8

%emem"er that the "alloon inflates at the end of diastole, Eust after the aortic valve

closes * the rapid inflation is what augments the perfusion of the coronar! arteriesthrough the ostea. This rapid inflation can produce a pressure wave that+s actuall! higher

than the patient+s s!stolic pressure, and that high pressure wave is referred to as

diastolic augmentation. That+s the high waveform in the middle of the three pea4s.


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;$( )ow does inflation help8

Inflation helps "! forci"l! perfusing the coronar! arteries, instead of letting them "e

perfused passivel!. =oo4 at the 1PDP2 point in the diagram "elow * that+s the pressure

perfusing the coronaries generated "! the inflation of the "alloon. A lot of pressure This

is often enough to control angina/ischemia along with ischemic s!mptoms, and can

sta"ili3e an ischemic patient until the! can go to either the cath la" or the @%.

;$$ 7hat are all those initials pointing to the different parts of the timing waveforms8

# 9 # 9


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ver!"od! has their own s!stem for la"elling the important points on a "alloon timing

waveform, "ut the! refer to the same events. Htarting at the left:

$ PHP: meaning the 1patient+s s!stolic pressure2.

$ ?e-t is IP * here I thin4 the! mean 1inflation point2, which of course is also what8$

correct, the dicrotic notch.

$ ?e-t8 7hat do the! mean "! PDP8 I have no idea. I would call this the 1augmented

diastolic pea42.

$ After that8 BADP * that+s what I call it as well.

$ Then * APHP: this I thin4 means 1assisted patient s!stolic pressure2. lose enough *

I call this 1assisted s!stole2.

$ D? * o4a!, this one the! call the dicrotic notch.

$ PADP: pro"a"l! 1patient+s aortic end$diastolic pressure2. 7hich is to sa!, the

patient+s diastolic, unassisted.

;$ )ow do I ma4e sure m! inflation timing is right8


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# 9

The safe position for the control 4no"s is alwa!s inwards towards the center * the

inflation 4no" is the left$hand one on the console, and turning it to the left,

countercloc4wise * outwards from the center * will move the inflation wave to the left

5earlier6 as !ou watch on the arterial line trace. The inflation wave should coincide with

the dicrotic notch. Hee the arrow8

As a note: !ou want the angle there where the inflation wave goes up from the notch to

"e nice and sharp. 1risp2, I thin4 is the word the! use.

Deflation Timing


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;$ 7hat is the 1point of isovolumic contraction28

This refers to the point in the cardiac c!cle when the cham"ers have filled with "lood at

the end of diastole * the cham"er walls are "uilding up pressure to start s!stolic

contraction, and this is the point at which the heart is wor4ing the hardest.

;$#' 7hat is 1m!ocardial stro4e wor428

>!ocardial stro4e wor4 is the effort that the heart puts out with each s!stolic contraction.

In cardiogenic shoc4, the pump is having a hard time pumping * so stro4e wor4 is

something !ou want to tr! to reduce * which is e-actl! what "alloon deflation does.


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;$## )ow does deflation help8

%apid deflation of the "alloon creates an area of lowered pressure in the aorta Eust

ahead of the empt!ing left ventricle. Hort of li4e suction. The suction helps empt! the

ventricle with each "eat, and ta4es some of the wor4load off of the cardiogenic heart.

Almost ever!one with cardiogenic shoc4 died "efore the invention of the IABP "ecause

there was no wa! to assist the failing =C * now the survival num"ers are prett! good.

;$## )ow do I ma4e sure m! deflation timing is right8

The deflation 4no" is the right$hand one on the console. Turning the 4no" cloc4wise, to

the right, moves the deflation wave to the right 5later6. >ove the 4no" to the right until the

BADP loo4s sharpened, and lower than the patients+ diastolic, "ut not so far that it

"egins to rise * chec4 the diagram to help !ou remem"er which points are supposed to

"e lower than which.


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Hee how the second diastolic 5the assisted one6 is lower than the first one 5thepatient+s68 =i4e the inflation point, the point at the BADP 5the point of the arrow on the

right6 should "e nice and sharp. If this point "egins to rise, !ou need to reset the timing

to correct it.

;$#9 7hich wa! do I turn the 4no"s on the console8

This is worth repeating * the safe positions of the 4no"s are turned 1inwards2 towards

the center of the console. Jou time inflation "! moving the left$hand 4no"

countercloc4wise, or to the left, awa! from the center. Deflation is timed with the right$

4no", again, starting from the center, towards the right, awa! from the center.

Timing Pro"lems


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;$#; I 4now that there are two "ig "ad timing errors * what are the!, wh!

are the! so "ad, and how do I ma4e sure I don+t ma4e them8

The two "ig "ad timing errors are earl! inflation and late deflation.

The! "oth come from moving the timing 4no"s too far awa! from center.

;$#< 7hat is earl! inflation8

arl! inflation is Eust that * the inflation 4no" is turned too far to the left, and the inflation

wave actuall! comes "efore the dicrotic notch. To the left of it. This means that the

"alloon is inflating "efore the aortic valve closes, pumping "ac4wards into the =C, whichis alread! having a hard time empt!ing itself


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>ore arrows. )ere the!+re pointing to the inflation wave, which is wa! out ahead of

where it ought to "e. 5IP I guess stands for 1inflation point2.6 Hee where it sa!s D?8

That+s where the inflation wave should "e. 57h!86 Ac4 I have to sa!, Eust loo4ing at this

wave is enough to give me chest tightness

;$#( 7hat is late deflation8

=ate deflation is when the "alloon remains inflated too long * the heart is tr!ing now to

pump against an inflated "alloon. Bad The deflation 4no" has "een turned too far to the

right * move it "ac4 towards the center, ma4e sure the BADP is lower than the patient+s

diastolic pressure on the waveform, and start over.


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Hee the BADP all the wa! up there8 The patient+s end$diastolic pressure is that PADP

that !ou see down lower * this is also a certified Big Bad timing error * don+t let this

happen.


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;$# Are there 1good2 timing errors8

Hure $ if the 4no"s are too far inwards, then the "alloon is safel! inflating and deflating *

it+s Eust not reall! helping much. )ere+s the opposite of earl! inflation: what can it "e "ut

1late inflation28 Duh. Hee the inflation point8 7hich wa! will !ou turn the inflation 4no" to

fi- this8 )ow does the deflation loo48

)ere+s the other one. This is the opposite of late deflation * has to "e 1earl! deflation2.

7on+t hurt the patient, "ut doesn+t help either. )ow would !ou fi- this one8 )ow does the

inflation loo48


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;$# an the G "e used for timing8

Jes * there are timing mar4ers that !ou can use to time "! G, and the Transact

console that we use does this automaticall!. Actuall! in practice, we never do this,

"ecause we never, ever, "alloon people in our I0 without an arterial wave * if onl!

"ecause we transduce the 1root line2 that+s "uilt into the "alloon to give us one.


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;$#& 7hat if the patient is "eing paced8

In practice * !es, !ou can "alloon a paced patient. I haven+t done this m!self in a while,

"ut I remem"er that there used to "e a 1pacer reEect2 mode on the older IABP consoles *

we should put this question to the "alloon techs for a "etter answer.

Balloon Tech ar! sa!s: If the patient is A$pacing, use the %$wave trigger mode, 5see a

couple questions down6, and decrease the gain to ma4e the Q%H smaller * that wa! the

"alloon will trigger off of the A$spi4e. 7ith C$pacing, use the same %$wave trigger mode,

and the "alloon will trigger off the C$spi4e.

;$9' 7hat if the patient is having ectop!8 @r a$fi"8


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Balloon pump consoles reall! don+t li4e irregular rh!thms. There are lots of claims "!

companies that ma4e the consoles that their machines trac4 a$fi" with good timing * I

haven+t seen it !et. =i4ewise ectop! * "alloons "ecome unhapp! with F=Bs 5funn!

loo4ing "eats6 of an! 4ind * seriousl! consider having the team tr! to a"olish ventricular

ectop! in the patient if the!+re "alloon dependent. Amio * whatever. 7atch their

electrol!tes: GO, >ag =i4ewise it might "e a good idea to tr! to convert a person from

a$fi" to sinus rh!thm, for the same reason.

;$9# 7hat is 1triggering28

The console needs some wa! to 4now where it should start * we can adEust the timing

from there, "ut the machine needs to see some signal from the patient to tell it when to

start inflation and deflation.

;$99* 7hat is 1trigger mode28


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The console can use several wa!s to recogni3e trigger signals * the most commonl!

used is 1%$wave2. The "alloon techs will wor4 with !ou to figure out which mode to use.

@n the Transact console, sometimes 1pea4s2 mode wor4s well * I don+t 4now enough

a"out this. There are pacema4er trigger modes too * we need to loo4 into this.

;$9$ )ow often do I need to chec4 m! "alloon timing8

Jou certainl! want to chec4 the "alloon timing as soon as !ou get into the patient+s room.

I usuall! ta4e a quic4 loo4 at the patient, the monitor, and then the console. I set the

IABP ratio to #:9, and I ma4e sure that the timing is as good as I can get it. Then I print a

timing strip and stic4 it on the "ac4 of the flow sheet. The timing ma! change as the

patient+s condition does: changes in heart rate, "lood pressure, arr!thmias 5o"viousl!6 *all can ma4e differences in the! wa! the timing will need to "e set. Be alert


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actuall! seen an!one need platelet transfusion, "ut !ou definitel! see drops in the

counts. An!"od! 4now wh! this is8

Balloon Tech ar!: 1the platelet count drops "ecause the "alloon ph!sicall! inEures them

as it operates.2

Travelling Dawn points out: 1ma4e sure that this heparini3ed patient doesn+t have )IT2

-cellent point. The patient might need Argatro"an instead of heparin.


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which ma4es sense, since the "alloon would inflate and deflate in s!nc with

compressions. 7e need to follow up with the "alloon techs on this question.


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so that the! can "e 4ept safel! sedated until the "alloon can come out. @ther people do

Eust fine on the "alloon. Be vigilant.


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and "e read! to head off surprises. 7or4 with the team, and with !our peers, and have a

plan read! if the patient should "ecome agitated * don+t wait until it happens


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Hhut the console down * !ou do ?@T want to "e pumping helium into the patient+s

arterial circulation. This "alloon needs to come out promptl! * notif! the appropriate

people immediatel!. At this point of course, if the patient is "alloon dependent, !ou ma!

have real trou"le. Thin4 a"out what to do to support them in the period of time until the"alloon can "e replaced $ the 1chemical "alloon2 might "e something to thin4 a"out.

%emem"er how it wor4s8


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Print a strip for each leg to document the difference * the vascular people will "e ver!

interested in these, and will pro"a"l! want to do a set for themselves. I tape the strips to

the "ac4 of the flow sheet.

Bear in mind that a change in pulses ma! "e the earl! signal of something threatening

the foot, or the leg. An! significant change, sa! from palpa"le pulse to dopplera"le pulse

should start !ou thin4ing, and communicating with the team. Home people thin4 that all

IABP patients should have "aseline and followup PC%s * I thin4 that a patient with a

warm e-tremit! and with sta"le pulses pro"a"l! doesn+t need them, since the! onl! tell

!ou what !ou alread! 4now. It+s the pulses that !ou can+t feel that should worr! !ou. An!time !ou thin4 !ou need a PC%, get one.


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$ ; required amputation 5I+ve never seen either this or fasciotom! happen6.

$ There were three aortic perforations. All were fatal. Do not let these patients sit up


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This is what happens when "ad germs get into !our patient along the routes created "!

the devices stuc4 into him: the "alloon pump, PA line, or whatever. It+s the same as an!

other septic picture: the patient gets hot, tach!, dilated, h!potensive, and it+s treated li4e

an! other septic situation: fill the tan4, squee3e the tan4, 4ill the "ugs. It+s also a goodidea to tr! to remove the piece of equipment that+s causing the pro"lem: swan, IABP *

sometimes it can "e hard to tell where the pro"lem is coming from, so !ou+ll see the

team go in and pull ever! line the patient has, and replace them.

ust ma4e sure that !ou have pressor access if !ou need it, which ma! mean that a new

central line will have to go in "efore the old ones come out. It can "e helpful to remindthe team that a femoral line can "e placed and used quic4l!, without an -$ra! * even

though the!+re considered the 1dirtiest2 of the central lines, the! can save a situation

from going from 1mildl! stressful2 to 1call a code2. nsuring that the patient has the right

4ind of IC access is !our Eo".


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Htents loo4 li4e the little springs that come inside "allpoint pens.

=ittle metal mesh tu"es that are put into place in the cath la" * the! are placed inside the

coronar! arter!, and then clic4ed open, so that the! hold the lumen of the arter! open

wide Eust where the tight spots are. asier than "!pass surger!. I don+t 4now how long

the! last, "ut I do 4now that patients with them need to ta4e something li4e Plavi-,

"ecause platelets love to stic4 to things li4e stents * an!thing irregular * and the!+d clot

off as a result.

http://www.surger!.usc.edu/divisions/vas/graphics/stents.Epg

@"viousl! there+s "een a lot of progress in the stent world since this article was written.

7ow * si- !ears ago alread!8 ?owada!s stents are coated with some 4ind of drug$

releasing material that inhi"its clot formation * prett! smart a!ne sa!s that the patients

still ta4e Plavi- for a while after the stents go in * not sure for how long.
http://www.surgery.usc.edu/divisions/vas/graphics/stents.jpghttp://www.surgery.usc.edu/divisions/vas/graphics/stents.jpg


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($ 7hich "alloon console do we use8

7e use the Bard compan!+s Transact IABP console. The console drives and controls the

"alloon: it holds the helium tan4, which nowada!s is a little gold thing the si3e of !our

fist. It has a prett! good computeri3ed "rain that helps !ou with timing * in fact it will tr!

to time the "alloon all "! itself, and sometimes can do a good Eo". The control panel is

divided into fairl! o"vious groups:

Power 5A or "atter! * the "alloon will wor4 for a time on "atter! * a couple of hours8 *

"ut we onl! do this when we+re transporting to and from the cath la" or the @%, and the

"alloon techs usuall! handle this.6

hoice of either s4in wires, monitor signal, or arterial wave for trigger signal. The two

wire s!stems "ac4 each other up * the console needs some wa! to see what the!

patient+s rh!thm is. The neat thing a"out the Transact is that if the patient loses all her

wires, !ou can time the machine off of the arterial line waveform * !ou alwa!s have one

of these "ecause there+s one "uilt into the "alloon itself.

hoice of triggers: %$wave, pea4s, pacer * there+s lots of choices. onsult with the

"alloon techs a"out this * a"out &'M of the time we run on %$wave trigger.


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ontrols to stop and start the "alloon: off, stand"!, purge, run, automatic. Bear in mind

that the "alloon will run in non$automatic mode, "ut the gas alarms will "e off * meaning

that if the line 4in4s, or lea4s, or for an! reason the "alloon loses volume or gas !ou

won+t 4now it. Be careful.

7eaning controls: to set the ratio of "allooned "eats to the patient+s own "eats: # to #, 9

to #, ; or to #. %emem"er that timing is alwa!s chec4ed with the "alloon set to a ratio

of 9 to #. Jou+ll see the "alloon techs time the console at # to # * I don+t 4now how the!

do this, "ut he!, it+s much more their thing than mine * I don+t argue with the pros.

>onitor screen * this can "e set to see the patient+s arterial waveform or the waveform

that sees the "alloon itself inflating and deflating. Jou have to 4now what "oth are

supposed to loo4 li4e. >ore on these later on. Jou can set the monitor to either

waveform, change the scale, free3e the screen, all those things. There+s a printer as well

* I print a strip of the patient+s arterial waveform with the ratio set at 9 to #, to show how

well the "alloon is wor4ing, and stic4 it on the "ac4 of the flow sheet. It can "e hard to

see the waves clearl! on the console monitor, so for timing what I do sometimes is set

the scale on the "edside monitor so that the art$line waveform is reall! enormous and

clear, and then do m! timing.

($#$ 7hat is the purpose of the 1"alloon pressure waveform28


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%emem"er that all these waveforms are coming from transducers, which are hoo4ed up

to lines, that are connected to and 1loo4ing at2 something * either a vessel or cardiac

cham"er in the patient, or in this case the "alloon that+s going into the patient. This is the

waveform coming from a transducer "uilt into the console * it loo4s at how the "alloon iswor4ing as it inflates and deflates, and the wave is supposed to loo4 a certain wa!.

hanges in the waveform can tell !ou different things.

=atel!, our main pro"lem has "een that we don+t get enough "alloons in our unit, and

lots of people go to the class and then don+t see one for ; months. Htressful. )opefull!

soon we ma! "e a"le to get a simulator that will sta! on the unit, hoo4ed up to a console,and we+ll pla! with it to the point where ever!one will "e more comforta"le.

($9$ )ow often should I chec4 it8

ertainl! switch "ac4 and forth from "oth waveforms on the console at the "eginning of

the shift and ever! hour or so after that.


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($$ an I assume that the "alloon pressure waveform is o4a! if m! arterial$line timing

waveforms are o4a! too8

>! e-perience is that if the patients+ arterial waveforms are clear and correct, that means

that the "alloon is wor4ing the wa! it ought to "e, and that the "alloon waveform will "e

o4a! as well.

($;$ 7hen do I have to worr!8

I alwa!s worr!.


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($


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=ot of waves Important: an! pressuri3ed line that goes into a patient needs to "e

connected to the monitor, if onl! so !ou+ll 4now if it comes disconnected. @nce !ou have

a chance to wor4 with the machine a couple of times, the setup will ma4e more sense *

e-pect to "e confused at first.

($$ 7hat is the 1root line28

The root line is the arterial line "uilt into the "alloon. It runs along the length of the

device, opens up at the end, and reads the pressure in the aorta where the "alloon tip is.

($$ 7h! does the root line transducer need to "e air$filtered8

7e go to a lot of trou"le to ma4e sure that air doesn+t get into the patient+s arterial

circulation. 5Cenous too.6 If a pressuri3ed transducer "ag "egan for some dum" reason

to pump air into a patient+s aorta, the result would "e an air em"olus * Eust as "ad as an!

other em"olus, li4e a clot, travelling along in the arter!, eventuall! causing an infarct

somewhere.


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($&$ 7h! do we mar4 the root line 1?o Fast Flush28

Again, to prevent air in the line from going into the patient. If for an! reason !ou need toaspirate or flush the root line, !ou don+t want to hit the flusher and push several inches of

air that might happen to "e in the tu"ing along into the patient. The idea is that !ou+re

supposed to do all these moves manuall!, using a ten cc s!ringe, watching for air the

whole time.

($#'$ 7h! can+t I draw "loods from the root line8

7hat if it "ecame clotted8 And !ou had no radial line8 ould !ou time the "alloon

without an arterial wave8 ?ot properl!, an!how.


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($##$ an I ever8

Jou reall! should not. If !ou+re in an e-treme situation, !ou do what !ou have to, "ut it+s

not a good idea. Insist on a radial line if !ou thin4 the patient needs one.

($#9$ There seem to "e eight arterial "lood pressure waves coming from this patient.

7hich one do I "elieve8

People argue a"out this one. I usuall! "elieve the highest pressure I see. %emem"er

though that the highest pressure that the monitor reports is usuall! not the patient+s

s!stolic pressure * it+s the augmented diastolic pressure, which is often higher than the

patient+s when the "alloon is wor4ing right. >APs are usuall! a "etter guide.

($#$ 7h! do I need to transduce all of them8


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If a pressuri3ed arterial line were to come disconnected, the alarms would let !ou 4now.%emem"er to set and chec4 alarm limits for ever!thing.

($#;$ )ow do I chec4 the helium level8 )ow do I change the helium tan48

There+s a gauge on the side of the console * the helium tan4 for the transact console is

supposed to last a ver! long time * months8 I+ve never had to change one, "ut there+s

alwa!s a spare in the equipment "ags that some with the machine, and I+ll ma4e sure

that we have some manuals availa"le.

($#


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$ >anuall! inflate and deflate the "alloon if the console is going to "e down for more

than #< minutes. 0se a "ig catheter$tip s!ringe 5we call these 10 guns2 for some

reason6, and use a"out #'cc less than the "alloon+s volume, inflating a"out #' times a

minute. The idea is to prevent the formation of clots on the "alloon * don+t worr! a"outtr!ing to time it to the patient. 5That would "e a neat tric4 1)e! gu!s, watch this26

$ Don+t ever put air into the root line. 5eepers, wh! would !ou86

$ Tell the cardiolog! people what+s going on right awa!.

($# 7h! can+t I run the console with the gas alarms off8

Jou can, "ut it+s not a good idea "ecause it+s not reall! safe. The gas alarms are what

tell !ou if something has changed a"out the inflation or deflation of the "alloon * if the

line is 4in4ed, !ou won+t 4now, if the line lea4s, !ou won+t 4now, and so on. There are

times when !ou do have to run with the gas alarms off * recentl! I too4 care of a man

whose "alloon was 4in4ed Eust inside the insertion site * the decision had "een made to

leave it in place, so we ran it with lots of advice from the "alloon techs, who agreed that

it might onl! run that wa! if the gas alarms were left off.


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($# )ow do I reset the console if it alarms8

It depends on wh! it alarmed. If the patient rolled over and the line is 4in4ed, thenresetting the machine won+t wor4. The console actuall! is prett! good at telling !ou

what+s wrong * read the messages at the top of the screen. >a4e sure the line is clear,

then hit stand"!, then auto * that will restart at # to #, with gas alarms on.

($#& 7hat do I do if the console sa!s 1gas lea428

>a4e sure the clear "alloon line is tightl! connected at "oth ends to the patient and the

console, then restart the console. If !ou get the message again, !ou might have to run

the length of the tu"ing through a pan of water to see if there+s a pinhole lea4. @r !ou

can listen along the length of the line with a stethoscope. >ost of the time there+s no

detecta"le lea4, and the machine does ma4e message mista4es sometimes. Be alert to

the possi"ilit! of "alloon rupture though * inspect the line for "lood. If !ou see an! at all,

the console must "e shut off, and the "alloon has to come out.


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($9' @r 1no trigger28

This means that the console can+t see the patient * either the s4in wires or the monitor

wires have come off. Tr! switching to the other s!stem from whatever it is !ou+re using,

and see if the console will wor4. If neither wire s!stem wor4s, change to the arterial

trigger * there+s a "utton for it, and the machine will trigger prett! well off of the root line

waveform until !ou get electrodes and wires re$connected to the patient.

($9# 7hat if I have to travel with the patient8

The onl! travelling that !ou+ll do with a "allooned patient is either to or from the cath la",

or rarel! to the T scanner. If the patient goes to the @%, the!+ll "e moved "! anesthesia

and a "alloon tech. ither wa!, if !ou have to go an!where, A=7AJH call in the "alloon

tech to go with !ou. The console has a set of inputs on one side for running when the

patient is connected to a "edside monitor * on the other side is a set of inputs for travel

ca"les. The equipment "ag has an ca"le for triggering, and an arterial ca"le for the

root line.


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($99 7hat if there+s a lot of water in the "alloon line8

If there+s a lot of condensate in the line it can ma4e the console unhapp!. I was taught

that we were supposed to stop the console 5stand"!6, disconnect the tu"ing from the

console and drain it downwards towards the floor onto a chu- or something, reconnect,

purge, and then restart. I+ve seen ver! little condensate with the newer console * we

should chec4 with the "alloon techs a"out this.

Balloon Tech ar!: the machine purges itself ever! $; hours, and removes an! water in

the line when it does.

($9 Hhould I ever turn the console off8

The onl! time that I+d shut the console off would "e if I thought that there was a "alloon


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rupture, with "lood in the "alloon line. To stop the console temporaril!, push the stand"!

"utton. Hometimes house officers will as4 !ou to do this so the! can assess heart

sounds, or "owel sounds. This is o4a! ver! "riefl!, "ut remem"er that a "alloon$

dependent patient ma! not handle this well.

($9; 7hen should I call the "alloon tech for help8

An! time !ou thin4 !ou need it. >ost pro"lems can "e solved "! a little group thin4ing

among the nurses in the unit, and a call to the nurses in the 0 might "e useful, "ut if

!ou thin4 !ou have a pro"lem !ou can+t fi- * that+s wh! the techs are there.

($9< )ow do I page the "alloon tech8

During the da! the! carr! in$house pagers that !ou can call through the regular page

operators. At night the! have a different paging num"er * if the page operator doesn+t

have it, the 0 or the HI0 will. Hometimes the techs do sta! in$house overnight if

there are a lot of consoles running, or if there are unsta"le patients in the units.


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($9( )ow do I 4now if the helium is getting low8 )ow do I change the helium tan48

There+s a pressure gauge on the right side of the console that shows the currentpressure in the tan4 * if it gets too low, a message will flash on the screen that the tan4

will need changing soon. hanging the tan4 turns out to "e prett! eas! * according to

the "alloon tech who tal4ed us through it on the phone one night:

a$ leave the console running

"$ find the "ig "lac4 lever on the right side of the console, and pull it outwards, awa!

from the machine until it stops

c$ grasp the helium tan4 5a ru""er glove will help, "ecause it+s a little hard to gra"6,

and unscrew it

d$ screw in the new tan4 firml!

e$ push the "lac4 lever "ac4 down, which spi4es the new tan4


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f$ the gauge should show a nice high pressure.

$ 7hat a"out documentation8

Do it carefull!.

$# 7hich pressures do we document8

In the space on the flow sheet where we put the "lood pressure, we still write the s!stolic

and diastolic num"ers from the monitor, "ut !ou have to remem"er that the higher

num"er will "e the highest pressure pea4 that the transducer sees * which is usuall! the


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augmented diastolic when we+re "allooning.

$9 )ow do I document pulses8

I ma4e two columns mar4ed left and right, and mar4 1palp2, or 1dop2, or 1a"sent2 for each

DP and PT. @n each side I write 1cool2 or 1warm2, underlined if there+s "een a change.

$ Hhould I paste in the PC% strips8

Definitel!. I sometimes ta4e one of the stic4! sheets that we use for "lood product slips

and stic4 them on that * that sta!s with the flow sheet so that people can find them

quic4l!.


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$; 7hat a"out the weaning ratio8

7e use a split column to mar4 the ratio ever! hour, and to document that we+ve

o"served the waveform: ratio on top, li4e #:#, and a chec4 mar4 "elow.

$< 7hat goes on the flow sheet, and what goes in m! note8

I tr! to cover the "asics in m! note and leave the details to the sheet. For e-ample, I

might sa!:

C: Pt. in sta"le sinus rh!thm, no ectop!, =ido at #, ?T at 9'', heparin titrated to scale

with am result (.. ?o c/o HHP or H@B. IABP f- well at #:#, site dressing changed -#

for sm amt sang drainage, site clean. Hee timing strips on flow sheet for details. Distal

pulses: = 5IABP6 DP and PT doppelera"le onl!, foot cool "ut >H intactR % DP and PT

palpa"le, foot warm. PC%s taped to flow sheet, showing good waveforms for "oth legs.

0@ qs, L


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%esp: Pt. on ;liters nasal cannula @9, AB ;am: #9( $ ;# $ .;9, %% 9'+s, BBH grossl!

clear, afe"rile, denies H@B

I: tolerating diet with no difficult!, B> -# soft formed guiac neg, am glucose ##9

Htuff li4e that.

?ow * documentation people8 Jou+ll notice, right off, that I don+t use nursing diagnoses.

Alteration in realit!8 Potential versus actual8 As evidenced "! the doodah doodah da! of

the eelang "adoodang "ada!8 Are !ou serious8

I consider this a crucial point, actuall!, although it ma4es me a su"versive in m! own

profession * or would, if I hadn+t "een doing it so long. I 4now that m! attitude gives the

people at the oint ommission the conniptions, "ut the point is that what+s wrong with

!our patient is ?@T an 1Alteration in ardiac @utput2 . Actuall!, of course, it IH an

alteration, "ut that stuff is all so much window dressing * what+s reall! wrong with !our

patient8 )e+s having a rudd! huge >I, is what The more time !ou spend worr!ing a"out

!our nursing diagnoses * in fact, in Ancient ?urse >ar4ie+s opinion, A?J time !ouspend doing that is time ta4en awa! from thin4ing a"out !our patient. Instead of that

Eun4, watch her electrol!tes eepers


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@r put it this wa!: if one of the oint ommissioners came into !our I0 with a rudd!

huge >I, what do !ou thin4 the!+d want !ou to "e worr!ing a"out8

$ 7hat is "alloon weaning8

The "alloon does have to come out of the patient at some point. 7eaning is the process

of changing the ratio so that the "alloon supports at first ever! other "eat 5#:96, and then

ever! fourth, or eighth "eat, and o"serving how well the patient tolerates the wean.

$# Is there a weaning protocol8

Jes. 7hat !ou+re tr!ing to do is to see if the patient gets into trou"le if !ou tr! to wean


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the "alloon. Ho the first thing is to get a "aseline G with the "alloon at # to #, along

with a set of num"ers: CP, P7, output, inde-, HC%, HC, all that good stuff. Then !ou

set the IABP at 9 to #, and tr! to go for two hours, at the end of which !ou do another

G, and shoot the num"ers again, loo4ing for ischemic changes on the G, and

an!thing that might indicate that the patient isn+t tolerating the wean, li4e a rising wedge

pressure, dropping output, rising HC%. hest pain If nothing "ad occurs, !ou tr! twohours at # to ;, again followed "! G and num"ers, and finall! # to with G, etc.,

followed "! a return to # to # when the weaning is done.

$9 7hen should we start weaning the "alloon8 7hat is 1stunned m!ocardium28

It depends on wh! the "alloon went in. %emem"er that there are two main reasons for

an IABP * to help 4eep tight lesions open in the coronar! arteries 5inflation6, or to help a

failing =C in cardiogenic shoc4 5deflation6. The first reason includes "allooning a patientfor Eust a da! or two after stent placement, after which hopefull! the!+d tolerate a rapid

wean and removal. In that situation, anticoagulation is reall! of critical importance * do

!ou want to "e the one that let the patient clot off her "rand new stents8

The second situation is more difficult, "ut hopefull! somewhat predicta"le. The idea is

that a heart that+s "een hit "! cardiogenic shoc4 will need a certain amount of time to

recover. 7hat is there to recover8 It turns out that around the area of infarct 5!ou don+t

have acute cardiogenic shoc4 without a "ig infarct6 is an area that is still alive, still read!

to pump, "ut da3ed, or as the! sa! 1stunned2. This area of 1stunned m!ocardium2 will

eventuall! come "ac4 to wor4, "ut not for a given period of time, usuall! a"out a wee4.

Ho the person who ma! have an F of #9M right after an enormous >I ma! have a

much "etter F a wee4 later, after the stunned areas come "ac4 and start to wor4. The


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goal of "allooning this patient is to get them through that period of time, with the "alloon

functioning as an =CAD * a left$ventricular assist$device.

Ho * the answer to the question8 In the second case8 A"out a wee4.

$ )ow do I 4now if the patient is tolerating the "alloon wean8

The patient will remain sta"le according to all the things !ou+re following: Gs, cardiac

output, central pressures will all sta! sta"le.


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$; )ow do I 4now if the!+re not8

The! "ecome s!mptomatic. hest pain, ischemia on G, "lood pressure drops, wedge

pressure rises, o-!genation gets worse. 5Thin4 a"out sending "lood gases if !ou thin4

the patient+s condition ma! "e changing.6

$< Hhould I stop weaning if the patient is having trou"le8

A"solutel! stop the wean. o to the house officers and show them !our num"ers, !our

Gs, and !our "lood gases. The game plan ma! have to "e changed. In the case of

cardiogenic shoc4, !ou ma! have to "riefl! tr! a wean for several da!s in a row until the

stunned part of the heart starts wor4ing again.


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$( )ow long can a "alloon sta! in8

It+s varia"le. I+ve heard of patients "eing "allooned for longer than a month when the!+re

waiting for transplant. Ten da!s is the usual rough limit.

$ 7ho pulls the "alloon8

The interventional fellow comes to the unit, or, in some cases, the techs can pull the

"alloon.

$ 7hen should I turn off the heparin "efore a "alloon gets pulled8

The medical team should spea4 with the interventional people to determine this, or


105/106

sometimes the fellow will call !ou in the unit to plan things. Jou should tr! to get a

specific time, and "e ver! clear. @ne source said that heparin can "e stopped four hours

"efore the "alloon comes out, with the console running at #:# to prevent clot formation.

$& 7hat should I worr! a"out after the "alloon gets pulled8

Jour concern is the site and the perfusion to the leg. Provide site care as it+s ordered *

cardiolog! still li4es sand"ags, although it seems that angiograph! doesn+t. hec4 the

site for drainage, ecch!mosis, swelling, an!thing that might mean that there was

"leeding into the tissue around the site. hec4 the pulses in the affected leg, and

compare with previousl! * is the leg and foot warmer now8 Are the pulses stronger8

Document properl!. Geep the patient flat for the ordered amount of time. et clear

orders a"out when, or if, the patient is to "e re$anticoagulated, or started on oral

anticoagulation, or not anticoagulated at all. 7hen+s the Plavi- due8

Home sources:

www.r-list.com5a ver! useful site for finding pharmaceutical info6
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http://critcare.lhsc.on.ca* the we"site of the =ondon 5@ntario6 )ealth Hciences entre,ritical are Division

www.ispu".com/Eournals/ITCH/Col9?9/ia"p.html* The Internet ournal of Thoracic

and ardiovascular Hurger!

www.cardio$info.com/Kdisc(/''''''e.htmthe ohns )op4ins protocol cited in the C

Tal4 ducators and Professionals Discussion roup

www.datascope.com/ca/a"stractK#.html1Cascular omplications from Intraaortic

Balloons: %is4 Anal!sis
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Intra Aortic Ballon