IABP when , why and how ?
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intra aortic ballon pump is a mechanical device for circulatory support , here we discuss why we need it and when to use it and how to use it
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IABP when , why and how ?
- 2. When to use this ! Ongoing ischemia refractory to medical therapy. Prophylactic placement for high-risk patients with critical coronary disease High-risk patients undergoing off-pump surgery to maintain hemodynamic stability during lateral wall or posterior wall grafting. Unloading for cardiogenic shock or mechanical complications of myocardial infarction (acute mitral regurgitation, ventricular septal rupture).
- 3. Postcardiotomy low cardiac output syndrome unresponsive to moderate doses of multiple inotropic agents. Postoperative myocardial ischemia. Acute deterioration of myocardial function to provide temporary support or serve as a bridge to transplantation.
- 4. *2 Primary Benefits of IABP The primary purpose of the IABP is to increase Coronary Oxygen Supply during Diastole. The next purpose of the IABP is to Decrease Coronary Oxygen Demand during Systole.
- 5. *Secondary Benefits of IABP Decreased Heart Rate Decreased Blood Pressure Increased Cardiac Output.
- 7. Cardiac Output = Stroke Volume x Heart Rate normal: 4 – 8 L/min Cardiac Index = normal: 2.5 – 4.0 L/min/m 2 CO BSA Hemodynamics
- 8. CO = HR x SV HR Sinus Node Endocrine CNS Baroreceptors SV Preload Afterload Contractility
- 9. Myocardial Oxygen Balance Preload Afterload Heart Rate Contractility O2 Extraction Diastolic Time Diastolic Pressure Coronary Artery Flow Demand Supply
- 11. *Counterpulsation Synchronization of the pumping of the IABP with diastole (Inflation) and Systole (Deflation) is called counterpulsation.
- 12. Balloon Placement To pump Left Subclavian Descending Thoracic Aorta Kidney
- 14. Balloons exert their hemodynamic effect by volume displacement
- 15. *Inflation during Diastole The primary purpose of the IABP is to increase Coronary Oxygen Supply during Diastole.
- 16. Benefits of Inflation • Increased coronary blood flow • Increased diastolic pressure • Potential for increased coronary collateral circulation • Increased systemic perfusion
- 17. Deflation at Onset of Systole
- 18. *Deflation During Systole The next purpose of the IABP is to Decrease Coronary Oxygen Demand during Systole
- 19. Benefits of Deflation • Decreased Afterload • IVC Phase Shortened • Increased Stroke Volume • Enhanced Forward Cardiac Output
- 20. Signs of Improved Clinical Condition Increased cardiac output, 0.5 – 1 L/min Increased urine output Decreased preload Decreased pulmonary congestion Improved mentation Decreased heart rate Decreased lactic acidosis Increased pulse pressure and pulse rate Inflation Deflation
- 22. Absolute Contraindications • Aortic Insufficiency • Dissecting Aortic Aneurysm
- 23. Relative Contraindications • End-Stage Cardiomyopathy in a patient not a candidate for transplant • End-stage Terminal Disease • Abdominal Aortic Aneurysms, not resected
- 24. Complications
- 25. Increased Complication Risk PVD Female Gender Diabetes Hypertension Nicotine Use Obesity Shock SVR
- 26. Complications Aortic Wall Dissection Rupture Local Vascular Injury Emboli Thrombus Plaque Air
- 27. Complications IAB Rupture Helium Embolus Catheter Entrapment Compromised circulation due to catheter – Limb ischemia – compartment syndrome
- 28. In nearly all circumstances the IABP will be inserted via the Femoral Artery.
- 29. Pre-Insertion Assessment 1. Skin color of both legs 2. Skin temperature of both legs 3. Capillary refill ability of both legs 4. Quality of pulses in both arms & legs 5. Baseline sensation and movement of both legs 6. Complete neuro check
- 30. Adult IAB Sizing Recommendations Diastole Systole <162cm <5’4” <1.8m2 <182cm <6’0” >1.8m2 >182cm >6’0” Height BSA 30cc 40cc 50cc
- 31. Access Femoral Artery May be done with or without a syringe
- 33. Timing
- 34. How is proper timing achieved? • Always performed using the arterial pressure waveform as the guide
- 35. Arterial Pressure Waveform PSP Dicrotic Notch PSP Dicrotic Notch AVOAVO AEDP IVC 25% SV75% SV X X
- 37. Arterial Pressure Waveform Without IABP With IABP assist 1:2
- 39. DN DN Correct Inflation: Just prior to DN
- 40. When inflation timing is correct there should be a sharp “V” shape at the dicrotic notch.
- 41. Augmentation should be higher than PSP unless: 1. Patient’s SV significantly greater than balloon volume 2. Balloon is positioned too low 3. Hypovolemia 4. Balloon is too small 5. Improper timing 6. Partial obstruction of gas flow PSP AUG
- 42. APSP < PSP CORRECT DEFLATION : BAEDP < PAEDP PSP APSP BAEDP PAEDP
- 43. Timing Errors • Early Inflation • Late Inflation • Early Deflation • Late Deflation
- 44. Early Inflation
- 45. Early Inflation Correct Timing move inflation AUG DN
- 46. Late Inflation
- 47. Late Inflation Correct Timing move inflation AUG DN
- 48. Early Deflation
- 49. Early Deflation Correct Timing move deflation PSP APSP
- 50. Late Deflation
- 51. Late Deflation Correct Timing move deflation BAEDP PAEDP
- 52. # 1
- 53. Inflation is Good Deflation is early
- 54. # 2
- 55. Inflation Is early Note that the Dicrotic Notch on inflation appears higher than non-inflation Deflation is normal
- 56. # 3
- 57. Inflation is Good Deflation is Good
- 58. # 4
- 59. Appears Good but we really cannot make comparisons on 1:1 timing.
- 60. # 5
- 61. Inflation is Early Deflation is Early
- 62. # 6
- 63. Inflation is late Deflation is good
- 64. Helium Delivery
- 65. Balloon Inflation 0 transducer pump helium BPW compressor Vacuum / compressor system
- 66. Balloon Deflation 0 transducer pump helium BPW vacuum Vacuum / compressor system
- 68. BPW in Irregular Diastole (Afib)
- 70. Fill Failure Pump did not fill adequately with helium to establish the balloon pressure waveform baseline Verify helium tank not empty, all catheter connections intact
- 71. Gas Loss
- 72. 0 300 Classic BPW of an IAB too large for the aorta
- 73. Triggering
- 74. Definition
- 75. Options
- 76. FOR GOOD, CONSISTANT TRIGGERING IT IS IMPORTANT TO PROVIDE THE PUMP WITH A GOOD ECG SIGNAL Good Choices – Unidirectional QRS with minimal artifact Poor Choices – Biphasic QRS, tall T or P waves, wandering baseline, artifact present
- 77. This lead will give you both triggering and timing problems
- 78. ECG Newer Systems will automatically initiate Arrhythmia Timing when several irregular diastolic intervals occur. Arrhythmia Timing allows for more consistent and appropriate deflation of the IAB during irregular rhythms.
- 79. Timing with Irregular Rhythms Arrhythmia Timing Conventional Timing
- 80. V Pacer
- 81. Arterial Trigger The IABP will detect changes in arterial pressure to initiate inflation and deflation. It is the trigger of choice when CPR is in progress.
- 82. Internal The balloon inflates and deflates at a preset rate regardless of the patient’s cardiac activity. This mode is only to be used when there is no cardiac output and no ECG but many newer systems can detect pressure differences from CPR
- 83. Cardiac Arrest What do you do with the IABP?
- 84. Augmentation
- 85. Augmentation refers to how full we fill the IABP balloon during operation. During normal operation the IABP will be operated at 100% augmentation The IABP should never be operated below 50% augmentation.
- 86. Low augmentation can result in the peak diastolic augmentation being lower than unassisted systole and the wave form will look irregular. Augmentation is frequently used in conjunction with timing to wean the patient from the IABP.
- 87. Other Complications Of IABP
- 88. Balloon Rupture Balloon Rupture can allow a large gas embolism to enter the body. The IABP must never be operated if a Balloon rupture is suspected.
- 89. The classic sign of a balloon rupture is rust colored specs inside the IABP helium tubing in conjunction with loss of helium pressure. It the rupture is large it may be RED.
- 90. Gas Loss
- 91. Transducer Position The transducer should be placed in line with the phlebostatic axis. During transport it is critical that the transducer be secured at a fixed point on the patient.
- 92. For every inch variance to the phlebostatic axis there is a 2 mm/HG inverse change in pressure. Increase height by 4 inches and pressure reads 8 mm/HG lower
- 93. All of the transducer connections must be tight to prevent rapid blood loss. There must not be any air in the transducer lines.
- 94. weaning Criteria for weaning Ratio , augmentation and heparin
- 95. weaning IABP support can be withdrawn when the cardiac output is satisfactory on minimal inotropic support (usually 1 mg/min of epinephrine or 5 mg/kg/min of either dopamine or dobutamine). However, earlier removal may be indicated if complications develop, such as leg ischemia, balloon malfunction, thrombocytopenia, or infection.
- 96. weaning Weaning is initiated by decreasing the inflation ratio from 1:1 to 1:2 for about 2– 4 hours, and then to 1:3 or 1:4 for 1–2 more hours. Once it is determined that the patient can tolerate a low inflation ratio with stable hemodynamics, the IABP should be removed. If there is an anticipated delay in removal of more than a few hours for manpower reasons or because of the need to correct a coagulopathy, the ratio should be increased to at least 1:2 to prevent thrombus formation.
- 97. Removal of the ballon
- 98. Hussein Khairy Elkhayat Lecturer (consultant) of Cardiothoracic Surgery Faculty of Medicine, Assiut university, Assiut,Egypt. P.Box 71526 Mobile : + 2 010 0 55 49 6 53 Work : + 2 088 241 37 73 Fax : +2 088 2333327 Website: http://www.aun.edu.eg/membercv.php?M_ID=4489 For more information , please contact me : dr_khayat@Hotmail.com Thank you