IABP

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1. IABP JOHNY WILBERT, M.SC[N] LECTURER, APOLLO INSTITUTE OF HOSPITAL MANAGEMENT AND ALLIED SCIENCE

2. The Intra-Aortic Balloon Pump (IABP) is a circulatory assist device that is used to support the left ventricle. The IABP uses counterpulsation where aortic blood is displaced with the inflation and deflation of the balloon catheter, which is timed to the cardiac cycle. INTRA AORTIC BALLOON PUMP COUNTER PULSATION (IABP)

3. CORE FUNCTION

4. INDICATIONS

5. Severe aortic insufficiency Aortic or abdominal aneurism Severe peripheral vascular disease CONTRAINDICATIONS

6. INSERTION AND SIZE The balloon catheter is inserted either percutaneously or surgically by cutdown into the patients’ femoral artery.

7. Connect to mains power to ensure the battery is preserved. Check the helium tank is open at the back of the pump. Ensure both an ECG and pressure trace can be obtained from the patient on the screen of the IABP. The IABP can obtain a trigger, which stimulates the pumping of the balloon. PROCEDURE

8. Frequency when first commencing pumping is on 1:1, which means that for each heart beat the balloon, will be inflated. To commence balloon pumping, inflation and deflation points should be set at the midline and then once pumping is established, timing should be reassessed. Connect the extension tubing to the balloon catheter and on the balloon console at the back. PROCEDURE(cont..)

9. Helium is used as it is easily dissolves in blood than air and prevents the risk of air emboli if the catheter ruptures. HELIUM GAS

10. The end of the balloon should be just distal (1-2 cm) to the take-off of the left subclavian artery Position should be confirmed by fluoroscopy or chest x-ray POSITIONING

11. MODES OF IABP Trigger Frequency Augmentation

12. PHYSIOLOGY OF IABP LV contraction : - Isovol. Contraction (b) - maximal ejection (c) LV relaxation: - start of relaxation and reduced ejection (d) - isovol.relaxation (e) LV filling: - LV filling , rapid phase (f) - slow LV filling (g) - atrial systole( a)

13. PHYSIOLOGY OF IABP( CONT..)

14. PHYSIOLOGY OF IABP( CONT..)

15. PHYSIOLOGY OF IABP( CONT..)

16. Inflation and deflation of the balloon Blood is displaced to the proximal aorta by inflation during diastole. Aortic volume ( afterload) is reduced during systole through vacuum effect created by rapid balloon deflation Decrease in SBP by 20 % Increase in aortic Diastolic Press. by 30 % ( raise coronary blood flow) HEMODYNAMIC EFFECTS 

17. Increase in MAP Reduction of the HR by 20 % Decrease in the mean PCWP by 20 % Elevation in the COP by 20% HEMODYNAMIC EFFECTS  (cont..)

18. HEMODYNAMIC EFFECTS (cont..)

19. IABP WAVEFORM

20. INTERPRETING IABP WAVEFORMS

21. INTERPRETATION ( Cont...)

22. INTERPRETATION ( Cont...)

23. First change from 1:1 to 1:2 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp “V” at inflation. Check if diastolic augmented wave is › systolic wave CHARACTERISTICS OF NORMAL WAVEFORM

24. Confirm if end diastolic wave following the augmented wave is less than an non augmented wave. Is Deflation slope ok. CHARACTERISTICS OF NORMAL WAVEFORM

25. INTERPRETATION ( Cont...)

26. INTERPRETATION ( Cont...)

27. LATE INFLATION Inflation of the IAB markedly after closure of the aortic valve. Waveform Characteristics: • Inflation of IAB after the dicrotic notch. • Absence of sharp V. Sub optimal diastolic augmentation

28. EARLY INFLATION

29. EARLY DEFLATION

30. LATE DEFLATION Late deflation of the IAB during the diastolic phase. Waveform Characteristics: • Assisted aortic end diastolic pressure may be equal to the unassisted aortic end diastolic pressure. • Rate of rise of assisted systole is prolonged. • Diastolic augmentation may appear widened

31. VARIATION in balloon pressure wave forms

32. VARIATION in balloon pressure wave forms

33. VARIATION in balloon pressure wave forms

34. CATHETER KINK Rounded balloon pressure waveform - Loss of plateau resulting from a kink or obstruction of shuttle gas - Kink in the catheter tubing Improper IAB catheter position Sheath not being pulled back to allow inflation of the IAB - IAB is too large for the aorta IAB is not fully unwrapped H2O condensation in the external tubing

35. GAS LEAK due to a loose connection a leak in the IAB catheter - H2O condensation in the external tubing a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane

36. Anticoagulation-- maintain apTT at 50 to 70 seconds. CXR daily – to R/O IAB migration. Check lower limb pulses - 2 hourly. Hip flexion is restricted, and the head of the bed should not be elevated beyond 30°. NURSING INTERVENTION

37. Never leave in standby by mode for more than 20 minutes Daily Haemoglobin (risk of bleeding or haemolysis) Platelet count (risk of thrombocytopenia) Renal function (risk of acute kidney injury secondary to distal migration of IABP catheter) Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications NURSING INTERVENTION(Cont..)

38. Timing of weaning: Patient should be stable for 12 – 24 hours Decrease inotropic support Decrease pump ratio From 1:1 to 1:2 or 1:3 Decrease augmentation Monitor patient closely If patient becomes unstable, weaning should be Immediately discontinued Weaning of IABP

39. THANK YOU