Standard

Rationale

• The Nurse:Patient ratio for a patient with an IABP is 1:1.
• A ratio of 2:1 may be required at the discretion of the charge nurse.
• The nurse assigned to relieve for breaks will be approved to care for the patient on the IABP.

• The invasiveness of the IABP warrants intensive monitoring.
• The patient requiring an IABP to support cardiac performance may have multisystem instability.
• To ensure console management/troubleshooting in the nurse's absence. 

• Ensure that a set of skin and external leads are connected and functional.
• Assess both leads for function q. shift and confirm assessment on IABP flow sheet.
  
  

  To connect backup trigger with Datex bedside monitor:

  1. Obtain P3 Module and cable and connect to Datex bedside monitor.
  2. Connect and zero the peripheral arterial pressure transducer into the P3 pressure module (instead of P2).
  3. Connect the 2 phone jacks on the distal end of the P3 cable to the ECG and Pressure input recepticals on the back of the Datascope pump.

• A back-up triggering mode must be readily available.
• Select the desired ECG source from the Patient Waveform box on the IABP panel.

• Adjust trigger modes as required to ensure balloon pumping.
• Use ECG trigger for most situations.  Pressure trigger is a suitable trigger if the ECG is temporarily lost or the patient has no ECG rhythm and is receiving CPR. 
• Avoid the use of the pacemaker trigger modes.

• Trigger modes may require changing to ensure optimal balloon function.
• When using the pressure trigger during CPR or severe hypotension,  the pressure threshold can be reduced to ensure that the pump recognizes systolic events.  Adjust by using the arrows in the auxiliary trigger option. 
•  ECG trigger mode will work well for patients being paced.  The pacemaker trigger modes will only work for fixed rate pacing.  If the patient is in a pacemaker trigger mode, the pump will ignore native beats and only operate with paced impulses.

• Transduce the aortic arterial line (balloon lumen)  to the Datascope pump.
• Mount the aortic line pressure transducer on an IV pole connected to the foot of the bed.
• Check the transducer position hourly, to ensure that it is level with the mid-axillary line.

• Monitoring of the aortic line by the Datascope enables rapid transport of patients while on the IABP.
• The Datascope pressure module provides an alternate BP source in the event that the bedside monitor should fail.
• Avoid taping the transducer to the IABP or mounting on the Datascope IV pole, as it is too difficult to accurately level the transducer.  An IV pole connected to the foot of the bed provides better visibility for assessing the transducer level. 

• Monitor and record pressures obtained from the Datascope monitor on the IABP flow sheet hourly and prn.
• Titrate drugs to a desired MEAN BP obtained from the Datascope monitor.*
• Use the BP obtained from the Datascope pump when calculating hemodynamics.* 

• With optimal balloon inflation, the DBP is augmented to become higher than the SBP.  The bedside monitor displays the SBP as the highest pressure measured.  If the balloon is successful at augmenting the DBP above the SBP, the SBP displayed by the bedside monitor will actually be the augmented DBP.  If augmentation is sub optimal, the augmented pressure may not exceed the SBP...in this case, the SBP will remain the highest pressure and will be displayed by the bedside monitor appropriately.
• The Datascope console differentiates between the SBP, augmented pressure and end diastolic pressure.   It will also display assisted and unassisted systole and diastole if the pump is placed in 1:2 or 1:3.
• Aortic and peripheral systolic and diastolic pressures are not necessarily the same; peripheral arterial lines often amplify the SBP.  Mean BP will usually correlate much more closely and is a better indicator of BP.
• Aortic pressure represents the central or core BP.  It is a better indicator of BP than a peripheral arterial line, as long as the aortic line is patent and displaying accurate values.
• Pressure trends and consistency among pressure measurements are the most important findings.

• Evaluate Cardiac Output within 1 hour of any change in the assist interval.

• To assess whether the change is tolerated.

• Obtain an arterial timing strip and balloon waveform q.12.h. and prn. 
• Evaluate the timing and attach the tracing to the IABP record. 

• To evaluate timing and provide a record for future reference.

• If the augmentation volume is reduced for the purpose of weaning, return the pump to full augmentation volume at a ratio of 1:1 for 5 minutes each hour.
• Do not increase the augmentation volume if the balloon volume has been reduced due to aortic size.

• To reduce risk of platelet aggregation.
• Balloons that do not fully inflate are prone to vertical folds which can predispose the balloon to rupture.
• Ideally, appropriately size balloons are inserted that permit full inflation.  Occasionally, patients can be temporarily vasoconstricted, necessitating balloon volume reduction.  Balloon volume increases may be possible as the patient's condition improves.

• Assess capillary refill and pedal pulses q1h.
• Assess capillary refill and left radial pulse at the start of each shift and q6h. 
• Notify the cardiovascular surgeon of any change from the previous hour. Document on flow sheet.

• The balloon catheter or thrombus can obstruct flow to the distal extremities. 
• If the balloon migrates too high, it can obstruct flow to the left subclavian artery.

• Change IAB site dressing q2days, using 2% chlorhexidine solution. (As per central line dressing procedure).
• Observe site and report any signs of infection to the physician.

• To remove skin contaminates and minimize the risk of wound sepsis.

• The patient will have a daily chest x- ray.

• To assess position of the IAB and to assess for sign of pulmonary complications such as secretions or atelectasis.

• Maintain HOB 300. 
• Avoid hip flexion. 
• Log roll or straight lift  for CXR.

• Hip flexion can put strain on the insertion site and cause vascular trauma.
• Raising the head of the bed can shorten the aorta and permit migration of the IABP catheter.
• Ideally, keep the HOB elevated versus supine, to reduce risk for aspiration.

• Provide chest vibration to promote secretion clearance q4h - 6h and prn.

• Immobility and sternal pain predispose patient to secretions and atelectasis.

• Measure urinary output q1h.

• Decreased urine production can occur as a result of low cardiac output, balloon placement that is too low, prerenal failure from a thrombus, hypotensive shock or surgical cross clamping.

• Perform a neurologic assessment, using the Glasgow Coma, q1h if unconscious or q. shift if the patient is awake.

• Decrease C.O., cerebral embolus or migration of IAB may impair cerebral function. ICU psychosis secondary to sensory overload/sensory deprivation/sleep deprivation is common.

• Change the assist interval as required to assess the adequacy of balloon timing.
• Obtain an order to change the assist interval for reasons other than timing assessment.
• Return the patient to the previously tolerated assist control interval if signs of intolerance are observed during weaning (e.g. chest pain, hypotension, arrhythmias, ST changes).
• Notify the physician if signs of intolerance are identified.

• The assist interval must be in 1:2 or 1:3 to evaluate deflation.
• If the patient demonstrates evidence of myocardial ischemia/dysfunction related to weaning, prompt correction must take place to prevent permanent myocardial injury.

• The perfusionist will assess the console function daily.

• The perfusionist is responsible for the electrical and mechanical performance of the console.

• Notify the perfusionist when the "helium low" light illuminates.

• The helium tanks are kept in the perfusionist's equipment room.
• The pump automatically refills  2 hours from the last fill.  If no additional fills are initiated, the pump should continue to operate for 48 hours following a low helium alert.

• A CCTC Balloon approved nurse may change the helium tank or switch to a new pump, if required, and the perfusionist is unavailable.
• Notify the perfusionist of any pump malfunction.

• In the event of sudden pump failure at night, it may be much quicker to have security assess a new pump.
• The System 98 is very easy to initiate: 
• To switch pumps, transfer the helium line, pressure transducer and ECG leads from the back of the malfunctioning pump to the new pump.
• Ensure that the helium tank is open (counter-clockwise) and position the inflation and deflation markers midposition. 
• Turn the pump on.  Wait until the ready signal appears. Pumping can now be initiated.
• For on-line help, select the "HELP" key.

• Obtain another pump immediately in the event of pump shutdown due to a console failure.
• Initiate manual inflation and deflation of the balloon if 15-20 minutes of balloon inactivity occurs.
• Inflate and deflate 8-10 time per minute with air, using a volume 10 cc less than the balloon size (the balloon size is marked on the balloon catheter).  A slip lock syringe is required to fit the helium line.
• Air is instilled into the lumen where helium is normally inserted. NEVER instill air into the aortic (arterial) lumen of the catheter.
• Never manual inflate a balloon if rupture is suspected.

• Manual inflation and deflation is done to prevent clot formation; there is no attempt to provide cardiac assistance with manual inflation.
• The goal is to quickly expand and collapse the balloon.  The volume of air used should be 10 cc less than the size of the balloon. Rapid deflation is desired to minimize the risk of impeding ventricular outflow. 

 N.B.we are not attempting to mimic the pump, therefore, timing of balloon movement to the cardiac cycle is not important. 

• Stop pumping and clamp the helium line immediately if balloon rupture is identified.
• Blood in the helium line is diagnostic of balloon rupture.

• The patient is without IABP assistance. Exsanguination could occur quickly from an aortic catheter

• Assess PT/PTT prior to removal of the IAB.
• Ensure that the patient has blood on hand.
• Removal, compression and coagulation of the insertion site is the responsibility of the cardiology/cardiovascular team.
• Assess site and color, capillary refill and pulses of distal extremity q 15 minutes X 1 hour and q 1 h X 8 hours following balloon removal.
• Limit activity following balloon removal as follows:
• flat (may keep existing pillow under head but do not allow patient to lift head or flex hip) X 4 hours
• no chest vibrations X 4 hours
• log roll after 4 hours
• normal activity after 8 hours

• Although rare, hemorrhage can occur post removal.
• Thrombocytopenia is common in IABP patients
• Hematoma, retroperitoneal blood loss or thrombus complications can occur.
• Mechanical vibrators may loosen an unstable clot.
• Raising the head or flexing the hip may increase aortic pressure and place strain on the newly formed clot.
• There is currently no clinical evidence to guide activity restrictions in critically ill patients following balloon removal; current research exists in CCU patients following angioplasty or angiogram procedures.

• Plug the pump into an AC outlet and turn the helium tank off following removal. 

• To keep the battery charged and conserve on helium.

• The IAB approved nurse may disconnect helium tubing if required to remove condensation or replace damage tubing.
• Refill balloon following any helium tubing disconnection.

• Excessive condensation can be removed as follows:
• place pump on standby
• hold the "manual fill" button for 2 seconds to place in the manual fill mode (gas alarms will be disabled when in the manual fill mode)
• disconnect helium tubing at the connection that is halfway between the pump and the patient catheter
• place the tubing with the condensation below the level of the pump
• place the pump into the assist mode and allow moisture to pump downward towards the floor
• when finished, place pump in standby and reconnect helium tubing
• press the "autofill" mode and hold for 2 seconds until the pump returns to the autofill mode
• refill the balloon
• select assist

• DO NOT draw blood from the aortic line under normal circumstances.
• Draw blood specimens from a peripheral arterial line.
• If no other arterial line is available, the nurse can draw blood from the aortic line with an order from the Senior Resident

THE  PUMP MUST BE ON STANDBY DURING BLOOD WITHDRAWAL AND FLUSHING

• If air or clot enters the arterial port of the IAB, the embolus enters directly into the aorta. During balloon inflation, the embolus can travel COUNTER NORMAL FLOW and travel to the cerebral or coronary circulation. 

• If flushing of an aortic line is required:
• draw up 10 - 20 mL normal saline in a sterile syringe
• place pump in standby mode
• vigorously aspirate 10 mL of blood from the stopcock closest to the balloon catheter
• inject blood and spread over a 4 X 4 gauze and inspect carefully for clots
• if clots are visible, repeat procedure until clear
• once specimen is free of clots, slowly and steadily flush the catheter with 10 - 20 mL of saline
• if line is hard to flush, do not force saline injection
• backflush blood from stopcock
• replace sterile cap
• resume pumping

• Care must be taken to prevent flushing of clots into the aorta.
• Clots entering the aorta can enter the coronary or cerebral circulation.
• Access to the cerebral or coronary circulation can be facilitated by inflation of the balloon, therefore, the pump must be on standby during flushing.

• Switch to pressure triggering once pump alarms due to loss of ECG rhythm (remember to select "assist" after changing trigger modes)
• Reduce the pressure threshold if balloon fails to pumping from pressure trigger  (decrease arrows in auxiliary box under trigger options)
• The balloon pump does not need to be disconnected during defibrillation. 
• Deflate the balloon volume during CPR.

• Internal trigger is only required if the patient is asystolic and has a pulse pressure (difference between systole and diastole) of < 7 mmHg (the lowest pressure threshold option).  The survival in this setting is unlikely.
• Balloon inflation on "Internal" is not in phase with the cardiac cycle and will impede ventricular outflow; if internal trigger is selected and the patient has an ECG, the pump will continually alarm to identify the need to choose a more appropriate trigger mode.
• The balloon volume should be deflated to prevent aortic trauma during CPR.