Guidelines for intraaortic balloon counterpulsation

GUIDELIN

ES FOR

INTRAAORTIC

BALLOON

COUNTERPULSATION

BY- DR. A

RMAAN SIN

GH

GUIDELINES FOR MANAGEMENT OF DECOMPENSATED LEFT HEART FAILURE

IN CARDIAC SURGERY PATIENTS

If drug therapy fails:

• IABP • ECMO • VAD

Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;19:278-292.

INTRAAORTIC BALLOON COUNTERPULSATION

Indications:

• Cardiogenic shock • Postcardiotomy LV systolic failure unresponsive to inotropes • Persistent myocardial ischemia (preop or postop) • Complications of acute MI • Preoperative IABP (high-risk patients) • Support for high-risk catheterization or failed PCI • Cardiac support during non-cardiac surgery



Physiologic effects:

• Diastolic aortic pressure ↑• Coronary blood flow ↑ • Myocardial oxygen delivery ↑ • LV wall tension & afterload ↓ • Myocardial oxygen consumption ↓• Stroke volume ↑• Cardiac output ↑



Contraindications:

• Severe aortic insufficiency • Aortic aneurysm • Aortic dissection • Descending thoracic aortic atheroma • Aorto-iliac-femoral occlusive disease • Lower extremity ischemia • Dynamic LVOTO



Timing of counterpulsation:



IABP timing frequency:



IABP timing modes:

• Automatic

• Semiautomatic (operator must adjust inflation & deflation)

• Manual (operator must adjust inflation & deflation)

(& can set fixed rate)



Timing of inflation:

• First identify the dicrotic notch (when the aortic valve closes)

• If inflation is too early the balloon inflates before the aortic valve closes and pumps blood backwards into the LV, and ↑ LVEDV & LVEDP

• If inflation is too late there will be sup-optimal coronary perfusion



Early inflation:

Interpreting intra-aortic balloon pump waveforms. Nursing 2009;39 Cardiac Insider:9-10.


Late inflation:



Timing of deflation:

• First identify the dicrotic notch (when the aortic valve closes)

• If deflation is too late the balloon remains inflated too long, causing ↑ afterload because the heart is trying to pump against an inflated balloon

• If deflation is too early there will be inadequate afterload reduction and sup-optimal coronary perfusion



Late deflation:



Early deflation:



Troubleshooting:

• Poor augmentation timing error incorrect position of balloon ↓ SVR ↑ compliance of arterial tree

• Loss of triggering • Balloon leak / balloon rupture



Complications:

• Lower extremity ischemia • Insertion site bleeding / hematoma • Retroperitoneal hematoma • Aortic dissection or perforation • Malperfusion syndrome • Thrombocytopenia • Infection / sepsis



IABP weaning & removal:

• Decrease inotropic support • Decrease IABP ratio • Discontinue heparin (+ platelet transfusion?) • Deflate balloon • Remove balloon while alternating pressure above and below insertion site to

expel clots • Apply constant pressure to insertion site at least 30 min


GUIDELINES FOR MANAGEMENT OF LEFT HEART FAILURE

IN CARDIAC SURGERY PATIENTS

Weaning acute support:

• Reduce inotropic support to low level • Wean IABP support • Remove IABP • Wean ventilatory support • Continue low dose inodilator therapy during ventilator weaning • Loop diuretic & ACE inhibitor


IABP QUIZ

Early inflation:

Courtesy of Datascope, Fairfield, NJ.

http://lifeinthefastlane.com/wp-content/uploads/2010/03/early-inflation_labelled1.jpg?9d7bd4

IABP QUIZ

Early deflation:


IABP QUIZ

Late inflation:


IABP QUIZ

Late deflation:


IABP QUIZ

Which timing errors are more deleterious?


Guidelines for intraaortic balloon counterpulsation

Health & Medicine

Transcript of Guidelines for intraaortic balloon counterpulsation