You may need it if your heart is unable to pump enough blood for your body. Patients are considered for ECMO in the setting of cardiac and/or respiratory failure when the process is potentially reversible and the risk of mortality is high. Oxygenated blood is pulled out of the LA and pumped back into the arterial circulation through a percutaneously placed cannula in a femoral artery.11,16 A heparinized saline solution runs continuously through the console to the pump head to promote lubrication and cooling and decrease clot formation within the pump chamber. The TandemHeart system (LivaNova) is a percutaneously implanted extracorporeal centrifugal-flow pump designed to deliver up to 5 L of flow to replace a patient’s CO. Historically, most patients in cardiac care units (CCUs) have been admitted with the diagnosis of acute myocardial infarction (AMI) or a complication of AMI. Problem is few staff RNs are certified. After insertion, an activated clotting time goal of 160 to 180 seconds is recommended while the catheter is implanted, but nurses can expect their institutions to implement weight-based partial thromboplastin time or anti-Xa protocols as well.18 Special consideration is required when using 2 different Impella catheters at the same time (eg, RP and 5.0). Critical Care Nursing … During diastole, the IABP inflates and displaces blood from the descending aorta while increasing diastolic pressure in the aortic root. Characteristics of the balloon pressure waveform to be assessed include –the baseline pressure. A major inherent limitation of balloon counterpulsation is that it depends on native cardiac function, so that the weaker the left ventricle (LV), the less effective the IABP is in augmenting cardiac output (CO).5 Despite several recent trials showing that the IABP does not improve clinical outcomes in AMI and shock, the IABP remains the most common mechanical intervention used, with more than 50 000 implantations per year in the United States alone.6. Introduction to the intra-aortic balloom pump and its associated aortic pressure curve In VV ECMO, cannulation techniques can include 2 sites (bilateral femoral veins, or femoral vein and RIJV) or a single site using a double-lumen cannula (DLC). All three of these patients will need an intra-aortic balloon pump (IABP) as part of their management. Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation. Complications associated with counterpulsation include distal-extremity ischemia secondary to obstruction of blood flow due to catheter size, vascular damage, bleeding, thrombus formation, catheter rupture, infection, catheter migration, and hazards associated with prolonged immobility. When a mechanical complication occurs such as clots or air in the circuit, oxygenator or pump malfunction, tubing rupture, or accidental decannulation, it is considered an emergency and the patient will be temporarily removed from ECMO until support can be reinstated. Benefits of the IABP include an increase in coronary and cerebral perfusion pressure during inflation, a decrease in workload and oxygen consumption during deflation, and an increase in CO. Policy Title: Care of the Patient with an Intra Aortic Balloon Pump (IABP) - Adult Policy Summary: It is the policy of *** to safely utilize an intra aortic balloon pump to increase coronary artery perfusion, … Counterpulsation Applied: An Introduction to Intra-Aortic Balloon Pumping, October 2005, Arrow International (available from CVICU and CCU Nursing Units and Clinical Nurse Educators CCU and CVICU) Goldich, Guy (2011) Getting in sync with intra-aortic balloon pump therapy, Nursing … Contemporary European guidelines identify IABP therapy as not routinely indicated and potentially harmful (class III recommendation) in cardiogenic shock.9, Counterpulsation is the fundamental principle underlying the IABP. Ultrasound PhysicsCritical Care NursingCardiac NursingBalloon PumpBlood Pressure RemediesLower Blood PressureMedical InformationNurse … Instead of focusing solely on Sao2, the nurse should assess the heart rate, blood pressure, ability to wean off vasopressors, lactate levels, and urine output as indicators of adequate tissue perfusion.24, To achieve the above-mentioned Sao2 level, patients are placed on resting ventilator settings, which most often are represented by a positive end-expiratory pressure setting of 10 mm Hg, a low respiratory rate, and the lowest Fio2 possible. aka Cardiovascular Curveball 005. The nurse should assess the device’s placement signals and anticipate a chest radiograph and echocardiogram to confirm placement after compressions.18, Hemolysis is a risk when patients have these mechanical support devices, as blood cells may become damaged while going through the pump. Timing Waveform Analysis. The intra-aortic balloon pump can save the patient's life by providing temporary support to the heart. It consists of a cylindrical polyurethane balloon that sits in the aorta, approximately 2 centimeters (0.79 in) from the left subclavian artery. catheter is not kinked or leaking, and that optimal counterpulsation is occurring (for details, see Nursing Practice & Skill … Intra-aortic Balloon Pump: Assessing the Pressure Waveform ). Complications of Intra-Aortic Balloon Pump IABP. If a patient’s cardiac function begins to improve and ECMO flows are decreased, his or her pulsatility may return.29, A complication nurses may witness in a patient who is receiving VA ECMO is LV stun. Maccioli GA. Intra-Aortic Balloon Pump Therapy. To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Jennifer Eaton is a nurse in the operating room, Tufts Medical Center. Intra-Aortic balloon pump (IABP) therapy was first introduced in the 1960s for the treatment of cardiogenic shock. This pulsatile waveform reflects the catheter’s pressure difference between its internal sensor, which should reflect ventricular pressure, and its external sensor, which should reflect aortic pressure.18, In patients with low native heart pulsatility, the placement may be difficult to determine on the basis of the waveforms and pressure readings alone, and the AIC will indicate that the position is unknown. The rationale for monitoring the patient’s oxygen saturation and blood gases from the right arm is to accurately reflect what the brain and the heart are receiving to avoid ischemic events. Purpose: To outline the nursing management of patients requiring an Intra-Aortic Balloon Pump. Exact timing is based on appropriate inflation and deflation of the balloon during the cardiac cycle. Intra-aortic Balloon Pumps. Because of the complexity of caring for patients with AMCS devices, it is vital that nurses receive additional training to obtain a strong understanding of hemodynamics so that they can accurately assess subtle or sudden changes and intervene as appropriate. Search for other works by this author on: Kenneth P. Shanahan is Clinical Nurse Director of Cardiovascular Services, Tufts Medical Center. Counterpulsation Applied: An Introduction to Intra-Aortic Balloon Pumping, October 2005, Arrow International (available from CVICU and CCU Nursing Units and Clinical Nurse Educators CCU and CVICU) Goldich, Guy (2011) Getting in sync with intra-aortic balloon pump therapy, Nursing Fall 2011 Cardiac Insider Vol 41 pp.10-13. The intra-aortic balloon pump (IABP) remains the most commonly utilised haemodynamic support system for patients with severe coronary artery disease, acute heart … Hemolysis is less common with the Impella 5.0 pump. doi: https://doi.org/10.4037/ccn2020764. When used to support LV function, the device decreases LV volume and stroke work, pulmonary artery occlusion pressure (PAOP), and myocardial oxygen consumption while increasing mean arterial pressure, mixed venous oxygen saturation, and organ perfusion.16 The device may work as a bridge to recovery, durable VAD implantation, or heart transplant. Through a variety of cannulation configurations, patients are supported on either venoarterial (VA) ECMO or venovenous (VV) ECMO.24. After an initial evaluation with an echocardiogram and a PA catheter, patients with confirmed cardiogenic shock, defined as a cardiac index of less than 2.2, are further categorized as having RA-, LV-, or BiV-dominant shock on the basis of their right atrial and pulmonary capillary wedge pressures. Education and awareness regarding oxygen content and delivery are imperative in patients receiving VV ECMO to circumvent requests to increase resting ventilator settings.29 Venovenous ECMO provides no hemodynamic support to the patient. In most adults, venous inflow cannulas range from 21 to 25 French and arterial outflow cannulas from 15 to 21 French. Venoarterial ECMO is indicated in adult patients who require hemodynamic support as well as respiratory support in the setting of a potentially reversible cause of heart failure. Alternatively, afterload-reducing medications can be implemented. For insertion of catheter, please see Insertion of Intra-aortic Balloon Catheter protocol. 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