With the Impella RP, a 22-French catheter is inserted into a femoral vein, removing blood from the inferior vena cava and pumping it into the PA to unload the RV.20, Each of the Impella catheters is controlled by an Automated Impella Controller (AIC) that displays flow rate, performance (P) level, purge fluid rate, purge fluid pressure, alarm notes, and catheter position information. Many nursing considerations for the Impella devices involve monitoring these parameters.18, The placement waveform and the motor current are derived from 2 different pressure readings on the Impella catheter, which help determine the location of the Impella and can trigger placement alarms. An intra-aortic balloon pump (IABP) is a type of therapeutic device. The Impella 2.5 (12 French), Impella CP (14 French), and Impella 5.0/LD (21 French) offer up to 2.5 L, 3.5 L, and 5 L of flow, respectively.11  The Impella works by directly unloading the LV. About IABPs. If the cannula is pulled back into the RV, CO will drop, tricuspid regurgitation will be present, and arrhythmias may occur.5,11,16, The Impella platform of AMCS devices (Abiomed) includes 4 axial-flow catheters. The nurse can expect to start or increase vasopressors, increase ventilator settings, and, in some circumstances, provide CPR while the circuit components are being changed out.27, Measuring cardiac recovery and readiness for decannulation in these patients involves performing an echo-cardiogram. The AIC controls the entire purge line and maintains adequate purge pressure between 300 and 1050 mm Hg to prevent blood from compromising the motor.18  The nurse must change the purge fluid bag and change the purge fluid tubing, cassette, and pressure tubing per hospital policy. 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. The following guidelines have been prepared to establish a quick reference guide for the safe. Through a variety of cannulation configurations, patients are supported on either venoarterial (VA) ECMO or venovenous (VV) ECMO.24. The aortic valve normally has three cusps: right, left, and posterior. The well-oxygenated blood ends up circulating only in the lower half of the patient’s body, which can cause the falsely high interpretation of a patient’s oxygenation status.26,28  Interventions include increasing flows, increasing the ventilator, switching to central cannulation, inserting an additional cannula to return oxygenated blood to the RIJV, or converting to VV ECMO.28, Frequent blood samples will be drawn from VA ECMO patients to assess tissue perfusion (mixed venous oxygen saturation, lactate), blood counts (hemoglobin, hematocrit, platelets), and coagulation (anti-Xa, partial thromboplastin time, fibrinogen). Clinical signs of recirculation are a decrease in Sao2, an increase in venous oxygen saturation, the presence of bright red, well-oxygenated blood within the venous catheter of the circuit, and hemodynamic responses to hypoxia.29, Patients receiving VV ECMO are ready for decannulation when the sweep to the oxygenator can be shut off and the patient’s own lungs demonstrate effective gas exchange as evidenced by arterial blood gas values.24  Because of the absence of hemodynamic support, VV ECMO will not deliver oxygen to the same extent as VA ECMO will. 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). The IABP is a cardiac assist device consisting of a long, cylindrical polyethylene balloon at the end of a flexible catheter. The intra-aortic balloon pump (IABP) remains the most commonly utilised haemodynamic support system for patients with severe coronary artery disease, acute heart … Crit Care Nurse 1 February 2020; 40 (1): e1–e11. However, with minimal recirculation and a suitable native CO, the patient will receive sufficient ECMO support for adequate oxygenation of end organs and tissues.29. For right ventricular support, the only axial-flow pump is the Impella RP. At the end of systole (when the aortic valve closes) the balloon … This phenomenon, referred to as North-South syndrome, can occur in peripherally cannulated patients when their native cardiac function begins to return but their lungs continue to be compromised. Because of the use of 2 separate purge systems, the heparin concentration of each bag should be carefully evaluated to prevent larger doses of heparin from being unintentionally administered to the patient. 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. While the patient is using the support device, the nurse should monitor the plasma-free hemoglobin level, which is the best indicator of hemolysis.18,23, Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass circuit that uses a centrifugal-flow pump. The nurse can perform this evaluation at the bedside by monitoring central venous pressures with a central venous catheter or by monitoring RA pressures and PAOP with a PA catheter. The Intraaortic balloon is placed within the descending aorta. Michele Esposito is a clinical cardiology fellow, Tufts Medical Center. Baltimore, MD:Williams and Wilkins;1997 Shinn AE, Joseph DL. An intra-aortic balloon pump (IABP) is a device that … and Cottrell D. Nursing care of patients receiving Intra-aortic Balloon … 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. Cardiovascular nurses caring for these patients require skills and knowledge that enable prompt recognition and treatment … Intra-aortic Balloon Pumps. Extracorporeal membrane oxygenation allows their lungs to rest on non-injurious ventilator settings while providing gas exchange for them within the circuit. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org. You may need it if your heart is unable to pump enough blood for your body. Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation. This process results in over-distention within the ventricle, which can lead to further myocardial damage and acute pulmonary edema and can result in formation of clots in the LV. An intra-aortic balloon pump (IABP) is a type of therapeutic device. A VA ECMO circuit is composed of a cannula placed in a vein to drain deoxygenated blood from a patient, which is then drawn into the ECMO circuit by a centrifugal-flow pump. … This article discusses the indications, rationale, function, and potential complications of IABP therapy. Extracorporeal membrane oxygenation is indicated in most instances in the presence of an 80% mortality risk, a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (Fio2) of less than 80, and/or a Murray score of 3 to 4 from the previously mentioned lung failure.21  Other considerations when evaluating patients for VV ECMO are length of time receiving mechanical ventilator support, age, comorbidities and preexisting conditions, and likelihood of bridge to lung transplant.24, Cannula selection and placement are crucial elements in ECMO, which enable maximum support to be provided to the patient. (IABP). On-Line Program Annual Review ; Special Care Manual SP I 2.0 SP - I 2.3 SP I 2.4 SP - I 6.0. This was a case study of a 7-year-old child. In most adults, venous inflow cannulas range from 21 to 25 French and arterial outflow cannulas from 15 to 21 French. He had poor cardiac output after the procedure and required the insertion of an intra-aortic balloon pump … 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. "Principles of intra-aortic balloon pump counterpulsation." The IABP is effective because of the unique anatomy of the aortic valve cusps and their relationship to the origin of the two coronary arteries. When transplant cardiologists at Debakey Heart and Vascular Center at Houston Methodist Hospital began using percutaneously placed axillary intra-aortic balloon pumps (PAxIABPs) in 2007 as a bridge to heart transplants, a literature search revealed no precedent or published nursing … Samantha R. Asber is Nurse Manager, Cardiac Catheterization Laboratory, Tufts Medical Center, Boston, Massachusetts. Navin K. Kapur is Executive Director, CardioVascular Center for Research and Innovation, and Director, Acute Mechanical Circulatory Support Program, Tufts Medical Center. The study aims to identify the nursing diagnoses and interventions for a child requiring intra-aortic balloon pump support. It is a long, thin tube called a catheter with a … At the end of the program, the learner will be able to ; List steps to initiate intra aortic balloon pump therapy using the AutoCAT2 Series IAB pump. 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 … {{{;Ž}ƒ#âtp¶8_\. Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation. The other right ventricular devices are extracorporeal centrifugal-flow pumps. Guidelines for Management of the Intra-Aortic Balloon Pump Purpose: To outline the nursing management of patients requiring an Intra-Aortic Balloon Pump (IABP). Acute mechanical circulatory support devices include pumps for left or right ventricular failure and can be categorized as pulsatile or nonpulsatile. When looking at the IABP waveform, the nurse should see inflation occur at the dicrotic notch, which represents the onset of diastole, and deflation should occur before the next systole.5,7,8,12  Inflation is triggered automatically by the R wave of the electrocardiogram. The Impella 5.0 requires a surgical cutdown of either the axillary or the femoral artery. The intra-aortic balloon pump (IABP) remains the most commonly utilised haemodynamic support system for patients with severe coronary artery disease, acute heart failure and cardiogenic shock. Complications of Intra-Aortic Balloon Pump IABP. A flattened waveform would indicate that the catheter is either entirely in the ventricle or in the aorta and not correctly placed across the aortic valve. 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. If in the RV support configuration the Protek-Duo migrates forward into a PA branch, the patient will show signs and symptoms of respiratory failure, such as tachypnea and oxygen desaturation. Although all ECMO patients require a perfusionist or an ECMO specialist (a specially trained registered respiratory therapist or registered nurse) at the bedside at all times, the critical care nurse should be aware of indications, mechanics, and specific considerations in caring for these patients. Exact timing is based on appropriate inflation and deflation of the balloon during the cardiac cycle. The cannula insertion site should be closely monitored, as cannula dislodgment is a life-threatening complication. For insertion of catheter, please see Insertion of Intra-aortic Balloon Catheter protocol. The intra-aortic balloon pump can save the patient's life by providing temporary support to the heart. 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. Algorithm for the use of acute mechanical circulatory support devices in cardiogenic shock refractory to 1 or more vasopressors or inotropes. The IABP … Critical Care Nursing … Pharmacological support, such as vasopressors, may be needed to augment hemodynamic demands. Australian Critical Care (2009) 22, 125—131 The intra-aortic balloon pump in heart failure management: Implications for nursing practice Peter A. Lewis BN RM MN.Ed PhDa,∗, Darian A. 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. The blood then passes through a membrane oxy-genator that removes carbon dioxide and adds oxygen and then finally delivers oxygenated blood back to the patient through a cannula placed in an artery. This device is contraindicated in patients who have left or right atrial thrombus.11, A 21-French cannula is placed via the right femoral vein into the inferior vena cava and advanced through the RA to the LA through a transseptal puncture. and effective use of IABP … In the LV configuration, if the cannula retracts across the intra-atrial septum, the nurse would see rapid arterial oxygen desaturation, as the retraction would cause a right-to-left shunt.5,11,16  If a retraction occurred, flows would need to be decreased and immediate imaging obtained to reposition the cannula. About every 2mths or longer we receive an IABP pt. Given the higher magnitude of Impella 5.0 flow, this device is often favored over the 2.5 or CP devices for patients with advanced heart failure requiring prolonged support.21  Axillary insertions allow for the option of mobilizing the patient, which can be critical for surgical optimization if the patient needs a bridge to a durable VAD or to transplant.11,22  The Impella LD can be surgically inserted directly into the aorta during open heart surgery, often when a patient is unable to come off of bypass because of LV failure. Dorothy Didomenico is Cardiovascular Critical Care Clinical Educator and Advanced Cardiac Life Support Coordinator, Tufts Medical Center, and president of the Greater Boston chapter of the American Association of Critical-Care Nurses. "Intra-aortic balloon pump timing: review of evidence supporting current practice." Intra-aortic balloon pumping and nursing care: what did we learn in the last decade? Normal fill pressure … This phenomenon is caused by inadequate ejection of the LV, exacerbated by the high afterload induced by the ECMO arterial cannula pressurizing the aorta. This article provides a comprehensive overview of contemporary AMCS devices, with a specific focus on nursing considerations (see Table). The ECMO circuit is also afterload sensitive, and decreased flows will be seen in the setting of high systemic vascular resistance, hypertension, kinked arterial cannulas, and thrombus in the oxygenator.26, Because of the large-bore cannulas used with VA ECMO, limb ischemia is another potential complication. Historically, most patients in cardiac care units (CCUs) have been admitted with the diagnosis of acute myocardial infarction (AMI) or a complication of AMI. If the patient does not have a reliable R wave (low-voltage electrocardiogram, electrocautery interference, and 100% paced), a pressure trigger can be selected instead. It is most often used for patients with persistent cardiopulmonary failure that is refractory to conventional therapies such as volume resuscitation, inotropes, vasopressors, and other AMCS devices. 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, … Search for other works by this author on: Kenneth P. Shanahan is Clinical Nurse Director of Cardiovascular Services, Tufts Medical Center. Acute mechanical circulatory support devices are becoming more widely used in the intensive care environment to help achieve higher levels of hemodynamic support than can be accomplished by using pharmacological interventions alone. The centrifugal-flow pumps include the TandemHeart (LivaNova) and VA ECMO. The IABP should not be used in patients with aortic dissection, significant aortic regurgitation, or thoracic aneurysms.8  Whether the IABP is still recommended for cardiogenic shock is currently under debate. ?§€:¢‹0ÂFB‘x$ !«¤i@ڐ¤¹ŠH‘§È[EE1PL”ʅ⢖¡V¡6£ªQP¨>ÔUÔ(j What is Nursing Care Of Patient On Intra Aortic Balloon Pump? On full IABP support, the nurse will see a 1:1 ratio, providing 3 times the number of balloon inflations as at the 1:3 setting, which may be used when weaning a patient off of IABP therapy.12, The most common access site for the IABP is the femoral artery; however, axillary implantation is occurring more frequently to allow for early ambulation. doi: 10.4037/ccn2020764. Signs of this phenomenon include a flat pulse pressure, increased PA pressure and PAOP, decreased LV wall motion and aortic valve standstill seen on echocardiogram, and pulmonary hemorrhage. 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. As technologies for percutaneous coronary intervention (PCI) and implementation of early treatment for AMI have improved, the in-hospital mortality rate for AMI has declined to less than 10% and the number of patients surviving to hospital discharge has increased.1  Despite timely reperfusion, however, between 40% and 70% of patients with AMI subsequently develop heart failure within 5 years after discharge.2  Thus, the number of patients with heart failure has grown to more than 8 million in the United States alone, and CCUs are now managing more patients with acute heart failure and cardiogenic shock.3  A central aspect of CCU management for heart failure and cardiogenic shock is the use of acute mechanical circulatory support (AMCS) devices (Figure 1). The nonpulsatile devices can be further classified as axial-flow or centrifugal-flow devices. 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. Leslie Lussier is Director, Respiratory Care, ECMO, and Pulmonary Function Test Laboratory, Tufts Medical Center. If the devices were pulled back entirely into the aorta, there would be little difference in the placement waveform, but there would be a mal-positioning alarm, most likely paired with a change in patient status.18, With the Impella 5.0 and LD, the nurse will not see a ventricular or an aortic waveform as with the 2.5 or CP but should expect to see a pulsatile waveform on the AIC. For insertion of catheter, please see Insertion of Intra-aortic Balloon Catheter protocol. doi: https://doi.org/10.4037/ccn2020764. The growing use of acute mechanical circulatory support devices to provide hemodynamic support that has accompanied the increasing prevalence of heart failure and cardiogenic shock, despite significant improvement in the treatment of acute myocardial infarction. Please discuss these issues with the medical and nursing staff who are caring for your loved one. Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation. On all Impella devices, the nurse should always ensure that the motor current waveform is pulsatile, which indicates proper position and function. If the patient can hemodynamically tolerate it, ECMO flows should be turned down to reduce the LV afterload to a goal pulse pressure greater than 10 mm Hg to promote opening of the aortic valve. 2020 Feb 1;40(1):e1-e11. 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