Intra-aortic balloon pump therapy

Intra-Aortic balloon pump (IABP) therapy was first introduced in the 1960s for the treatment of cardiogenic shock. Since then it has
assumed a pivotal role in the treatment of those with heart failure and myocardial ischaemia and, according to Reid and Cottrell,is the
most widely used mechanical support. Cardiovascular nurses caring for these patients require skills and knowledge that enable prompt
recognition and treatment of sometimes life-threatening complications associated with balloon pump therapy. This article provides an
overview of the function of the pump, indications, potential complications and nursing care required.
How it works
IABP therapy is a method of mechanically assisting and supporting the coronary and systemic circulation in patients who have
myocardial pump dysfunction or in those with coronary ischaemia and/or undergoing complex high-risk percutaneous coronary
intervention. The IABP consists of a long polyurethane type catheter with a 10-15cm balloon at the end. This catheter is normally
inserted via the femoral artery and passed into the descending thoracic aorta until the tip is positioned 2cm just below the left
subclavian artery and the lower end of the balloon just above the renal arteries. The catheter tip is radiopaque so its position can be
evaluated on x-ray.The catheter attaches to a pressurised flush system, similar to that of an arterial line, and also to the pump itself
where helium is shuttled in and out of the catheter so that the balloon can inflate and deflate. The catheter comes in three sizes 34cc,
40cc, 50cc and is selected according to the height of the patient.
This type of therapy works by the balloon inflating and deflating in synchrony with the cardiac cycle. Therapy may be timed to 1:1, 1:2 or
1:3, implying that the balloon inflates and deflates according to each cardiac cycle, every second cardiac cycle or every third cardiac
cycle respectively. Inflation occurs just as diastole begins (diastole represents the heart relaxing, the ventricles filling and getting ready
for systole and the coronary arteries receiving their blood supply). Diastole is recognised as the presence of the dicrotic notch on the
pressure waveform, which triggers balloon inflation. This results in the movement of blood in the aorta into the coronary and up to the
carotid arteries, thus increasing coronary and cerebral perfusion (see Figure 1). Deflation occurs at the end of diastole just before
systole, which results in aortic blood being displaced down toward the mesenteric and renal arteries, increasing perfusion to these
organs, and thus reducing the afterload (the pressure in the aorta that the heart has to pump against) (see Figure 1). The net result of
inflation and deflation is increased coronary and cerebral perfusion and reduced myocardial workload respectively.

Indications
The goal of IABP therapy is to improve myocardial oxygen supply and
reduce myocardial oxygen demand. Although it was originally designed to
support patients in cardiogenic shock the indications have expanded
because of continued research. Table 1 lists the many indications for IABP
therapy. The most common indications are low cardiac output due to left
ventricular dysfunction and myocardial ischaemia. Other indications
include septic shock, cardiac support for non-cardiac related surgery and
support post correction of anatomical defects.
Indications for IABP therapy
Increase coronary artery perfusion

Refractory unstable angina

Impending infarction
Acute myocardial infarction
Support during PCI
Complications post myocardial infarction (VSD, papillary muscle rupture, acute mitral regurgitation)
Myocardial contusion
Ischaemia related intractable ventricular arrhythmias
Bridge to cardiac surgery

Reduction in afterload

Ventricular failure unresponsive to pharmacological therapy

Cardiogenic shock
Post-surgical myocardial dysfunction/low cardiac output syndrome
Bridge to cardiac transplantation
Bridge to other form of circulatory support

Nursing care
Prior to insertion of the IABP a baseline assessment is performed incorporating lower and upper limb perfusion. This serves as a
baseline for assessments post insertion. Upper limb assessment is essential so that balloon migration obstructing blood flow down the
left subclavian artery can be detected promptly. This assessment involves documentation of palpation of the relevant pulses, assessing
capillary refill, temperature and colour of the limbs. A set of baseline vital signs is recorded heart rate, blood pressure, respiratory rate,
oxygen saturations and temperature, which are used to assess improvement or deterioration in the patients condition.
Education plays a pivotal part in nursing care. This is a frightening time for the patient and family. Patient education should include the
reasons why the IABP is being inserted, what the pump does, potential complications, nursing care involved such as hourly nursing
assessments, and limitations. The limitations in activity that the patient will experience should be explained such as bed rest and
reduced movement of the affected leg. In relation to complications patients are educated about the risk of bleeding at the insertion site
and are advised to put pressure on the site when coughing or sneezing and to notify the nurse promptly if they experience pain in the
lower back or a sudden burning, pain or wetness at the insertion site.
Patients and families are instructed to report symptoms that may be suggestive of impaired peripheral perfusion such as tingling,
numbness, coldness, pallor and pain to a nurse as this may be indicative of limb ischaemia.

Aside from gathering the equipment specific to IABP insertion, nursing care involves preparing the patient, eg. attaching the patient to
the pumps ECG leads and labelling them, setting up the transducer and levelling it with the patients phlebostatic axis (fourth intercostal
space mid axilla which is the level of the left atrium), in addition to prepping the groin site. The patient is assessed for their tolerance of
lying flat and also their need for sedation or anxiolytics as per hospital guidelines.
Following insertion, nursing care involves cardiovascular/ haemodynamic assessment, fluid balance, positioning and pressure area
care, observation of the balloon catheter and line, the catheter insertion site, limb perfusion, neurological status and providing
psychological support for patient and family. Table 2 summarises the main elements of nursing care as illustrated by Catton.

Elements of nursing care

Assess cardiovascular hourly, or more frequently depending on clinical acuity, noting mean arterial pressure, augmented pressure heart
rate, oxygen saturation and perfusion state (lower and upper limb perfusion assessment)
Assess and observe for any alteration in neurological status
Confirm timing, ratio and trigger of intra aortic balloon pump hourly
Strict intake and output record aim for output 0.5ml/kg/hr report any sudden decrease in urinary output (signs of decreased renal
perfusion due to low cardiac output or migration of the catheter to the renal arteries obstructing blood flow)
Ensure the transducer is level with the phlebostatic axis, flushed hourly and zeroed four hourly or on change of patient position. Always
flush with the pump on standby
Check all connections, observe the balloon catheter for presence of blood which may indicate balloon puncture/rupture hourly
Monitor for signs of pulmonary oedema or ischaemia
Monitor temperature two-to-four-hourly, observing for signs of infection such as erythema/inflammation and pain at the insertion site and a
raised white cell count
Observe for bleeding at cannulation sites, venepuncture sites, urinary catheter, and insertion site as a complication of anticoagulation
therapy
Educate the patient re importance of passive limb exercises, keeping the affected leg straight
Encourage deep breathing exercises to promote adequate ventilation and lung expansion preventing the development of chest infections
Provide skin care and pressure area care may need a pressure relieving mattress and if needed two-hourly turns
Assist with nutrition and hydration as patient should be no higher than 30 which is challenging when eating or drinking
Provide on going psychological support and education as required

From a cardiovascular perspective it is vital that all monitoring cables and systems are securely connected and that the IABP is set to
the correct trigger (the trigger is the parameter which stimulates inflation and deflation, eg. on ECG the balloon will deflate on the R
wave), which is normally set to ECG. Cardiovascular assessment involves heart rate and rhythm, augmented pressure (pressure that
the balloon exerts when inflated to push the blood into the coronary and carotid arteries), mean arterial pressure, temperature,
respiratory rate and oxygen saturations.3 The aim is that the mean arterial pressure is maintained between 60-70mmHg which indicates
adequate peripheral perfusion.5 This is confirmed by the patient being warm to touch, good capillary refill, no evidence of cerebral
hypoxia and urinary output = 0.5ml/kg/hr. Cardiovascular assessment is performed hourly or more frequently if haemodynamic status
deteriorates.
Regarding the IABP, the pump should be checked hourly for correct settings such as timing, balloon inflating to its maximum capacity
and that the trigger is at the correct setting. As with any invasive haemodynamic monitoring system the pressure bag should be inflated
and maintained at 300mmHg, thus ensuring optimal flush system, which is required for line patency. The level of the transducer is at the
phlebostatic axis that is confirmed using the spirit level and is changed as per patient position. Patient position is an important
consideration if the IABP is to be effective. The patient should be no higher than 30, which ensures patency of the balloon, continuous
flow to the balloon, and reduces the risk of catheter kinking and obstructing the passage of helium into and out of the catheter.
Potential complications
When caring for patients receiving this therapy nurses must be alert for possible occurrence of complications. Table 3 lists the potential
complications associated with IABP therapy. Thoroughness when obtaining the patients medical history is essential for recognising
factors that predispose the patient to the development of complications. Reid and Cottrell1 list the following as risk factors: female
gender, pre-existing peripheral arterial disease, older age, diabetes mellitus, smoker, hypertension and obesity. Limb ischaemia and
bleeding are two complications associated with this therapy and will be discussed in detail.

Potential complications
Infection at site of insertion
Haematoma and bleeding at insertion site
Limb ischaemia, absent pulses and compartment syndrome
Thrombocytopenia
Coagulation disturbances
Aortic dissection
Displacement of the balloon catheter obstructing left subclavian artery or renal artery perfusion
Vascular complications
Balloon leak, rupture, gas loss from the balloon
Timing issues

The primary causes of limb ischaemia are obstruction of a small or diseased femoral artery by the catheter, formation of thrombus from
direct arterial injury during IABP insertion and thromboembolism. Prior to insertion a lower limb perfusion assessment involving both
legs must be completed. This involves confirming presence of the pedal pulses dorsalis pedis and posterior tibial in both feet,
assessing capillary refill and temperature and observing the colour of the limbs (cyanosis, pale, mottled). There is no palpable dorsalis

pedis in 8-10% of the general population and this should be documented on nursing assessment prior to IABP insertion.1 if the pulses
are not palpable a doppler should be used to determine the presence of pulses that are difficult to palpate. This assessment is repeated
during IABP therapy as per hospital guidelines. In our hospital it is completed hourly. Acute ischaemia of the limbs may produce the six
Ps pain, pallor, pulselessness, poikilothermia (cold), paraesthesia and paralysis.1 In cases of limb ischaemia occurring, removal of the
balloon catheter restores perfusion, rarely a partial or full amputation is necessary.
Bleeding at the insertion site is commonly encountered and may be due to anticoagulation therapy or associated thrombocytopenia.
Patients receiving IABP therapy are normally maintained on an anticoagulation regimen to avoid thrombus formation at the tip of the
catheter or within the folds of the balloon. Thrombocytopenia can result from anticoagulation therapy or from platelet destruction due to
mechanical trauma that occurs during inflation of the IABP catheter. Baseline full blood count and anticoagulation screen should be
reserved prior to and during therapy to observe for changes such as a decrease in haemoglobin and to monitor the effect of
anticoagulation therapy prescribed.
The insertion site dressing should be transparent which enables visual inspection of the site. Change of dressing is as per clinical need
and hospital guidelines, aseptic technique must be employed to minimise the risk of infection. Frequency of monitoring depends on
patients clinical condition and as acuity determines. Indications of bleeding may manifest as oozing, bruising or haematoma formation
at the insertion site or by swelling in the thigh area.
Signs of retroperitoneal bleeding include the patient becoming hypotensive and complaining of back, flank or abdominal pain unrelieved
by changes in position. Treatment of bleeding includes applying pressure to the insertion site and administration of blood products as
required.
Nursing care involves checking the insertion site every hour for bleeding or haematoma formation and documenting findings. In addition
the full blood count and anti-coagulation screen is observed for a decrease in haemoglobin and platelet count or evidence that the
patient is receiving too high dose of anticoagulant.
Weaning and removal
Once the patients condition has stabilised the IABP is considered for removal. This is preceded by a process of weaning the pump from
1:1 to 1:2 and finally 1:3, and observing the patient for ischaemic chest pain or development of heart failure symptoms such as
breathlessness, hypotension and tachycardia. Once the patient is stable the IABP can be removed. Post removal the patient is kept on
bed rest with the leg kept straight as per local guidelines.
Nursing care involves observing for recurrence of symptoms as well as checking the insertion site for haematoma formation ooze or
symptoms suggestive of retroperitoneal bleed every 15 minutes for the first hour, half hourly for the next two hours and thereafter hourly
or as clinical acuity dictates. In addition lower limb perfusion is assessed at these times confirming adequate perfusion and presence of
pedal pulses.
IABP is a form of circulatory support for those presenting with ischaemia or heart failure. Nursing care involves care of the pump as well
as assessing patient from a cardiovascular and haemodynamic perspective .