Professional Documents
Culture Documents
10/16/2013
10/16/2013
10/16/2013
10/16/2013
Journal of Cardiothoracic and Vascular Anesthesia, Vol 17, No 6 (December), 2003: pp 736-739
Intraoperative Transesophageal Echocardiographic Imaging of an Intra-aortic Balloon Pump Placed via the Ascending Aorta
Kent H. Rehfeldt, MD,* and Roger L. Click, MD
THE USE OF A perioperative intra-aortic balloon pump(IABP) in cardiac surgical patients is relatively common, occurring in 2% to 12% of cases.1 Although a femoral arteryinsertion site is typically used, the failure rate for IABP insertion via the femoral artery has been reported to be around 5%.2,3In patients in whom the IABP cannot be inserted from a femoral approach, placement via the ascending aorta may bepossible. When this transthoracic approach is used, intraoperative transesophageal echocardiography (TEE) is especiallyuseful in confirming correct position of the IABP in the thoracic aorta, as described in the following cases.
5 10/16/2013
From the Section of Cardiology and Cardiovascular Surgery, Norfolk General Hospital and Eastern Virginia Medical School, Norfolk, Virginia
Prophylactic Use of Intra-aortic Balloon Pump in Aortocoronary Bypass for Patients with Left Main Coronary Artery Disease
H. R. RAJAI, M.D., et al Aortocoronary bypass surgery in patients with left main coronary artery disease is reported to have an operative mortality of between 1.4 and 39%. It is generally accepted that the operative mortality in this group of patients is considerably greater than in routine bypass candidates, presumably due to the large amount of myocardium threatened by a single lesion. In an effort to preserve threatened left ventricular myocardium, intraaortic balloon pumping was instituted prophylactically prior to sternotomy in 20 consecutive patients with left main coronary artery disease (luminal narrowing greater than 50%). Sixty per cent of these patients had New York Heart Association Class IV angina, 25% had Class III, and 15% Class II. Fifty per cent of the patients in this group presented with unstable angina. Operative patients requiring left ventricular aneurysmectomy and/or valve replacement, were excluded. No operative deaths have been encountered in 20 consecutive patients managed in this manner. One patient displayed signs of myocardial infarction in the postoperative period. Correctable peripheral vascular ischemic complications of pump insertion were encountered in three patients. Preliminary results from this ongoing study support the hypothesis that 10/16/2013 6 prophylactic intra-aortic balloon pumping is a low risk procedure that should be utilized
Objectives
Demonstrate a basic understanding of the purpose
and monitoring
10/16/2013
IABP PURPOSE
Improves cardiac function during cardiogenic
shock. 26-28 cm balloon surrounds end of centrally placed catheter (from groin) Placed into descending thoracic aorta Inflates in diastole - fills coronary arteries retrograde Deflates in systole - decreases LV afterload
8 10/16/2013
Indications
1. Refractory ventricular failure
2. Cardiogenic shock
3. Unstable refractory angina 4. Impending (To threaten to happen) infarction
10/16/2013
Indications
7. Cardiac support for high-risk general surgical
valvuloplasty
10 10/16/2013
Contraindications
Severe aortic insufficiency 2. Abdominal or aortic aneurysm 3. Severe calcific aorta-iliac disease or
11
10/16/2013
Contraindications
Contraindications: Incompetent aortic valve
(because inflation increases aortic regurgitation) Nursing: Head of bed must be kept 30 degrees or lower. Must monitor for infection or bleeding IABP augments cardiac output by 15% & provides total support for the heart; which allows the heart to recover
12
10/16/2013
13
10/16/2013
What is an IABP?
ventricular systolic work, left ventricular end-diastolic pressure, and wall tension
Decreases oxygen consumption Increases cardiac output,
14
15
10/16/2013
The System 97e is a helium charged, mobile, Intra-Aortic Balloon Pump (IABP).
16 10/16/2013
It is inserted into the descending aorta via the femoral artery either percutaneously or by surgical cut-down. The balloon rapidly deflates just before ventricular systole to reduce the impedance (A measure of the total opposition to current flow in an alternating current circuit) to left ventricular ejection
17
10/16/2013
It consists of a catheter
so that the tip is approximately 1 to 2 cm below the origin of the left subclavian artery and above the renal arteries.
On chest x-ray the tip
18
10/16/2013
Surgical Indications
Post Surgical Myocardial Dysfunction
(CPB)
Cardiac support following correction of anatomical
defects
Maintenance of graft patency post CABG 19
10/16/2013
Desired Outcome
Appropriately timed blood volume displacement (30
50 mL) in the aorta by the rapid shuttling of helium gas in and out of the balloon chamber, resulting in changes in inflation and deflation hemodynamics
20
10/16/2013
Insertion Techniques
A percutaneous placement of the IAB via the femoral
artery using a modified Seldinger technique (a needle is used to puncture the structure and a guide wire is threaded through the needle; when the needle is withdrawn, a catheter is threaded over the wire; the wire is then withdrawn, leaving the catheter in place.)
After puncture of the femoral artery a J-shaped guide
wire is inserted to the level of the aortic arch and then the needle is removed.
The arterial puncture side is enlarged with the
21
successive placement of an 8 to 10,5Fr dilator/sheath 10/16/2013 combination. Only the dilator needs to be removed
22
10/16/2013
Insertion Techniques
Continuing, the balloon is threaded over the guide
wire into the descending aorta just below the left subclavian artery.
The sheath is gently pulled back to connect with
the leak-proof cuff on the balloon hub, ideally so that the entire sheath is out of the arterial lumen to minimize risk of ischemic complications to the distal extremity.
23 10/16/2013
Insertion Techniques
There are alternative routes for balloon insertion.
In patients with extremely severe peripheral vascular
disease or in pediatric patients the ascending aorta or the aortic arch may be entered for balloon insertion.
Other routes of access include subclavian, axillary or
iliac arteries.
24 10/16/2013
an outer tube, a balloon, a tip and an inner tube, a proximal portion of said inner tube disposed within the outer tube and a distal portion of said inner tube extending beyond a distal end of the outer tube, the tip, a distal end of the inner tube, and a distal end of the 25 balloon membrane are
10/16/2013
Arterial Pressure
Balloon Pump 26 Console
10/16/2013
27
10/16/2013
28
10/16/2013
Inflation
It inflates immediately
29
10/16/2013
the intra-aortic balloon positioned in the descending thoracic aorta, just below the left subclavian artery, but above the renal arteries.
30 10/16/2013
The principles of
counterpulsation state that the balloon should be inflated at the start of diastole, just prior to the Dicrotic Notch.
Aortic volume and pressure are
1. 2. 3.
4.
5.
32
Increased coronary perfusion pressure Increased systemic perfusion pressure Increased O2 supply to both the coronary and peripheral tissue Increased baroreceptor response Decreased sympathetic stimulation causing decreased Heart Rate, decreased Systemic Vascular
10/16/2013
Deflation
The balloon rapidly
33
10/16/2013
1.
Afterload reduction and therefore a reduction in myocardial oxygen consumption (MVO2) Reduction in peak systolic pressure, therefore a reduction in LV work Increased Cardiac Output Improved ejection fraction (The amount of blood pumped out of a ventricle during each heart beat. The ejection fraction
2.
3. 4.
34
10/16/2013
Heart Rate Stroke Volume Mean Arterial Pressure Systemic Vascular Resistance
35
10/16/2013
IAB in sheath IAB not unfolded IAB position Kink in IAB catheter IAB leak Low Helium concentration
36
10/16/2013
37
10/16/2013
opens, beginning of systole PSP = Peak systolic pressure, 65-75% of stroke volume has been delivered
38
DN = Dicrotic notch, signifies aortic valve closure and the beginning of diastole
10/16/2013
The rule of inflation is: inflate just prior to the Dicrotic Notch
To accomplish the goals
timed inflation is a pressure rise PDP/DA = Peak diastolic pressure or diastolic augmentation, this is the pressure generated in 39 the aorta as the result of
10/16/2013
pressure, this is the patient's unassisted diastole PSP = Peak systolic pressure, this is the patient's unassisted systole PDP/DA = Peak diastolic pressure or diastolic augmentation, this is the pressure generated in the aorta as the result of inflation BAEDP = Balloon aortic end diastolic pressure, this is the lowest pressure produced by deflation of the IAB APSP = Assisted peak systolic pressure, this systole follows balloon deflation and should reflect the
40
10/16/2013
Inflation Hemodynamics
Coronary artery blood flow and pressure are
increased
Increased renal and cerebral blood flow
41
10/16/2013
Triggering
It is necessary to establish a reliable trigger
stimulus to cycle the pneumatic system, which inflates and deflates the balloon
The trigger signal tells the computer that another
Triggering
In most cases it is preferable to use the R wave of
43
10/16/2013
Trigger Loss
The console MUST see a trigger to initiate an
inflate/deflate cycle
If no trigger is seen when the clinician attempts to
be sounded
10/16/2013
Trigger Loss
If the current trigger is lost the clinician can
disconnected the Arterial Pressure trigger may be selected until the ECG is re-established
45
10/16/2013
ECG Trigger
preferred, it is very important to give the IABP a good quality ECG signal and lead
10/16/2013
46
inappropriate triggering
10/16/2013
47
ECG Gain
provides consistent, appropriate triggering, it is important to ensure the QRS complex has adequate amplitude
The computer has a minimum height requirement to
48
pressure curve
Therefore AP trigger should be considered a backup
49
10/16/2013
ratio, e.g. if in 1:1 there should be one assist marker per ECG complex
Flash heart symbol next to HR on screen
50
10/16/2013
Trigger Loss
Possible Cause
1.
Operator Action
1.
ECG
2.
3. 4. 5.
6.
Loose or disconnected ECG leads Current type of ECG trigger is not appropriate ECG signal too small Very noisy ECG Monitor input disconnected Patient's cardiac activity ceased
2.
3.
4. 5.
6.
Check electrodes, lead wires and connections. Change to alternate appropriate ECG trigger. Change lead selection; change trigger source; check electrode placement. Increase ECG gain if applicable. Change to AP trigger. Check connections from monitor and secure. CHECK PATIENT FOR CARDIAC ACTIVITY
51
10/16/2013
Trigger Loss
Possible Cause
Operator Action
Arterial Pressure
1.
1.
Check arterial tracing; flush line; check transducer and monitor input; change to ECG trigger.
Change to ECG trigger CHECK PATIENT FOR CARDIAC ACTIVITY
2.
2.
3.
3.
52
10/16/2013
ratio of 1:2.
This ratio facilitates comparison between the
patients own ventricular beats and augmented beats to determine ideal IABP timing.
Errors in timing of the IABP may result in different
weaning from the IABP may begin by gradually decreasing the balloon augmentation ratio (from 1:1 to 1:2 to 1:4 to 1:8) under control of hemodynamic stability.
After appropriate observation at 1:8 counterpulsation
54
10/16/2013
of the balloon. The environment within the balloon and the surrounding forces that affect balloon behavior all contribute to a predictable pattern of gas flow and pressure.
The Arrow International IABP consoles have in-line transducers that
important for efficient troubleshooting of the console as most of the alarms are based on this gas surveillance system. 10/16/2013
Hypertension
Hypotension
56
10/16/2013
57
10/16/2013
deflation artifacts. This is generally indicative of something impeding the rapid inflation and deflation of the IAB, such as kinking of the gas lumen. This may result in poor augmentation and/or poor afterload reduction. It may also lead to helium/gas loss alarms in higher Heart Rates when in a 1:1 assist ratio. It may precede high pressure/kinked line alarms. The goal is to eliminate the partial obstruction, if 10/16/2013 possible, to enable the
58
Abnormal Waveform Variation: Helium Loss / Gas Loss / Gas Leakage Alarms
baseline is below 0.
This indicates that a
portion of the gas that went out to the balloon did not return to the pump.
10/16/2013 59
1.
Observe for blood in the gas tubing. If even a slight amount were present, it would indicate a balloon rupture.
1. Do not resume pumping. Notify physician
Check connections where gas tubing connects to IAB and to pump. 1. Secure if loose. Check for kinks, as they may trap gas in the IAB. If water is present in the gas tubing, remove the condensation. Pushing the helium through the water during inflation and deflation slows down 10/16/2013 gas transition. If gas transition is prolonged too
3. 1.
60
61
1.
Reposition patient. Keep affected leg straight. Use rolled towel under hip to hyperextend hip. Apply slight traction to the catheter if suspect kinking at the insertion site or in the artery.
2.
3.
Introducer sheath may be kinked which in turn is kinking the balloon. Suspect this particularly if placement of the sheath was difficult. Pull sheath back or rotate sheath a partial turn.
62
10/16/2013
1.
Check placement of the balloon; it may be too high or too low. IAB may be partially wrapped if alarm occurs shortly after insertion. Take steps to facilitate unwrapping (consult IAB manufacturer). The balloon may be too large for the patient. Reduce the helium volume the balloon is inflated with. It is recommended to not reduce the volume below 2/3 of maximum. For example, do not decrease volume in a 40cc IAB below 27cc.
2.
1.
63
10/16/2013
Indicates too
10/16/2013
64
1.
2.
3.
This condition may occur during ascent (an upward slope) in air transport since gas expands as you go up in altitude (elevation). Reset the alarm and restart pumping.
The volume will be adjusted automatically for current barometric pressure. In the AutoCAT, ensure that the tubing to the condensation bottle (located behind the helium tank) is not kinked. 10/16/2013
4.
5.
6.
65
Thrombocytopenia
Immobility of the balloon catheter Balloon leak
Infection
Compartment syndrome
66
10/16/2013
IABP COMPLICATIONS
Aortic dissection during insertion
67
Reduction of platelets, RBC destruction Peripheral emboli Balloon rupture with gas embolus Renal failure (balloon occlusion of renal artery) Vascular insufficiency of catheterized limb
10/16/2013
Complications of IABP
The following patients are at the greatest risk of
68
10/16/2013
Complications of IABP
Aortic wall dissection, rupture or local vascular
69
10/16/2013
Treatment of an air embolism is as follows Administer 100% oxygen and intubate for significant
respiratory distress or refractory hypoxemia.
Oxygen may reduce bubble size by increasing the
down) position and rotate toward the left lateral decubitus position.
This maneuver helps trap air in the apex of the
70
ventricle, prevents its ejection into the pulmonary 10/16/2013 arterial system, and maintains right ventricular
Complications of IABP
IABP Rupture: Helium embolus or catheter
entrapment (take or catch as if in a snare or trap) COFFEE GROUNDS seen in the drive line is a precursor to a rupture NOTIFY RT & PHYSICIAN!!!!! IF THERE IS A FLAGRANT (bad or offensive) RUPURE OF THE IABP CLAMP THE GAS LINE!!!!!
71 10/16/2013
Complications of IABP
Infection Check catheter insertion site often STRICT ASEPTIC TECHNIQUE Restrict movement while IABP in place
72
10/16/2013
Complications of IABP
Obstruction Malposition Too high obstruction of left subclavian, carotids CHECK LEFT RADIAL ARTERY PULSE Too low obstruction of renal and mesenteric
Complications of IABP
Compromised circulation due to catheter Ischemia
Routine nursing care and monitoring
Compartment syndrome
Rare complication seen in the LE (lupus erythematosus)
Complications of IABP
Hematologic ALL PATIENTS Typed & Crossmatched!!! Bleeding REMOVE THE DRESSING!!! PUT ON STERILE GLOVES!!! HOLD PRESSURE!!!
75
10/16/2013
1. 2. 3. 4. 5. 6. 7. 8. 9.
Zero Baseline (on console) Balloon Pressure Baseline Rapid Inflation Peak Inflation Artifact Balloon Pressure Plateau (IAB fully inflated) Rapid Deflation Balloon Deflation Artifact Return to Baseline (IAB fully deflated) Duration of Balloon Cycle
10/16/2013
76
Case report Successful surgery for perforation of the thoracic aorta caused by the tip of an intra-aortic balloon pump Thomas Wolff *, Peter Stulz Klinik fur Herz- und Thoraxchirurgie, Kantonsspital, Spitalstrasse 21, CH-4031 Basel, Switzerland We describe a case of perforation of the thoracic aorta caused by the tip of an intraaortic balloon pump. The perforation was confirmed by computed tomography (CT) scan and immediate surgical repair was successful. Vascular injury due to the insertion of an intra-aortic balloon pump is quite common but is predominantly confined to limb ischemia or injury to the femoral or iliac artery. Iatrogenic aortic perforation leading to significant bleeding is much less common and usually fatal. 1997 Elsevier Science B.V.Keywords: Aortic injury; Intra-aortic balloon pump; Complication
10/16/2013
77
Circ J 2002; 66: 423 424 Perforation of the Descending Aorta by the Tip of an Intra-Aortic Balloon Pump Catheter
Ryo Shiraishi, MD*; Yukio Okazaki, MD; Kozo Naito, MD; Tsuyoshi Itoh, MD Perforation of the proximal descending aorta occurred in a patient on intra-aortic balloon pump (IABP) supportafter emergency coronary intervention for acute myocardial infarction. The IABP catheter was inserted under fluoroscopic guidance into the right femoral artery without difficulty, but after 8 h on IABP support the patient went into shock with a left hemothorax. Emergency surgery was performed with cardiopulmonary bypass and a perforation of the proximal descending aorta with active bleeding was found and successfully repaired. A distorted descending aorta in which the IABP catheter was kinked, as in the aortic arch, was discovered during surgery and confirmed postoperatively with 3-dimensional computed tomography scans, particularly in the lateral view. Not only the antero-posterior but also the lateral fluoroscopic view is recommended to prevent aortic perforation by a kinked IABP catheter. (Circ J 2002; 66: 423 424)
78
10/16/2013
Conclusions
1.The consistent application of intra-aortic balloon
pump support of patients with coronary artery disease and its complications has provided a therapeutic platform for direct surgical intervention on otherwise unstable patients with cardiac ischemia, heart failure, and shock.
This integrated approach to the treatment of
80
patients with coronary artery disease has profoundly affected how this disease process is 10/16/2013 managed throughout the world.
Potential benefits of this therapy include (1) compression of existing air bubbles, (2) establishment of a high diffusion gradient to speed dissolution of existing bubbles, and (3) improved oxygenation of ischemic tissues and lowered intracranial pressure.
Circulatory collapse should be addressed with
81
10/16/2013
Thank you
82
10/16/2013