iabp- instrumentation, indications and complications
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IABP- Instrumentation Indications and Complications
Dr Sajeer KTSenior ResidentDeptof Cardiology MCH Calicut
1
2
Intra aortic balloon counter pulsation( IABP)
Concepts - Systolic unloading - Diastolic augmentation
3
4
Indications for IABP
1 Cardiogenic shock
2 In association with CABG
Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion
- Postcardiotomy cardiogenic shock
- Associated with acute MI - Mechanical complications of MI - MR VSD
3 In association with nonsurgical revascularization- Hemodynamically unstable infarct patients- High risk coronary interventions
- severe LV dysfunction LMCA complex coronary artery disease
4 Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia
5
Contraindications to IABP
Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism
6
7
LV contraction - Isovol Contraction (b) - maximal ejection (c)
LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)
LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)
Cardiac cycle
8
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
2
Intra aortic balloon counter pulsation( IABP)
Concepts - Systolic unloading - Diastolic augmentation
3
4
Indications for IABP
1 Cardiogenic shock
2 In association with CABG
Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion
- Postcardiotomy cardiogenic shock
- Associated with acute MI - Mechanical complications of MI - MR VSD
3 In association with nonsurgical revascularization- Hemodynamically unstable infarct patients- High risk coronary interventions
- severe LV dysfunction LMCA complex coronary artery disease
4 Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia
5
Contraindications to IABP
Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism
6
7
LV contraction - Isovol Contraction (b) - maximal ejection (c)
LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)
LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)
Cardiac cycle
8
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
3
4
Indications for IABP
1 Cardiogenic shock
2 In association with CABG
Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion
- Postcardiotomy cardiogenic shock
- Associated with acute MI - Mechanical complications of MI - MR VSD
3 In association with nonsurgical revascularization- Hemodynamically unstable infarct patients- High risk coronary interventions
- severe LV dysfunction LMCA complex coronary artery disease
4 Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia
5
Contraindications to IABP
Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism
6
7
LV contraction - Isovol Contraction (b) - maximal ejection (c)
LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)
LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)
Cardiac cycle
8
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
4
Indications for IABP
1 Cardiogenic shock
2 In association with CABG
Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion
- Postcardiotomy cardiogenic shock
- Associated with acute MI - Mechanical complications of MI - MR VSD
3 In association with nonsurgical revascularization- Hemodynamically unstable infarct patients- High risk coronary interventions
- severe LV dysfunction LMCA complex coronary artery disease
4 Stabilization of cardiac transplant recipient before insertion of VADPost infarction anginaVentricular arrhythmias relathed to ischemia
5
Contraindications to IABP
Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism
6
7
LV contraction - Isovol Contraction (b) - maximal ejection (c)
LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)
LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)
Cardiac cycle
8
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
5
Contraindications to IABP
Severe aortic insufficiency Aortic aneurysm Aortic dissection Limb ischemia Thrombo embolism
6
7
LV contraction - Isovol Contraction (b) - maximal ejection (c)
LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)
LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)
Cardiac cycle
8
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
6
7
LV contraction - Isovol Contraction (b) - maximal ejection (c)
LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)
LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)
Cardiac cycle
8
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
7
LV contraction - Isovol Contraction (b) - maximal ejection (c)
LV relaxation - start of relaxation and reduced ejection (d) - isovolrelaxation (e)
LV filling - LV filling rapid phase (f) - slow LV filling (g) - atrial systole( a)
Cardiac cycle
8
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
8
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
9
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
10
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
11
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
12
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
13
Interpreting IABP waveforms
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
14
IABP ndashinstrumentation and techniques
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
15
The IAB Counter pulsation system
A flexible catheter -2 lumen bull first - for distal aspirationflushing or pressure monitoring bull second - for the periodic delivery and removal of helium gas to a
closed balloon
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
16
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
17
HEMODYNAMIC EFFECTS mdash Inflation and deflation of the balloon
bull Blood is displaced to the proximal aorta by inflation during bull diastole
bull Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
18
Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20
- Increase in aortic Diastolic Press by 30 ( raise coronary blood flow)
- Increase in MAP
- Reduction of the HR by 20
-Decrease in the mean PCWP by 20
- Elevation in the COP by 20
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
19
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
20
IABP catheter
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85 of aorta occluded (not 100)
The shaft of the balloon catheter contains 2 lumens - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire
- for monitoring of central aortic pressure after installation
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
21
Intra Aortic Balloon
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
22
IABP sizing chart
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
23
Benefits of larger volume IABs1048657 More blood volume displacement1048657 More diastolic augmentation1048657 More systolic unloading
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
24
Introducer needlebull Guide wirebull Vessel dilatorsbull Sheathbull IABP (34 or 40cc)bull Gas tubingbull 60-mL syringebull Three-way stopcock
IABP Kit Contents
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
25
Intraaortic balloon
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
26
Connect ECG
Set up pressure lines
Femoral access ndash followed by insertion of the supplied sheath(75 F)
0030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)
STEP BY STEP- IABP insertion
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
27
Before taking the Catheter out of Tray
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
28
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray)
Pull out the T- handle only as shown
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
29
bull Remove styletaspirateFlush
bull Insert the balloon only over the guide wire
bull Hold the catheter close to skin insertion point
bull Advance in small steps of 1 to 2 cm at a time and stop if any resistance
bull The IABP should advance freely
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD or dissection
- Kinking of IABP raquo improper inflationdeflation
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
30
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray
Positioning
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
31
Connecting to console - Connect helium gas tube to the console via a long extender - Open helium tank
- The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure
- Zero the transducer
Initial set-up- Once connected properly the console would show ECG and pressure waveforms- Check Basal mean pressure- Make sure the setting is at ldquoautordquo- Usually IABP started at 11 or 12 augmentation- Usually Augmentation is kept at maxim
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
32
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
33
Trigger modesTrigger - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected counter pulsation will interrupted
1ECG - uses the slope of QR segment to detect triggering point
2 AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
3 IN(Internal trigger)
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
34
ECG signal ndash most common bull Inflation - middle of T wave bull Deflation ndash peak of R wave
bull Pacer (va)
bull Arterial waveform
bull An intrinsic pump rate (VF CPB)
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
35
Auto Operation Mode1048657 Automatic lead and trigger selection1048657 Automatic and continuous inflation and deflation timing management
- User has ability to fine-tune deflation timing
1048657 Automatic management of irregular rhythmsSemi-Auto Operation Mode
1048657 Operator selects most appropriate lead and trigger source
Initial settings
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
36
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
37
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
38
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
39
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
40
Increased coronary perfusion
The ldquonormalrdquo augmented waveform
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
41
Not all Sub optimal augmentation is due to Timing errorskinks
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
42
Factors affecting diastolic augmentationPatient
- Heart rate- Mean arterial pressure- Stroke volume- Systemic vascular resistance
Intra aortic balloon catheter- IAB in sheath- IAB not unfolded- IAB position- Kink in the IAB catheter - IAB leak- Low helium concentration
Intra aortic balloon pump- Timing- Position of IAB augmentation control
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
43
How to check waveform is acceptable
First change from 11 to 12 augmentation
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
44
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
45
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
46
How to check waveform is acceptable
First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
47
How to check waveform is acceptable First change from 11 to 12 augmentation Check the dicrotic notch See if augmentation starts at that point This should produce a sharp ldquoVrdquo at inflation Check if diastolic augmented wave is rsaquo systolic wave
Confirm if end diastolic wave following the augmented wave is less than an non augmented wave
Is Deflation slope ok
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
48
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
49
Late Inflation Inflation of the IAB markedly after closure of the aortic valve Waveform Characteristics
bull Inflation of IAB after the dicrotic notchbull Absence of sharp V
Sub optimal diastolic augmentation
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
50
Early Deflation Premature deflation of the IAB during the diastolic phase
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
51
Late Deflation Late deflation of the IAB during the diastolic phase
Waveform Characteristicsbull Assisted aortic end diastolic pressure may be equal to the
unassisted aortic end diastolic pressurebull Rate of rise of assisted systole is prolongedbull Diastolic augmentation may appear widened
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
52
Once Arterial waveform is ok check balloon waveform
Normal Balloon Pressure Waveform
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
53
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
54
Variation in balloon pressure wave forms
Increased duration ofplateau due to longer
diastolic phase
Decreased durationof plateau due to
shortened diastolicphase
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
55
Variation in balloon pressure wave forms
Varying R-R intervalsresult in irregularplateau durations
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
56
Variation in balloon pressure wave forms
Increased heightor amplitude ofthe waveform
Decreased heightor amplitude of thewaveform
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
57
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing theballoon pressure waveform to fall belowzero baseline
- due to a loose connection- a leak in the IAB catheter- H2O condensation in the external tubing- a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
58
Catheter Kink
Rounded balloon pressure waveform- Loss of plateau resulting from a kink or obstruction of shuttle gas
- Kink in the catheter tubing- Improper IAB catheter position- Sheath not being pulled back to allow inflation of the IAB- IAB is too large for the aorta- IAB is not fully unwrapped- H2O condensation in the external tubing
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
59
ldquoBalloon too largerdquo
syndrome
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
60
Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily ndash to RO IAB migration
Check lower limb pulses - 2 hourly - If not palpable raquo - vascular obstruction - thrombus embolus or dissection (urgent surgical consultation)
Prophylactic antibiotics --
Hip flexion is restricted and the head of the bed should not be elevated beyond 30deg
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
61
Never leave in standby by mode for more than 20 minutes gt thrombus formation
Dailyndash Haemoglobin (risk of bleeding or haemolysis)ndash Platelet count (risk of thrombocytopenia) ndash Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications
Patient Management During IABP support
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
62
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
63
Weaning of IABP
Timing of weaning
- Patient should be stable for 12 ndash 24 hours - Decrease inotropic support - Decrease pump ratio
ndash From 11 to 12 or 13 - Decrease augmentation - Monitor patient closely
ndash If patient becomes unstable weaning should be immediately discontinued
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
64
IABP Removal
- Discontinue heparin six hours prior to removal
- Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance is met- NEVER attempt to withdraw the balloon membrane through the introducer sheath- Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
65
Thank you
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
66
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
67
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
A) Decrease in SBP by 20
B) Increase in aortic DP by 30
C) Decrease in MAP by 10
D) Reduction of the HR by 20
E)Decrease in the mean PCWP by 20
68
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
4 late inflation of the balloon can result in
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
69
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
5 A rounded balloon pressure wave form indicate
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
70
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
6 width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
71
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
72
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form
73
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
9 Identify the tracing abnormality
74
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
10 Identify the tracing abnormality
75
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
bull 1 Major physiological effects of counter pulsation include
A) increased coronary artery perfusion increased preload decreased after load decreased myocardial oxygen consumption
B) increased coronary artery perfusion increased preload increased after load decreased myocardial oxygen consumption
C) increased coronary artery perfusion decreased preload decreased after load increased myocardial oxygen consumption
D) increased coronary artery perfusion decreased preload decreased after load decreased myocardial oxygen consumption
76
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
2 the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection
77
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
3 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except
bullA) Decrease in SBP by 20
bullB) Increase in aortic DP by 30
bullC) Decrease in MAP by 10
bullD) Reduction of the HR by 20
bullE)Decrease in the mean PCWP by 20
78
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
4 late inflation of the balloon can result in
bull A) premature augmentation
bull B) increased augmentation
bull C) decreased augmentation
bull D) increased coronary perfusion
79
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
5 A rounded balloon pressure wave form indicate
bull A) helium leak
bull B) power failure
bull C) hypovolemia
bull D) balloon occluding the aorta
80
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
6 width of balloon pressure wave form corresponds to
bull A) length of systole
bull B) length of diastole
bull C) arterial pressure
bull D) helium level
81
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
7 true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso volumetric contraction
c) Most common trigger used is arterial pressure wave method
d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm
82
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
8 true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50 paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press Wave form
83
9
84
10
85
9
84
10
85
10
85
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