Nursing Care and Treatment of Ambulatory Patients With Percutaneously Placed Axillary Intra-aortic Balloon Pump Before Heart Transplant.

Transplant cardiologists in our hospital have performed the percutaneously placed axillary-subclavian intra-aortic balloon pump procedure since 2007. This procedure allows patients to mobilize and walk while they wait for a heart transplant, rather than remaining on bed rest as they would with a traditional femoral intra-aortic balloon pump. This procedure has presented challenges to the nursing staff. A 2007 literature search revealed no precedent or published nursing articles on this subject. This article reviews heart failure, medical treatments, complications of bed rest associated with the femoral intra-aortic balloon pump, the nursing challenges and unique problems of caring for patients with percutaneously placed axillary-subclavian intra-aortic balloon pumps, and our solutions for those challenges.

Intra-aortic balloon pump therapy--a primer for perioperative nurses.

The intra-aortic balloon pump (IABP) is a commonly used circulatory-assist device that increases myocardial oxygen supply and reduces myocardial oxygen demand, thus improving left ventricular function. The inflation and deflation pattern of the IABP is the opposite of the heart's rhythm. As the heart rests, the balloon inflates, displacing blood volume into the coronary sinus and systemic circulation. The balloon deflates just before ventricular ejection, decreasing the pressure that the ventricle must eject against. This article describes indications and contraindications for use of the IABP, insertion and timing of the device, and troubleshooting measures for common malfunctions.

Intra-aortic balloon counterpulsation complicated by limb ischaemia: a reflective commentary.

Intra-aortic balloon counterpulsation (IABC) is widely used to support the failing myocardium, particularly in patients with a background of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). CS is primarily due to left ventricular failure and is the most serious complication of AMI. Using Driscoll's 'What?' reflective model to guide critical thinking, an incident involving a patient who required IABC following AMI is explored. There are various complications associated with IABC, limb ischaemia being very common. Risk factors, which predispose patients to the development of limb ischaemia following intra-aortic balloon pump insertion, are discussed as are the issues surrounding their care. Nurses are in an ideal position to detect any complications that may occur. They should be familiar with the patient's medical history, including any risk factors, which could predispose them to the development of limb ischaemia. Consideration of these factors and the adjunctive treatment the patient may require can be used to plan care accordingly. Anecdotal evidence suggests that more patients are requiring haemodynamic support from IABC. Nurses and health care professionals who have the responsibility of caring for these patients need to be adequately trained in order to maintain a high standard of care. However, there appears to be a lack of evidence-based guidelines determining the optimum frequency of limb observations to assess for limb ischaemia. Further evidence as to the timing of limb observations is required in order that protocols can be written to guide the practice.

Understanding intraaortic balloon pumping.

Nurses are accountable for their care. Understanding the physiology and process behind any intervention improves patient care, while also increasing nursing satisfaction and skill and IABP is no exception. An awareness of IABP will facilitate sound nursing care, ensure early identification of possible complications or patient compromise, and lead to patient and relative satisfaction. It will also assist in the transition from caring for a patient whose needs are relatively straightforward, to caring for one subject to this complex medical intervention.

Intra-aortic balloon pump: nursing implications for patients with an iliac artery approach.

Long-term use of an intra-aortic balloon pump is often necessary for patients with severe left ventricular dysfunction who are awaiting cardiac transplantation. Complications caused by prolonged bed rest and immobility can occur when the traditional femoral approach is used for insertion of the balloon catheter. Insertion of the intra-aortic balloon catheter through the iliac artery is an alternative technique that allows patients to sit, stand, and walk while receiving counterpulsation. This approach is now being used to prevent the complications of immobility in patients awaiting cardiac transplantation. In this article, the special considerations, potential complications, and nursing interventions unique to the iliac artery approach are delineated.

Intra-aortic balloon pumping and stress in the coronary care unit.

This study compared the perceptions of psychological stress experienced by patients on the IABP with that of other patients in the CCU. During 13 weeks, structured interviews were conducted with 17 male and 10 female patients: Seven were treated with the IABP; 10 were not on the pump but were present during its use; and 10 were neither on the pump nor in physical proximity to it. To measure psychological stress, each patient responded to a list of 20 potentially stressful situations using a stress rating scale. Analysis of variance was used to determine differences in perceptions. The results identified factors in the CCU that patients perceived as stressful and were compared with those of earlier research. Data analysis demonstrated moderate support for the study's hypotheses. Stress levels of patients on the IABP were significantly higher than those of patients who were not on the IABP but present during its use. No significant differences were found between stress levels of patients on the IABP and patients with the IAPB absent or between those of the two groups who were not on the pump. Implications for nursing care of the patient on the IABP were also discussed.

Assessing the five points of the intra-aortic balloon pump waveform.

IABP timing challenges the nurse not only with a waveform analysis but also an understanding of complex physiologic concepts crucial to patient management. Optimizing timing through assessment of the five points of the IABP waveform permits the critical care nurse to increase the hemodynamic benefits of IABP therapy, potentially improving patient outcome.

Managing the challenge of IABP therapy.

The nurse's role requires the operation of the IABP, while at the same time, the ability to deliver quality nursing care. Knowledge of physiology, coordination of the principles of timing with hemodynamic effects, and skillful problem solving assure critical care nurses that they can effectively manage the IABP challenge.

Maximizing cardiopulmonary resuscitation in patients with intra-aortic balloon pumps.

Improved hemodynamics and blood flow have been reported in patients with IABPs who experience cardiopulmonary arrest and require CPR. The following research questions, however, remain unanswered: Is there a more effective method of using IABP to prevent cardiac arrest and the need for CPR? Is the timing of balloon inflation and deflation the same for patients undergoing CPR as it is for patients who do not require CPR? Would earlier or later inflation or deflation further enhance cerebral or systemic blood flow? What are the most effective ways for healthcare staff to maintain competency skills in CPR in patients with IABPs?

Nursing dynamics of pediatric intraaortic balloon pumping.

Care of the child on the IABP continues to be a challenging experience. Further advances in IABP technology will improve the rate of survival for children with complex congenital heart defects and other more complicated diagnoses. Likewise, this technology will enable critical care nurses to increase their expertise resulting in new gains in nursing knowledge.

Caring for the intra-aortic balloon pump patient. Most frequently asked nursing questions.

IAB counterpulsation poses specific nursing issues and challenges. The patient's arterial pressure reference points are expanded to five components as opposed to the usual systole and diastole. It is, therefore, crucial that procedures be developed that address issues such as computation of mean arterial pressure and documentation and titration of drips through the use of the 5 waveform components of the IABP patient. Peripheral vascular assessment is most important because of the potential for compromised flow. The ankle/arm index can be used as an objective measurement to quantify perfusion. Balloon inflation during diastole normally generates the highest pressure point in the counterpulsation cycle. Various factors can lower the magnitude of augmentation, and these need to be included in troubleshooting assessments.

Developing and implementing a standard of care for intra-aortic balloon counterpulsation.

This article summarizes the process for developing one standard of care for IABC within an integrated hospital system. Practice variations and new research findings create a need to review and update standards of care regularly. Assessing current practice, reviewing the literature, and consulting experts are part of the development process. Implementation of a new standard is a multifaceted challenge that involves several educational strategies. Evaluation of a standard of care is accomplished by assessing quality outcome indicators.

Clinical observations with real timing.

This article describes the hemodynamic effects of IABC therapy on patients supported with real timing. Criteria used to assess "proper" timing are discussed and challenged as they relate to the limited research available on the subject and to the cases in this article. It is important that clinicians who time the IAB consoles and assess therapeutic benefit of this therapy are aware of the different timing modalities and their potential benefits or ill effects in certain patient populations. The observations made by the authors strongly suggest the need for clinical research, case reports, and further evidence of valid assessment criteria to develop a research-based theory for practice of IABC timing and to provide criteria for selecting timing modalities for specific patient populations.

Correlation of balloon pressure waveforms to troubleshooting gas leakage and restriction alarms.

The balloon pressure waveform provides the clinician with a valuable tool for assessing the operating environment within the balloon and the catheter. The use of a calibrated balloon pressure waveform allows the clinician to assess gas leakage and catheter restriction alarms and implement corrective action. By combining assessment of the arterial pressure waveform with the balloon pressure waveform, proper treatment and safe, effective balloon pump support can be maintained.

Complications of intra-aortic balloon pumping. Preventable or not preventable?

This article summarized the most common and most serious complications associated with the use of the intra-aortic balloon pump, while at the same time focuses on guidelines for prevention. Complications associated with intra-aortic balloon pump use potentially threaten the outcome of the patient. Although risk factors play a role in the development of complications, many are preventable through early detection and intervention. It is important that the critical care nurses have an awareness of the potential complications of intra-aortic balloon pumping as early detection and rapid intervention will serve to decrease the incidence of the more serious and devastating complications associated with the use of the intra-aortic balloon pump.

Intra-aortic balloon pump issues from a management perspective.

This article summarizes the successful development and implementation of an IABP program. Administrative, fiscal, and educational considerations are described. It is important for nursing leaders to maintain a patient focus in an environment that currently reacts to both internal and external pressures.

Intra-aortic balloon pumping in the community hospital setting.

A community-hospital IABP program provides potentially lifesaving treatment for patients with lethal cardiac problems. Similar to the rapidly growing number of other community hospitals with IABP programs, Landmark Hospital in Rhode Island has successfully implemented this modality of cardiac care, once limited to tertiary care facilities. Although the challenges the community hospital faces when establishing an IABP program and maintaining clinical competency are unique, IABP in the community hospital is a proven treatment modality that decreases mortality rates.

Air transport of the patient requiring intra-aortic balloon pumping.

Air transport of the IABC patient requires a high level of skill and competence. The nurse caring for the IABP patient must be experienced in balloon pumping in a variety of settings (catheterization laboratory, operating room) and during unstable hemodynamic conditions, such as occur with arrhythmias, pacemakers, severe cardiogenic shock, and cardiac arrest. The nurse must be trained in all aspects of console operation and troubleshooting. Evanston Hospital, Evanston, Illinois, examined its experiences in ground transportation of 50 IABP patients over a 5-year period. The hospital has put forth several important principles that we have incorporated into our recommendations for air transport of the IABC patient: 1. Transport personnel should be completely familiar with the function of the IABP console; capable of handling bleeding at the balloon site, should it occur; capable of delivering intravenous medications, CPR, and ACLS; and proficient in operation of the ventilator, hemodynamic monitoring, and aerohemodynamics. 2. All patients must be stabilized before transfer. Appropriate management of hemodynamic instability and/or respiratory distress should be undertaken prior to beginning transport. 3. Medical personnel delivering care must transfer patients into and out of transport vehicles with minimal interruption of IABP. 4. Health-care professionals present during transport should be thoroughly familiar with the patient's medical status and anticipated complications. This article was not intended to teach basic principles of intra-aortic balloon pumping; rather its purpose was to discuss those characteristics of balloon pumping that are unique to flight transport and how they impact on balloon pumping. Console operation should follow manufacturer's recommendations. Table 3 summarizes features of the Aries, Datascope, Kontron, and Mansfield transport balloon pumps. Manufacturers and aircraft suppliers should be consulted for specific balloon-pump operating instructions, prior to assuming responsibility for care of the air-transport IABC patient. Well-established care plans and protocols for IABP have been published previously. Documentation of balloon-pump function during air transport is important, and can be an addenum to a standard ICU flowsheet (Fig. 4). The patient who presents at a community hospital with accelerating angina, complications following cardiac catheterization or myocardial infarction, emergency cardiac structural defects, or as a potential cardiac transplantation candidate may require institution of IABC as a life-saving intervention. Once the patient is stabilized, transport to a tertiary-care hospital that can provide advanced cardiac therapies is a logical trajectory.(ABSTRACT TRUNCATED AT 400 WORDS)

Vascular complications of the patient undergoing intra-aortic balloon pumping.

Despite advances in intra-aortic balloon catheters and consoles, the vascular complication rate of IABP has not decreased. Predisposing complication factors identified through research include gender, diabetes, peripheral vascular disease, catheter size, prolonged pumping, ankle-arm index less than 1.0, and insertion method. Signs and symptoms of leg ischemia due to thromboembolus or compartment syndrome may occur in as high as 40 per cent of patients. Assessment, documentation, and teaching remain important aspects of the nurse's role in the prevention and detection of vascular complications.