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Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Cardiovascular and Infusion

Intra-Aortic Balloon Pump (IABP) Set-Up, Insertion, Operation and Maintenance (Adult) (1.34A)

Intra-Aortic Balloon Pump (IABP) Set-Up, Insertion, Operation and Maintenance (Adult) (1.34A) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.34A

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
November 30, 2016


Administrative Manual
Nursing Manual (Red)
Other

Policy #: 1.34A

Original
Revision

Page
1
of 11

Title: Intra-Aortic Balloon Pump (IABP)
Set-Up, Insertion, Operation and
Maintenance (Adult)

I. PURPOSE

The purpose of the intra-aortic balloon pump (IABP) therapy is to reduce cardiac oxygen
demand and increase oxygen supply by decreasing the resistance of ventricular ejection and
improving myocardial oxygenation.

II. POLICY

A. In order to be able to care for the patient with an IABP, the critical care nurse shall attend
a workshop and/or demonstrate competence on the rationale, set-up, operation, trouble-
shooting and assistance with insertion and discontinuation of IABP therapy.
B. Until a nurse demonstrates competence in caring for the patient with an IABP, the critical
care Registered Nurse (RN) will work with a more experienced critical care RN who has
demonstrated competence in IABP therapy.
C. The critical care RN must demonstrate competency on an annual basis to care for the
patient with an IABP.
D. The provider or mid-level provider is responsible for insertion and removal of the IAB
catheter.
E. The central lumen of the IAB catheter should be flushed or have blood drawn while the
IABP is on stand-by.
F. Pressure trigger should not be used for patients with irregular heart rates. Pacing (A/V or
A) trigger should not be used unless patient is 100% paced.
G. No manual timing is allowed in the Intensive Care Units (ICUs).
H. IAB consoles are located primarily in the Heart and Vascular Care Procedure Center (3),
operating room (1), and B4/5 (1).

III. PROCEDURE

A. Equipment for bedside insertion
1. IABP console with ECG cable, pressure cable
2. IAB catheter and insertion kit
3. Fluoroscopy cart/bed and equipment, if requested by the provider – lead aprons
and sterile fluoroscopy cover
4. Sterile gowns x 4, gloves and drapes
5. Caps and masks
6. Clipper
7. 2% chlorhexidine solution
8. Sterile normal saline (bottle)
9. Sterile 4x4s


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10. Sterile basin
11. Xylocaine 1% and Xylocaine 1% with epinephrine
12. Safety scalpel
13. Stabilization device (StatLock) specific for IAB catheters
14. Arterial pressure monitoring equipment (transducer, normal saline bag and
pressure bag)
15. Chlorhexidine patch (Biopatch) and transparent dressing or CHG impregnated
dressing
B. Pre-insertion
1. Explain procedure and post procedure care to patient. Provider is to obtain patient
consent before the procedure (unless in an emergency). Refer to UWHC Hospital
Administrative Policy 4.17, Informed Consent.
2. Make sure all pre-procedure blood work is drawn (especially INR and PTT).
3. Set up pressure tubing for an arterial line according to UWHC Nursing Patient
Care Policy 1.11A, Arterial Catheter/Insertion, Maintenance, Blood Drawing and
Discontinuation (Adult).
4. Assess the following as a baseline prior to the insertion of the IABP catheter:
a. Skin color and temperature of extremity on side IABP will be inserted
b. Heart rate
c. Respiratory rate
d. Blood pressure
e. Cardiac output
f. Cardiac index
g. Systemic vascular resistance (if pulmonary artery catheter is in place and
according to provider order)
h. Urine output and bilateral peripheral pulses (mark location)
5. Clip hair as directed by the provider (usually the umbilicus to both groins).
6. Assist provider with patient positioning, preparation of insertion site and
maintenance of sterile technique. Clinicians within close proximity to the sterile
field must wear all four (4) components of personal protective equipment prior to
insertion of line. Refer to UWHC Hospital Administrative Policy 12.44, Personal
Protective Equipment.
C. IABP Set-Up
1. Console Preparation
a. Plug IABP console into red wall outlet and ascertain power is getting to
the IABP (check that green power light is illuminated).
b. Check/turn on helium, making sure it is greater than 200 pounds per
square inch (PSI). If helium is below 200 PSI, have the tank replaced by
cath lab staff.
c. On the IABP, turn power “ON”.
i. Select mode (auto or semi-auto). Auto is preferred mode.
ii. Select trigger. EKG is preferred trigger.
iii. Ensure inflation/deflation timing is at midpoint if in semi-auto
mode.
iv. Check that the following are all on “AUTO”:
• Slow gas alarm
• IAB fill
• Timing


Page 3 of 11

d. Prime pressure tubing.
2. Patient Preparation
a. ECG trigger: Attach electrodes to the patient if time permits.
b. Pressure trigger: If unable to attach the electrodes, use pressure as the
trigger.
D. IAB Catheter Insertion
1. Assist the provider with the procedure as directed. Provider will determine size of
balloon catheter.
2. Perform and document the universal protocol (time out). Refer to UWHC
Hospital Administrative Policy 8.48, Operative, Invasive & Other Procedures.
3. Continually monitor the patient’s physical and emotional status for any
complaints (especially back pain which may signify aortic dissection), cardiac
rhythm, peripheral pulses and vital signs during the procedure.
4. Type of intra-aortic balloon (IAB) catheter:
a. Conventional IAB catheter insertion:
i. Connect the arterial transducer tubing to the catheter’s central
lumen .
ii. Connect the transducer to the console’s pressure cable.
iii. Zero the transducer
iv. Connect pneumatic tubing to the console
b. Fiberoptic IAB catheter insertion:
i. Connect fiberoptic cable into the fiberoptic port of the console
ii. Connect pneumatic tubing to the console
5. Flush IAB central lumen before initiating pumping.
6. Attach IAB tubing to the IABP safety chamber/disc.
7. Autofill and press START.
8. Augmentation will increase to the maximal level automatically. Adjust as directed
by the provider.
9. Set augmentation alarm to 10 mmHg below patient’s augmented pressure.
10. Obtain an order for a portable chest x-ray as ordered by the provider.
11. If able, place the IABP in standby while taking a chest x-ray. Resume pumping
as soon as the x-ray has been taken.
12. Determine amount of catheter is at the skin exit site and document.
13. Apply a sterile dressing with antimicrobial disc and transparent dressing or CHG
impregnated dressing over the IAB insertion site, after the IAB is secured with
securement device (StatLock®) or sutures.
14. Catheter placement is confirmed by the provider or credentialed practitioner with
chest x-ray. Document pump settings, alarm settings, and pressures on the IABP
flowsheet of the clinical record. Document site, dressing, patency, and waveform
conditions in the IV flowsheet.
15. Post insertion, monitor patient vital signs and site as ordered (usually every 15
minutes x 4, every 30 minutes x 2, then once every hour).
E. IAB Operation
1. Provider will determine which parameter (pump mean arterial pressure [MAP],
monitor MAP, etc.) to use to titrate vasoactive infusions.
2. Optimize IABP timing on 1:2, comparing assisted and unassisted arterial
pressures, and then return IABP timing to ordered frequency (may use for
conventional and possibly fiberoptic IAB catheters).


Page 4 of 11

a. Optimal balloon timing is achieving the following:
i. Augmented pressure greater than unassisted systole and
assisted systole
ii. Unassisted systole greater than assisted systole
iii. Unassisted diastole greater than assisted diastole
iv. “V” shape where dicrotic notch and augmentation meet
v. “U” shape at assisted diastolic pressure on waveform
vi. Does not meet any of the characteristics for timing errors

Normal IABP Waveform with 1:2 Timing:


























MAP (if HR 60) = Systolic BP + (2 x Diastolic BP)
3

3. Inflation
a. Identify the dicrotic notch of the arterial waveform.
b. Slowly adjust inflation earlier until the dicrotic notch disappears and a
sharp “V” wave forms.
c. Optimal Inflation timing:
i. “V” at dicrotic notch
ii. Augmented pressure greater than unassisted systole and
assisted systole
iii. Unassisted systole greater than assisted systole
A
Mm
Hg120

100




80
Increased Coronary Artery Perfusion
B
C
D
E
F
A. One Complete Cardiac Cycle
B. Unassisted Aortic End Diastolic Pressure
C. Unassisted Systolic Pressure (Dicrotic Notch – Sharp “V”)
D. Diastolic Augmentation – coronary perfusion
E. Reduced (assisted) Aortic End Diastolic Pressure – afterload reduction
(unloading 5-15 mmHg)
F. Reduced (assisted) Systolic Pressure – Monitor MAP for Systemic
Perfusion

↓ Myocardial
O
2
Demand
A


Page 5 of 11

iv. Doesn’t meet any of the characteristics for inflation timing
errors
d. Inflation Timing Errors:







































4. Deflation
a. Set deflation so the assisted end diastolic pressure is less than the
unassisted end diastolic pressure and as low as possible (diastolic
reduction).
b. Set deflation so the assisted systolic pressure is less than the unassisted
systolic pressure (systolic reduction) while maintaining optimal diastolic




Unassisted
Systole
Diastolic
Augmentation
Assisted Aortic End
Diastolic Pressure
Assisted
Systole
Early Inflation

Inflation of the IAB prior to aortic valve
closure

Waveform Characteristics:
 Inflation of IAB prior to dicrotic
notch
 Diastolic augmentation encroaches
onto systole (may be unable to
distinguish)

Physiologic Effects:
 Potential premature closure of aortic
valve
 Potential increases in LV end-
diastolic volume and LV end-diastolic
volume pressure or PAWP
 Increased left ventricular wall stress
or afterload
 Aortic regurgitation
 Increased MVO
2
demand

Unassisted
Systole
Diastolic
Augmentation
Assisted
Systole
Dicrotic
Notch
Assisted Aortic End
Diastolic Pressure
Late Inflation

Inflation of IAB markedly after closure of
the aortic valve

Waveform Characteristics:
 Inflation of the IAB after the dicrotic
notch
 Absence of sharp V
 Sub-optimal diastolic augmentation

Physiologic Effects:
 Sub-optimal coronary artery
perfusion


Page 6 of 11

augmentation and without impeding the next systole.
c. Optimal timing:
i. Augmented pressure greater than unassisted systole
ii. Unassisted systole greater than assisted systole
iii. Unassisted diastole greater than assisted diastole
iv. “U” shape at assisted diastolic pressure on waveform
v. Does not meet criteria for deflation timing errors
d. Deflation Timing Errors:







Diastolic
Augmentation
Assisted
Systole
Assisted
Aortic End
Diastolic
Pressure
Unassisted
Aortic End
Diastolic
Pressure
Early Deflation

Premature deflation of the IAB during
the diastolic phase

Waveform Characteristics:
 Deflation of IAB is seen as a sharp
drop following diastolic
augmentation
 Sub-optimal diastolic augmentation
 Assisted aortic end diastolic
pressure may be equal to or less
than the unassisted aortic end
diastolic pressure
 Assisted systolic pressure may rise

Physiologic Effects:
 Sub-optimal coronary perfusion
 Potential for retrograde coronary
and carotid blood flow
 Angina may occur as a result of
retrograde coronary blood flow
 Sub-optimal afterload reduction.
 Increased MVO
2
demand


Page 7 of 11























5. Maintenance
a. Every hour until hemodynamic stable or as ordered by the provider and as
needed. Assess:
i. IABP timing (with pump on 1:2 frequency) and trigger
ii. Augmentation level
iii. Augmentation alarm is approximately 10 mmHg less than
augmented diastolic pressure
iv. Pressures: mean arterial, unassisted systolic, assisted systolic,
augmented diastolic, unassisted diastolic and assisted diastolic
pressures
v. Vital signs
vi. Peripheral circulation (sensation, temperature and pulses)
vii. Tubing for signs of IAB catheter rupture
viii. Check amount of catheter at the skin exit site
ix. Urine output
b. Assess catheter site every two (2) hours after the initial post insertion
groin and vascular checks.
c. Assess IABP timing whenever the heart rhythm changes and whenever the
heart rate increases or decreases by 10 beats per minute while on pressure
timing.
d. Every two (2) hours or as ordered by the provider and as needed. Assess:
i. Patient’s neurologic status
ii. Hemodynamics: pulmonary artery, central venous, and
pulmonary artery wedge pressures; cardiac output, cardiac
index, and systemic vascular resistance (if applicable)
iii. Catheter site

Unassisted
Systole
Diastolic
Augmentation
Widened
Appearance
Assisted Aortic End
Diastolic Pressure
Prolonged Rate
of Rise of
Assisted
Systole
Late Deflation

Deflation of the IAB late in diastolic
phase as aortic valve is beginning to open

Waveform Characteristics:
 Assisted aortic end-diastolic pressure
may be equal to or greater than the
unassisted aortic end diastolic
pressure
 Rate of rise of assisted systole is
prolonged
 Diastolic augmentation may appear
widened

Physiologic Effects:
 Afterload reduction is essentially
absent
 Increased MVO
2
consumption due to
the left ventricle ejecting against a
greater resistance and a prolonged
isovolumetric contraction phase
 IAB may impede left ventricular
ejection and increase the afterload



Page 8 of 11

e. Every eight (8) hours:
i. Verify console is plugged into red outlet
ii. Helium level in tank
iii. 60 mL syringe and stopcock on console
iv. Spare extension tubing available on unit (supplies are from
cath lab)
f. The head of the bed may be elevated to max 30 degrees. Consider placing
sign above the bed.
g. Turn the patient via log roll the patient every 2 hours and as needed.
Monitor skin for signs of deep tissue injury or pressure ulcer development.
h. The patient is on strict bed rest with the IABP in place.
i. Ascertain that the patient does not bend his/her leg while IAB catheter is
in. Consider using a leg immobilizer or medications as ordered by
provider.
j. Put the balloon on standby every four (4) hours and flush the central
lumen for 15 seconds. Then, resume pumping.
k. If IABP catheter is in standby for 30 minutes or longer, follow
manufacturer’s guidelines.
l. Change site dressing according to UWHC Nursing and Patient Care Policy
1.56 AP, Central Vascular Access Device Use, Maintenance and Removal
(Adult & Pediatric)
m. At change of shift, perform line reconciliation during bedside report.
6. Weaning and Removal of the IAB Catheter
a. Wean the IABP by decreasing the IABP frequency (to 1:2 or 1:3) and/or
decreasing the IABP augmentation volume, as ordered by the provider. If
weaning by decreased augmentation, the augmentation should not get
below 50% of maximum.
b. While weaning the IABP, assess the patient’s vital signs, hemodynamics
(if patient has a pulmonary artery catheter), heart rhythm, urine output,
neurological status and presence of chest pain/pressure. Notify the
provider of any significant changes.
c. Heparin drip should be stopped prior to removal as ordered by provider if
applicable.
d. IAB Catheter removal:
i. Assist the provider with the removal of the IAB.
ii. The provider will achieve hemostasis with manual pressure or
by applying a compression device at the insertion site. Wean
compression device off according to provider orders.
iii. Assess the insertion site for signs of bleeding or hematoma
formation, vital signs, distal pulses every 15 minutes x 4, every
30 minutes x 2, then every hour x 4, and as needed.
iv. Clean equipment according to UW Health Clinical Policy
4.1.7, Cleaning, Disinfection and Sterilization of Patient Care
Devices and Equipment.
F. Documentation
1. Document patient and pump information (see section III.E.5.a-d above) in the
IABP flowsheet of the clinical record.
2. Document other patient information in the designated areas of the clinical record.


Page 9 of 11

G. Special Instructions
1. If patient with conventional IAB catheter is admitted to UWHC, follow the
following steps to connect the catheter properly to the console.
a. Obtain console.
b. Place IAB electrodes on the patient’s chest in addition to the EKG leads
needed for the room monitor.
c. Connect IAB console pressure cable and adaptor to the patient’s
transducer and zero. Flush the transducer.
d. Connect pneumatic tubing to the safety disc and hit START.
e. Assess waveform timing.
2. Battery Operation: A fully charged battery can support IAB therapy for 60
minutes. IABP Failure: In the event of IABP mechanical failure, proceed with the
following (as necessary):
a. Remove the IAB connector cable, attach a 60 mL syringe to a 3-way
stopcock and rapidly inflate and deflate the balloon with 40 mL once
every minute. Hand pumping to be continued until new console arrives
and transferred over. Follow manufacturer’s guidelines.
b. Contact provider immediately. To obtain another IABP console:
i. Check or call B4/5 unit (263-8720) for spare console
ii. Contact Heart and Vascular Care Procedure Center charge
nurse during business hours (513-8562) or
iii. Contact the nursing supervisor to assist in obtaining one from
cath lab. Follow UWHC Nursing Patient Care Policy 8.39AP,
Repair or Replacement of Essential Equipment in Case of
Breakdown.
c. Connect the IAB to another IABP console following same steps in III.D.4-
9.
d. Notify the Clinical Engineering Department.
3. IAB “Rupture”: In the event the IAB “ruptures” (this is demonstrated by blood or
rust flakes within the balloon pneumatic tubing), place the IAB console on
standby, clamp the IAB catheter and notify the provider immediately. Prepare for
IAB removal (the IAB needs to be removed within 30 minutes).
4. Timing in Atrial Fibrillation: While in ECG trigger, set the timing to the majority
of the patient’s heartbeats, or adjust the deflation all the way to the right (the IAB
will automatically deflate on the R wave). ECG trigger preferred despite the mode
used. Pressure trigger should not be used for any irregular rhythm.
5. Emergency/Code: Ensure the balloon is inflating and deflating. If so, then
continue to monitor the patient and balloon pump for pumping action.
a. If the balloon is not inflating, change the trigger to pressure. With
effective CPR, the balloon should inflate with compressions while in the
pressure trigger.
b. If the balloon is still not inflating, then change the trigger to internal or
initiate hand pumping.
c. Defibrillation: In the event the patient needs external defibrillation, the
console is electrically isolated. It is safe to defibrillate the patient with the
IABP connected to the patient and pumping. Avoid contact with the IABP
console when defibrillating the patient.
d. With successful resuscitation, verify IABP timing is optimal. Assess and


Page 10 of 11

document cardiac rate and rhythm, IABP pressures, vital signs, peripheral
pulses, and waveform characteristics. Verify trigger and augmentation
alarm is set approximately 10 mmHg less than augmented diastolic
pressure.

6. Fiberoptic Sensor Module Failure:

There has been a failure of the
internal Fiber-Optic Sensor Module in
the IABP
• If a MAQUET/Datascope fiber-optic
IAB is NOT in use, continue normal
IAB use
• If a MAQUET/Datascope fiber-optic
IAB is in use, replace IAB with
another MAQUET/Datascope IABP
that supports the fiberoptic IAB
• If a replacement IABP is not
available, provide alternate A.P.
source (i.e., radial)
• Contact MAQUET Service for Fiber-
Optic Sensor Module repair

7. Fiberoptic Sensor Failure:
There is a failure in communication
of the Fiber-optic sensor signal with
the IABP
• Unplug Fiber-Optic Sensor
Connector and reconnect
• Relieve any visible kinks in orange
Fiber-Optic Cable
• If problem persists, disconnect Fiber-
Optic Sensor Connector and provide
alternate A.P. source (i.e., radial)

IV. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 4.17, Informed Consent
B. Hospital Administrative Policy 8.48, Operative, Invasive & Other Procedures
C. Hospital Administrative Policy 12.44, Personal Protective Equipment
D. UW Health Clinical Policy 4.1.7, Cleaning, Disinfection and Sterilization of Patient Care
Devices and Equipment
E. Nursing and Patient Care Policy 1.11A, Arterial Catheter/Insertion, Maintenance, Blood
Drawing and Discontinuation (Adult)
F. Nursing and Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric)
G. Nursing and Patient Care Policy 8.39AP, Repair or Replacement of Essential Equipment
in Case of Breakdown (Adult & Pediatric)

V. REFERENCES

A. Castellucci, D. (2011). Intraaortic balloon pump management. In D. Wiegand (Ed.),
AACN procedure manual for critical care (6
th
Ed.). St. Louis, MO: Elsevier-Saunders.


Page 11 of 11

B. Goldich, G. (2011). Getting in sync with intra-aortic balloon pump therapy. Nursing, 41
Suppl, 10-13. doi: 10.1097/01.NURSE.0000406632.71036.e0
C. Hanlon-Pena, P. M., & Quaal, S. J. (2011a). Intra-aortic balloon pump timing: review of
evidence supporting current practice. American Journal of Critical Care, 20(4), 323-333;
quiz 334. doi: 10.4037/ajcc2011542
D. Hanlon-Pena, P. M., & Quaal, S. J. (2011). Resource document: evidence supporting
current practice in timing assessment. American Journal of Critical Care, 20(4), e99-
e102. doi: 10.4037/ajcc2011136
E. Lewis, P. A., Ward, D. A., & Courtney, M. D. (2009). The intra-aortic balloon pump in
heart failure management: implications for nursing practice. Australian Critical Care,
22(3), 125-131. doi: 10.1016/j.aucc.2009.06.005
F. Parissis, H. (2007). Haemodynamic effects of the use of the intraaortic balloon pump.
Hellenic Journal of Cardiology. Hellenike Kardiologike Epitheorese, 48(6), 346-351.
G. Parissis, H., Soo, A., & Al-Alao, B. (2011). Intra aortic balloon pump: literature review
of risk factors related to complications of the intraaortic balloon pump. Journal of
Cardiothoracic Surgery, 6, 147. doi: 10.1186/1749-8090-6-147
H. Reid, M. B., & Cottrell, D. (2005). Nursing care of patients receiving: intra-aortic balloon
counterpulsation. Critical Care Nurse, 25(5), 40-44, 46-49.
I. The Joint Commission (2004). Universal Protocol.
http://www.jointcommission.org/standards_information/up.aspx
J. Yarham, G., Clements, A., Morris, C., Cumberland, T., Bryan, M., Oliver, M., . . .
Mulholland, J. (2013). Fiber-optic intra-aortic balloon therapy and its role within cardiac
surgery. Perfusion, 28(2), 97-102. doi: 10.1177/0267659112454156
K. http://www.maquet.com/us/products/cardiosave-iabp-hybrid/?ccid=195. Accessed on
November 11, 2016.

VI. REVIEWED BY

Clinical Nurse Specialist, Cardiology
Clinical Nurse Specialist, Cardiac Surgery, Cardiopulmonary Transplant and Mechanical
Circulatory Device Programs
Clinical Nurse Specialist, Cath Lab
Nursing Patient Care Policy and Procedure Committee, November 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer