Nursing Care of Patients Receiving: Intra-aortic Balloon Counterpulsation

The authors describe the indications for using IABC, potential risk factors and complications, the nursing care required, and education of patients and their families about IABC.Intra-aortic balloon counterpulsation (IABC) was introduced into clinical settings in 1967 for the treatment of cardiogenic shock.1 IABC is now used for more than 100 000 patients each year in the United States.2 In the past 3 decades, IABC has assumed a prominent role in the treatment of patients with a failing heart; the intra-aortic balloon catheter is the most widely used left ventricular assist device.3Patients receiving IABC require the same intense and expert nursing care required by all critically ill patients. In addition, specialized management is required to reduce the risk of complications and to minimize the morbidity associated with IABC. These acutely ill patients require nursing care based on specialized knowledge and skill. Prompt recognition and treatment of the sometimes life-threatening complications associated with IABC are essential. In this article, we describe the indications for using IABC, potential complications and the nursing care required, potential risk factors for complications, and education of patients and their families about IABC.To initiate IABC, a polyurethane, nonthrombogenic catheter is inserted, most commonly into the femoral artery, and threaded upward so that the distal tip of the catheter is in the thoracic part of the aorta just distal to the origin of the left subclavian artery. The proximal end of the catheter is connected to a balloon pump console that forces helium into and out of the balloon, inflating and deflating the balloon.Inflation occurs during the diastolic or resting phase of the heart. Displacement of blood, proximally to the aortic root and coronary arteries and distally to the systemic circulation, results in elevation of the diastolic pressure (Figure 1). Deflation occurs at the end of diastole just before the onset of the heart’s isovolumetric contraction (Figure 2). The displacement of the blood that occurs during inflation decreases the workload of the left ventricle by decreasing the systolic and aortic end-diastolic pressure or afterload. Thus, the mean pressures are elevated and tissue perfusion is improved.Although IABC was originally designed to assist patients in cardiogenic shock, the indications for IABC have expanded during the past 30 years because of continued research, the ease of catheter insertion, the increased availability of the technology, and a decrease in the size of the pump console.4 Table 1 lists many indications for IABC.The most common indication for use of IABC is low cardiac output due to left ventricular dysfunction. Low cardiac output can result from mechanical complications due to acute myocardial infarction or from left ventricular failure resulting in congestive heart failure.5,6 IABC is commonly used to relieve myocardial ischemia in such conditions as impending or acute myocardial infarction or unstable refractory or postinfarction angina.7 It has also been indicated for hemodynamic support during and after procedures such as angiography and angioplasty, for weaning from cardiopulmonary bypass, and as a bridge to and after heart transplantation.8,9When monitoring patients receiving IABC, critical care nurses must be alert for the possible occurrence of complications throughout the process. Table 2 lists potential complications attributed to IABC, including the nursing care and treatment for each. Each complication is addressed in more detail in the following sections.Limb ischemia is the most frequent complication of IABC.3 The primary causes are obstruction of a small or diseased femoral artery by the catheter, distal formation of a thrombus from direct arterial injury during insertion of the catheter, and thromboembolism.3Critical care nurses must complete an extensive peripheral vascular assessment before the intra-aortic balloon (IAB) catheter is inserted and should continue reassessments throughout the remainder of the patient’s stay in the hospital because long-term complications related to decreased perfusion to the extremity are not unusual. Nurses should start by assessing the skin’s color and temperature, observing for indications of poor perfusion and arterial insufficiency such as cyanosis, mottling, pallor, or coolness of each extremity. Then they should palpate the femoral, popliteal, dorsalis pedis, and posterior tibial pulses while marking the sites bilaterally with a permanent marker before the IAB catheter is inserted. Because 8% to 10% of persons in the general population do not have a palpable dorsalis pedis pulse,10 the absence of this pulse should be documented before the IAB catheter is inserted. The pulses are recorded on the assessment form by using numerical values to indicate the quality:A portable Doppler ultrasound device should be used to determine the presence or absence of distal pulses that are difficult to palpate, especially the dorsalis pedis and posterior tibial pulses. In addition, any neurological deficits or impairments of the lower extremities should be documented before the IAB catheter is inserted.Acute ischemia of the limb may produce the “6 P’s”: pain, pallor, pulselessness, poikilothermia (cold), paresthesia, and paralysis. Circulation checks of the femoral, popliteal, dorsalis pedis, and posterior tibial pulses should be completed every 15 minutes for the first hour after the catheter is inserted, every 30 minutes for the second hour, then every hour for 2 hours, and then every 4 hours thereafter until the catheter is removed. Bilateral capillary refill should be recorded in seconds.Circulation checks include using Doppler imaging to locate an impalpable pulse; comparing both lower extremities to detect differences or changes in color, temperature, and sensation; and using an ankle-brachial index to provide a more quantitative measurement of circulation. The ankle-brachial index is a noninvasive examination that provides objective baseline data for later comparison with subsequent measurements. It is a simple, painless, and objective method of detecting vascular changes in the lower limb associated with the patient’s subjective complaints.In order to measure the ankle-brachial index, the blood pressure cuff is put around the ankle above the malleolus. When the dorsalis pedis pulse has been located via Doppler imaging, the cuff is inflated in the usual manner until the Doppler signal is no longer heard. As the cuff is slowly deflated, the systolic pressure is recorded when the signal returns. The brachial systolic pressure is measured in the same manner and divided into the ankle systolic pressure to obtain the index11 (Table 3). Ideally, the IAB catheter is inserted into the leg that has the higher ankle-brachial index. Measurements of the ankle-brachial index can be useful in monitoring changes in blood flow to the limb, detecting the presence of acute ischemic changes, and monitoring progression of peripheral vascular disease.Maintaining body temperature, cardiac index, and systemic vascular resistance near normal levels is essential to promote maximum perfusion of the affected limb. Nitroglycerin can be applied topically to the limb in an attempt to increase blood flow if the limb becomes ischemic.4 In most cases, removal of the IAB catheter resolves the ischemia; rarely a partial or full amputation is necessary when irreversible, massive necrosis due to prolonged ischemia occurs.Critical care nurses must be alert for changes that can lead to compartment syndrome. Compartment syndrome is a condition in which increased pressure within a closed, unyielding fascial space reduces capillary blood flow to the point that the viability and function of the tissues enclosed in the fascia are at risk. The increase in pressure is due to increases in fluid pressure plus the contribution of cells, fibers, gels, and matrices. Compartment syndrome can be triggered by any condition that reduces capillary blood flow, such as difficulty of insertion of the catheter further reducing blood flow within small vessels, preexisting peripheral vascular disease, vasopressive drugs, lengthy periods of immobilization, and thrombosis.12 When an event occurs that affects the microvasculature, the result is diffuse ischemia within the compartment.Deep throbbing pain or pressure, paresthesia, and paralysis localized in the involved compartment are common complaints. The earliest objective findings of compartment syndrome are a swollen, palpably tense compartment, reflecting increased intracompartmental pressure. The compartment pressure may be high enough to cause nerve and muscle damage but not so high as to occlude the artery and obliterate peripheral pulses.Direct measurement of the pressure in the compartment is a more sophisticated method of quantifying the increase in compartmental pressure. A needle or catheter is inserted into the compartment, allowing direct measurement of the pressure. Normal capillary perfusion pressure is 25 mm Hg. Normal muscle tissue pressure is 0 to 12 mm Hg. When tissue pressure exceeds capillary perfusion pressure, the capillaries collapse. A compartment pressure of greater than 30 mm Hg is an indication of compartment syndrome that requires quick intervention, whereas a pressure of 70 mm Hg or higher requires acute surgical fasciotomy to avoid contractures or rhabdomyolysis with acute renal failure.12The anterior and lateral compartments are most often affected by chronic exertional compartment syndrome.12 The posterior compartment is deeper and does not respond as well or as quickly to fasciotomy as the other compartments. Elevation in the level of creatine phosphokinase is also used as an indicator of muscle ischemia in acute compartment syndrome. Early detection and surgical decompression of the affected area are crucial to avoid permanent damage of muscles and nerves and to increase the chances for functional recovery of the limb. The limb should be kept elevated at the level of the heart, and the patient’s hydration should be maintained at adequate levels. Mannitol has been used in some cases of compartment syndrome.12Dissection of the aorta is a serious complication of IABC that can be caused by trauma due to difficulty inserting, repositioning, or moving the catheter.4 Dissection occurs when the catheter causes a tear in the intimal wall of the aorta. The pressure within the aorta forces blood between the vascular layers. This forceful lengthwise channel of blood can strip the intimal layer from the adventitial layer along the aorta, resulting in obstruction of arterial branches along the path of the dissection or rupture of the aorta leading to catastrophic hemorrhage.Signs and symptoms of aortic dissection (Table 2) include patients’ reports of a ripping or tearing pain in the back or in the abdomen radiating to the back or chest. The peripheral pulses may be unequal, or blood pressure may vary between the right and left extremities. Peripheral pulses may decrease on one or both sides. Once the IAB catheter is inserted, cardiac output and renal function may decrease. Other indications of aortic dissection include decreases in blood pressure and hematocrit, signs and symptoms of shock, and an increase in abdominal girth. A chest radiograph will show mediastinal enlargement. Aortic dissection is an emergency complication commonly managed by surgical intervention.Complications arising from dislodgment of plaque or emboli in the femoral artery or aorta can occur at any point during IABC and result in an obstruction somewhere in the vasculature. Emboli that decrease capillary blood flow to the extremities could result in compartment syndrome, which has many of the same signs and symptoms as limb ischemia with symptoms of nerve compression. Emboli making their way to the cerebral circulation may cause an occlusion that evolves into neurological signs and symptoms of a cerebrovascular accident. Emboli that become lodged in the coronary arteries can lead to an acute myocardial infarction. Respiratory failure can occur if the emboli travel to the pulmonary artery. Prevention of this complication is key. Treatment generally consists of supportive care. Maintenance of ventilation, oxygenation, and anticoagulation with close monitoring are extremely important.After the IAB catheter is inserted, interventions to monitor for and prevent migration of the catheter are undertaken. The IAB catheter is positioned high in the aorta so that the lower end of the balloon does not compromise perfusion to the celiac, superior mesenteric, or renal arteries (Figure 1). On a chest radiograph, the proper position of the catheter is 2 cm below the origin of the left subclavian artery, or between the second and third ribs and above the renal arteries.2Migration of the IAB catheter during counterpulsation is a concern. Once inserted, the catheter should be taped securely, and the length of the catheter from the insertion site to the proximal end should be marked for reference. The patient should be instructed to lie flat, keeping the affected leg still and straight; a long leg or knee immobilizer can be used if necessary. The catheter may migrate as much as 1 to 4.5 cm when the patient sits up.2 The head of the bed should be elevated to no more than 30°, and flexion of the patient’s hip should be avoided.Inward migration of the IAB catheter creates the potential for occlusion of the subclavian or the carotid artery. Such occlusion will result in unequal or absent radial pulses and dampening or loss of the arterial waveform in the radial artery. The upper extremities must be assessed and documented before the catheter is inserted. The patient’s hands and extremities should be assessed for color, temperature, sensitivity, and motion along with the rate and rhythm of the radial pulses bilaterally. If the carotid artery becomes occluded, changes will be apparent in the patient’s level of consciousness, mental alertness, and orientation, or the patient may have unilateral neurological deficits. Outward migration of the IAB catheter may result in occlusion of the renal artery. Indicators of renal artery occlusion include the patient’s report of abdominal, back, or flank pain, fever, nausea, vomiting, or anorexia, followed by a decrease in renal output. The treatment for balloon migration is for the physician to reposition the catheter if possible or to remove the catheter and insert a new one.Another potential complication that can occur during any part of IABC is systemic or local bleeding. Thrombocytopenia from the use of anticoagulants in patients requiring IABC reduces the risk for thromboembolic complications but can increase the risk of bleeding. Thrombocytopenia also can be a result of platelet destruction due to the mechanical trauma that occurs during the inflation of the IAB catheter against the wall of the aorta. Hemoglobin level, hematocrit, platelet count, prothrombin time, and partial thromboplastin time must be monitored closely for changes that could indicate bleeding or the potential for bleeding.Indications of bleeding may be manifested as bruising or a hematoma at the insertion site or by an increase in the girth of the thigh. The patient may not initially be hypotensive, but becomes tachycardic and has a decrease in hemoglobin level and hematocrit. Retroperitoneal bleeding may be manifested by the patient becoming hypotensive and complaining of back, flank, or abdominal pain unrelieved by changes in position. The pulse distal to the catheter may be absent because of blood loss, a situation that requires immediate surgical intervention.Several factors can be checked in an effort to avoid bleeding complications when the IAB catheter is removed. Prothrombin and partial thromboplastin times should be less than 1.5 times the control; the activated clotting time should be greater than 200 seconds; and administration of anticoagulants should be stopped 1 to 4 hours before the catheter is removed. The physician should apply pressure above and below the site of insertion while removing the sheath and the catheter simultaneously, usually allowing the insertion site to bleed vigorously for 1 to 2 seconds to remove any clots at the site. The physician may choose to deploy a vascular hemostasis device.13The extremity must be evaluated closely for signs of ischemia for 24 hours after the catheter is removed. Once the IAB catheter is removed, pressure should be applied to the puncture site for 20 to 30 minutes continuously, or until hemostasis is achieved. Then a 4.5-kg (10-lb) sandbag and a compression bandage can be applied for 2 hours. The patient should be instructed to remain on bed rest for a minimum of 8 hours after removal of the catheter and to avoid exercising the extremity so as to prevent bleeding. Treatment for bleeding includes administration of platelets, blood cells, and other blood as or in the IAB catheter are indications of balloon When the catheter balloon immediate recognition of the rupture and removal of the IAB catheter are If the is a small the catheter may not any The balloon pump may indicate a or with inflation of the catheter may be blood in the catheter, the same potential for a or for of the IAB When the balloon with blood that a and the balloon As a the catheter be Treatment for an balloon is usually surgical the can be with a allowing the physician to the blood and remove the catheter by femoral artery second most frequent complication of IABC is at the catheter insertion which is manifested by fever, local and of are the same as with any elevation of body elevation of blood at the with and blood that show of and indications of primary of critical care nurses is of must be throughout the insertion during of the catheter, and when the insertion of their chronic disease, and tissue patients receiving IABC are for of pressure These patients generally have because of mechanical ventilation, or and hemodynamic The presence of the IAB catheter in the femoral artery patients to a decrease in tissue perfusion to the affected or such as that are designed to low tissue pressure reduce or pressure to a level below that of capillary pressure. should be every 1 to 2 hours to promote adequate and hydration also in the skin’s when a patient’s is essential for factors that can patients to the of complications related to IABC. from patients’ can assist critical care nurses in which patients are more to have complications related to IABC. Table 4 lists factors that put patients at risk for of such limb ischemia is more to in than in when the IAB catheter is inserted via the femoral This increased risk for peripheral vascular complications is often attributed to the differences between and in the of the femoral artery. The in increases the for blood flow and the risk of peripheral vascular is a if not the risk for the of vascular complications associated with factors to peripheral vascular include and Because of the peripheral vascular associated with the of lower limb ischemia is as much as times higher in patients than in patients when an IAB catheter is inserted in the femoral The patient’s lower extremities should be assessed for signs of poor perfusion such as loss of leg pallor, and ischemia of the lower limb in patients receiving IABC is 3 times more in than in patients have a higher of vascular complications than do Other risk factors such as low cardiac index, elevated systemic vascular and the use of are related to the of lower limb patients and patients’ families about IABC is to for the the patients will and to reduce patients and their families the of IABC and the patients’ is increases that patients will while receiving IABC should be If the catheter is inserted via the femoral artery, the patient will be on complete bed rest with the head of bed to no more than should be to apply an immobilizer to of the limb that has the catheter insertion site. must be at every 2 hours to prevent and promote should to patients and patients’ families that bleeding may occur at the catheter insertion site. should be to put pressure on the insertion site when or and to the if they pain in the lower back or a pain, or at the insertion and their families should be instructed to report symptoms of peripheral changes pallor, and to a while in the hospital and to a physician after from the patients should that if any pain in the extremity occurs when or while at especially at a physician should be and their families must that such a is serious and requires immediate and treatment to prevent possible tissue and their families must be to the patients’ for or especially on the or around any pressure and patients should be instructed to enough to avoid pressure on the and their families should that any of the changes, if must be to the of a physician the of IABC in 1967 for the treatment of cardiogenic shock, the IAB catheter has become the most widely used left ventricular assist IABC is not risk to must the against the before using IABC. Nurses for critically ill patients must be of potential patients are at high risk for possible complications of care nurses must be and in assessing circulation in the lower extremity. and assessment of the extremities is essential and after IABC. Because of the potential for long-term vascular complications related to the use of IABC, the peripheral vascular assessment should continue for at after the IAB catheter is removed. It should become a part of each patient’s especially if the patient has preexisting peripheral vascular the use of IABC, and management of complications must be the of care. The of the nursing assessment and interventions to minimize morbidity associated with IABC be Because of the high the of cases, and the of their critical care nurses must the nursing care and potential complications related to for patients receiving IABC. As more is and the data will and can be to prevent complications related to IABC.