Intra-Aortic Balloon Pump Insertion

[waterski232002]

Has anyone ever inserted an Intra-Aortic Balloon Pump emergently in the ED... or anywhere else for that matter (CCU, OR, etc). How do you do it? Any advice or tips/tricks? What good resources are there for reading about the procedure? It's not listed in Roberts and Hedges.

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[kungfufishing]

Weird I just had this conversation with another resident in my class. Unfortunately, neither of us have the answer either.

 

[leviathan]

Has anyone ever inserted an Intra-Aortic Balloon Pump emergently in the ED... or anywhere else for that matter (CCU, OR, etc). How do you do it? Any advice or tips/tricks? What good resources are there for reading about the procedure? It's not listed in Roberts and Hedges.

Insertion

1. heparinise patient prior to insertion of catheter providing there are no contraindications such as recent surgery. After cardiac surgery patient should be given low-molecular weight dextran at 20 ml/hr instead of heparin. (Do not exceed total daily dose of 10 ml/kg)
2. prep skin
3. fully collapse balloon applying 30 ml vacuum with 60 ml syringe
4. insert needle into femoral artery at 45° and pass it through both walls of artery. Withdraw needle until strong pulsatile jet of blood is obtained
5. pass guidewire through needle and advance until tip is is in thoracic aorta. Wire should pass very easily
6. pass sheath over wire in similar manner to insertion of PA catheter sheath
7. pass balloon over guidewire through sheath. Must be inserted to at least the level of the manufacturer’s mark (usually double line) to ensure that entire balloon has emerged from sheath
8. balloon should be positioned so that the tip is about 1 cm distal to the origin of the left subclavian artery. If fluroscopy is not available during insertion the distance from the angle of Louis down to the umbilicus and then to the femoral artery insertion site should be measured to approximate the distance the balloon should be advanced and the position should be checked on CXR
9. remove wire. Return of blood via central lumen confirms that the tip is not subintimal and has not caused a dissection.
10. flush central lumen with heparin saline and connect to transducer to monitor intra-aortic pressure
11. monitor Doppler ankle pressures and compare with preinsertion value

Balloon pump timing

* using central aortic pressure waveform and ECG identify dicrotic notch (aortic valve closure)
* determine time delay between R wave and aortic valve opening and closure and enter these values into the pump
* turn on pump and compare assisted and unassisted waveforms to determine whether timing is optimal (figure 1)
* if inflation is too early or deflation too late the balloon waveform is superimposed to varying degrees over the LV systolic component of the central aortic pressure waveform (ie inflation starts when the aortic valve is still open). This results in an increase in afterload which may result in premature valve closure and increase LV work. Also, ventricular emptying is incomplete, stroke volume decreased, cardiac output decreased and myocardial oxygen demand increased. In addition, can increase shunting in patients with a septal defect
* if inflation is too late or deflation is too early diastolic augmentation is suboptimal
* balloon inflation can be triggered by R wave, arterial waveform or pacing spike. Latter is a potentially lethal mode as loss of capture may result in balloon inflation during systole as the pump will continue to follow the pacing rate rather than the ventricular contraction rate

 

[TPS report]

Has anyone ever inserted an Intra-Aortic Balloon Pump emergently in the ED... or anywhere else for that matter (CCU, OR, etc). How do you do it? Any advice or tips/tricks? What good resources are there for reading about the procedure? It's not listed in Roberts and Hedges.

uhhh...yikes! 😱 I think I would try to speed dial the nearest attending or cards or CT surg? 😕 😕 😕

 

[dchristismi]

The last time I did this, my protocol was a follows:

1) Pick up phone
2) Stat call on-call interventional cards (We have a special number for emergent cath lab issues)
3) Whisk patient to cath lab for IABP/definitive management

 

[waterski232002]

The last time I did this, my protocol was a follows:

1) Pick up phone
2) Stat call on-call interventional cards (We have a special number for emergent cath lab issues)
3) Whisk patient to cath lab for IABP/definitive management

And if Interventional Cards isn't in house???? Or you don't have a cath lab (like the majority of hospitals in the country)?

 

[deleted87716]

That reminds me of something that happened when I was in residency (FM)...

Middle of the night, crashing CCU patient with maxed-out pressors, etc. Page the cardiology attending. He's half-asleep, sounds a little pissed that I woke him up. I rattle off the particulars. He curses and mumbles, "OK...why don't you go ahead and put in an aortic balloon pump...I'll be there in a couple of hours." Long silence from me. "Uh...an aortic balloon pump...? I've never even seen one of those before." Heavy sigh from the cardiologist. "Fine...I'll be there in a few minutes." *Click.*

Yeeeeeah...he might as well have asked me to go ahead and take the guy to the cath lab.

 

[dchristismi]

And if Interventional Cards isn't in house???? Or you don't have a cath lab (like the majority of hospitals in the country)?

Which is why I prefaced that with "last time I did this..." 😎

Leviathan, thanks for the overview. Is this even within our scope of practice? I think I would be more concerned with the timing aspect than the placement... and now that you have this balloon in there, what next? Just thinking about some of my rural experiences - if you don't have interventional cards on a relatively routine basis, where are you going to find nurses who are going to monitor and care for this critically ill patient and are familiar with the machines? (assuming the helicopters aren't flying, which would inevitably be the case)

And now that I think about it, would you even have the necessary equipment to do this if you don't have an in-house cath lab?

 

[FoughtFyr]

Which is why I prefaced that with "last time I did this..." 😎

Leviathan, thanks for the overview. Is this even within our scope of practice? I think I would be more concerned with the timing aspect than the placement... and now that you have this balloon in there, what next? Just thinking about some of my rural experiences - if you don't have interventional cards on a relatively routine basis, where are you going to find nurses who are going to monitor and care for this critically ill patient and are familiar with the machines? (assuming the helicopters aren't flying, which would inevitably be the case)

And now that I think about it, would you even have the necessary equipment to do this if you don't have an in-house cath lab?

It is in our scope, but only as a "hail mary" pass. Most of the programs with flight learn to "use" a IABP that is already in place, but inserting one would be a bear. While I'm pretty sure we can I don't know that I would.

- H

 

[whasupmd2]

What about these? Who's done them? What do you use?

 

[waterski232002]

It is in our scope, but only as a "hail mary" pass. Most of the programs with flight learn to "use" a IABP that is already in place, but inserting one would be a bear. While I'm pretty sure we can I don't know that I would.

- H

I agree with FoughtFyr... I do think that it should become a growing part of EM. The few pts I've seen in the ER/CCU who have acute decompensation from MR only get worse with medical management. Pressors and Fluids only act to increase afterload further flooding the lungs and making the patient more unstable. An IABP is what will save their life... And they may not be able to wait 30 min for a cardiologist to get in house.

We definitely CAN place one... but I agree that most of us wouldn't.... Probably mostly due to lack of education, experience, training, and fear of what we are not used to.

I think that as EP's get more comfortable and better at cardiac ultrasound (looking at regurgitation and ventricular fxn in addition to effusions), IABP insertion in the ER may become more of a reality. Most of these patients don't get their diagnostic TTE until they're in the CCU. Of course, this is probably a long ways away.

 

[waterski232002]

Insertion

1. heparinise patient prior to insertion of catheter providing there are no contraindications such as recent surgery. After cardiac surgery patient should be given low-molecular weight dextran at 20 ml/hr instead of heparin. (Do not exceed total daily dose of 10 ml/kg)
2. prep skin
3. fully collapse balloon applying 30 ml vacuum with 60 ml syringe
4. insert needle into femoral artery at 45° and pass it through both walls of artery. Withdraw needle until strong pulsatile jet of blood is obtained
5. pass guidewire through needle and advance until tip is is in thoracic aorta. Wire should pass very easily
6. pass sheath over wire in similar manner to insertion of PA catheter sheath
7. pass balloon over guidewire through sheath. Must be inserted to at least the level of the manufacturer’s mark (usually double line) to ensure that entire balloon has emerged from sheath
8. balloon should be positioned so that the tip is about 1 cm distal to the origin of the left subclavian artery. If fluroscopy is not available during insertion the distance from the angle of Louis down to the umbilicus and then to the femoral artery insertion site should be measured to approximate the distance the balloon should be advanced and the position should be checked on CXR
9. remove wire. Return of blood via central lumen confirms that the tip is not subintimal and has not caused a dissection.
10. flush central lumen with heparin saline and connect to transducer to monitor intra-aortic pressure
11. monitor Doppler ankle pressures and compare with preinsertion value

Balloon pump timing

* using central aortic pressure waveform and ECG identify dicrotic notch (aortic valve closure)
* determine time delay between R wave and aortic valve opening and closure and enter these values into the pump
* turn on pump and compare assisted and unassisted waveforms to determine whether timing is optimal (figure 1)
* if inflation is too early or deflation too late the balloon waveform is superimposed to varying degrees over the LV systolic component of the central aortic pressure waveform (ie inflation starts when the aortic valve is still open). This results in an increase in afterload which may result in premature valve closure and increase LV work. Also, ventricular emptying is incomplete, stroke volume decreased, cardiac output decreased and myocardial oxygen demand increased. In addition, can increase shunting in patients with a septal defect
* if inflation is too late or deflation is too early diastolic augmentation is suboptimal
* balloon inflation can be triggered by R wave, arterial waveform or pacing spike. Latter is a potentially lethal mode as loss of capture may result in balloon inflation during systole as the pump will continue to follow the pacing rate rather than the ventricular contraction rate

Leviathan....

What type of resident/attending are you? If you are EM, when have you placed an IABP?

 

[leviathan]

Leviathan....

What type of resident/attending are you? If you are EM, when have you placed an IABP?

Waterski, I am not in medicine yet. Critical care paramedics where I live can operate IABPs, but they cannot insert them. I know the EPs in this region can insert IABPs and the ones in more rural hospitals do so in cases where it is warranted before transport to a regional hospital.

 

[TPS report]

Has anyone ever inserted an Intra-Aortic Balloon Pump emergently in the ED... or anywhere else for that matter (CCU, OR, etc). How do you do it? Any advice or tips/tricks? What good resources are there for reading about the procedure? It's not listed in Roberts and Hedges.

uh, yeah. I do them all the time.

I also drill burr holes

and put in ventrics and bolts.

Sometimes I also do emergent laparatomies.

and quite often I do CABG procedures.

 

[waterski232002]

uh, yeah. I do them all the time.

I also drill burr holes

and put in ventrics and bolts.

Sometimes I also do emergent laparatomies.

and quite often I do CABG procedures.

Ummm.... I can tell you're not in EM. You really don't have a clue what is in or out of our spectrum of work. There is a big difference between an operation and a life-saving procedure. Burr holes, IABP insertion, and resuscitative thoracotomy are within our spectrum, laparotomies and CABG's are not. EP's used to perform burr holes in the ED, although now it has mostly fallen out of favor.

 

[FoughtFyr]

uh, yeah. I do them all the time.

I also drill burr holes

and put in ventrics and bolts.

Sometimes I also do emergent laparatomies.

and quite often I do CABG procedures.

Bolts have been put in in the ED, and burr holes drilled. While I have not done an emergent lap, I am trained to do so in the event a perimortem c-section is needed. I have been part of two emergent thoracotomies in the ED however. Push me a bit and I could probably open and pack an abdomen if I absolutely needed to...

- H

 

[waterski232002]

One of our residents did a perimortem C-section in the ER 6 months ago. 22 yo F 3rd trimester, picked up at home by EMS for SOB, coded en route, and upon arrival got a full sternum-to-pubic incision with successful delivery before OB had time to get down. Unfortunately, the baby and mother both still died. PE PE PE....

 

[bulgethetwine]

Waterski, I am not in medicine yet. Critical care paramedics where I live can operate IABPs, but they cannot insert them. I know the EPs in this region can insert IABPs and the ones in more rural hospitals do so in cases where it is warranted before transport to a regional hospital.

This was inevitable when you posted a verbatim list of the steps to insertion of an IABP...

No offence -- clearly you were trying to help -- but I think all of us could google the instructions. We were looking for some layman's advice from someone who has done it.

Are you headed for medicine in Vancouver at UBC?

 

[docB]

I've never done one. I've never seen or heard about one being done in the ED or by an EP.

 

[waterski232002]

One was placed in our ED a couple months ago, but it was done by a cardiologist.

 

[waterski232002]

Duplicate

 

[FoughtFyr]

Duplicate

Our flight team brought one out to a small ED, it was placed by a cardiologist and the patient flown here...

- H

 

[waterski232002]

That website leviathan got the IABP instructions on is a good one. It also goes over IABP wave forms. It's helpful for residents who have to manage these in flight.

http://www.aic.cuhk.edu.hk/web8/IABP.htm

 

[leviathan]

This was inevitable when you posted a verbatim list of the steps to insertion of an IABP...

No offence -- clearly you were trying to help -- but I think all of us could google the instructions.

No offense taken. Just the same, if he could google the instructions, then he wouldn't have been asking for them, right?

Are you headed for medicine in Vancouver at UBC?

Yes, why?

 

[bulgethetwine]

No offense taken. Just the same, if he could google the instructions, then he wouldn't have been asking for them, right?



Yes, why?

I know a lot of times if there is a procedure that I haven't done before, I might look it up in Roberts and Hedges, but then still ask someone else if they have any pointers. Often times the "textual" instructions fail to highlight particular areas that might be pitfalls... or they might be only one interpretation of a controversial procedure or, for example, anatomic approach. So even if someone got the google instructions, it would still be useful for us to share technique tips on this type of forum.

Having said that, if you hadn't google'd the instructions, I would not have found out about the site that you apparently got them from... and it is apparently a good resource -- so thanks!

Just curious if you were headed to UBC. A long long long time ago I thought about it up there. Love the mountains!

 

[leviathan]

I know a lot of times if there is a procedure that I haven't done before, I might look it up in Roberts and Hedges, but then still ask someone else if they have any pointers. Often times the "textual" instructions fail to highlight particular areas that might be pitfalls... or they might be only one interpretation of a controversial procedure or, for example, anatomic approach. So even if someone got the google instructions, it would still be useful for us to share technique tips on this type of forum.

I see what you mean.

Having said that, if you hadn't google'd the instructions, I would not have found out about the site that you apparently got them from... and it is apparently a good resource -- so thanks!

You're most welcome. 🙂

Just curious if you were headed to UBC. A long long long time ago I thought about it up there. Love the mountains!

Yes, it is definitely my #1 choice both for the location and the school's program itself.

 

[waterski232002]

For your information... I had not googled the instructions. I guess I'm old school. I didn't realize that there would be such a good resource that would be found easily by google...😀

I don't care how I get the info, as long as it is legit.

 

[TPS report]

Ummm.... I can tell you're not in EM. You really don't have a clue what is in or out of our spectrum of work. There is a big difference between an operation and a life-saving procedure. Burr holes, IABP insertion, and resuscitative thoracotomy are within our spectrum, laparotomies and CABG's are not. EP's used to perform burr holes in the ED, although now it has mostly fallen out of favor.

whatever you say. You're the boss.

 

[leviathan]

Ummm.... I can tell you're not in EM. You really don't have a clue what is in or out of our spectrum of work. There is a big difference between an operation and a life-saving procedure. Burr holes, IABP insertion, and resuscitative thoracotomy are within our spectrum, laparotomies and CABG's are not. EP's used to perform burr holes in the ED, although now it has mostly fallen out of favor.

I'm pretty sure TPS' post was tongue-in-cheek, just for the record.

 

[bartleby]

If it isn't in Roberts & Hedges, you probably shouldn't be doing it in the ED. : )

It's not listed in Roberts and Hedges.

 

[TPS report]

And if Interventional Cards isn't in house???? Or you don't have a cath lab (like the majority of hospitals in the country)?

uhhh....here's how. This is what you really need to do:


STEP 1:

STEP 2: then, take the stick out of your A$$

STEP 3: try to get laid so you can have an outlet for all that bizarro anger

 

[waterski232002]

TPS... what's up with the attitude? If you have anything constructive to say, I'm all ears. Otherwise, continue to rant and rave for no apparent reason.

 

[FoughtFyr]

whatever you say. You're the boss.

You are right. Waterski is a resident, you are a student. He is the boss.

TPS, usually nothing but love for you, but Waterski outdates you here by quite a bit. Lots of us have met Waterski IRL and you are kind of a new entity . Now, I find your "soap operas" amusing, but the attitude has no place here in what is a real discussion. You are a student - which is great, but remember the old adage "By the time you graduate medical school, half of what you learned will be outdated or proven wrong. The purpose of residency is to teach you which half". Now, I have managed an IABP in flight. I have been on the CCU team that has placed them. I have heard of our bird bringing them out to small hospitals to be placed. Combine those facts with the several helicopter services that always deploy MDs on flights and Waterski raises an interesting question. That question is EXTREMELY valid. Your responses are not. Please don't get yourself banned.

- H

 

[spyderdoc]

You are right. Waterski is a resident, you are a student. He is the boss.

TPS, usually nothing but love for you, but Waterski outdates you here by quite a bit. Lots of us have met Waterski IRL and you are kind of a new entity . Now, I find your "soap operas" amusing, but the attitude has no place here in what is a real discussion. You are a student - which is great, but remember the old adage "By the time you graduate medical school, half of what you learned will be outdated or proven wrong. The purpose of residency is to teach you which half". Now, I have managed an IABP in flight. I have been on the CCU team that has placed them. I have heard of our bird bringing them out to small hospitals to be placed. Combine those facts with the several helicopter services that always deploy MDs on flights and Waterski raises an interesting question. That question is EXTREMELY valid. Your responses are not. Please don't get yourself banned.

- H

TPS, I agree w/ FF. This is a legit question. Even one that I considered doing my residency research project on. As a moderator on this forum, I suggest you try to keep things constructive, or you will eventually get yourself banned.

 

[TPS report]

TPS... what's up with the attitude? If you have anything constructive to say, I'm all ears. Otherwise, continue to rant and rave for no apparent reason.

oh yes, sensei master-san.

do teach me, please, oh learned one. You are so stupendous.

you so wise, like confucious. no, better than confucious.

shower your enlightenment upon me.

teach me IABP!!

if only I could be just like you. maybe some day me so lucky

 

[SoCuteMD]

.

 

[waterski.232002]

Has anyone ever performed a burr hole emergently in the ED... or anywhere else for that matter (ICU, OR, etc). How do you do it? Any advice or tips/tricks? What good resources are there for reading about the procedure? It's not listed in Roberts and Hedges.

 

[BKN]

Has anyone ever performed a burr hole emergently in the ED... or anywhere else for that matter (ICU, OR, etc). How do you do it? Any advice or tips/tricks? What good resources are there for reading about the procedure? It's not listed in Roberts and Hedges.

I'm sure it's in the competition's book (Simon and Reichman?) They've got everything in it. But I really think if you're even gonna consider doing this you suck up to your brain cutter and get him to take you to the OR when he's turning an elective bone flap, Usually 3 good burr holes in that.

 

[waterski232002]

Nice that someone is posing as me with the above post about the Burr Holes. Hmmmm... could that be YOU TPS???? Notice the difference in name "waterski.232002" instead of "waterski232002".

This is pretty sad if you've taken enough time to come up with a whole new screen name and even copied my avatar. Actually, this is kinda scary... I seriously wonder if you are okay???

 

[basementbeastie]

Nice that someone is posing as me with the above post about the Burr Holes. Hmmmm... could that be YOU TPS???? Notice the difference in name "waterski.232002" instead of "waterski232002".

This is pretty sad if you've taken enough time to come up with a whole new screen name and even copied my avatar. Actually, this is kinda scary... I seriously wonder if you are okay???

DUDE, you only have 2 posts!!!!!!!!!! hahahahaha.....😱

 

[tkim]

Nice that someone is posing as me with the above post about the Burr Holes. Hmmmm... could that be YOU TPS???? Notice the difference in name "waterski.232002" instead of "waterski232002".

This is pretty sad if you've taken enough time to come up with a whole new screen name and even copied my avatar. Actually, this is kinda scary... I seriously wonder if you are okay???

You aren't the only one:

http://forums.studentdoctor.net/search.php?searchid=148881

right down to the avatar. very sad.

 

[JackBauERfan]

i wonder what you did to piss of this tps guy. I mean all your questions have been valid ones, and not out there, like 'can we learn to do caths in the ED' haah.

 

[Jeff698]

This is pretty sad if you've taken enough time to come up with a whole new screen name and even copied my avatar. Actually, this is kinda scary... I seriously wonder if you are okay???

Wow. You're famous! You know you've arrived when you have your own internet stalker. 🙄

Agreed...pretty scary.

Take care,
Jeff

 

[JackBauERfan]

Wow. You're famous! You know you've arrived when you have your own internet stalker. 🙄

Agreed...pretty scary.

Take care,
Jeff

i kinda wish I had an internet stalker....

 

[hyperbaric]

i kinda wish I had an internet stalker....

So where, exactly, are you over there in Alabama? Why haven't you answered my 3984754 PMs yet? J/K

Not to rob the thread, but couldn't bad behavior on SDN reflect badly on one's residency pursuit?

 

[docB]

This is definitely the most bizarre thread I've seen here in a while. Humerous yet creepy.

 

[SoCuteMD]

So where, exactly, are you over there in Alabama? Why haven't you answered my 3984754 PMs yet? J/K

Not to rob the thread, but couldn't bad behavior on SDN reflect badly on one's residency pursuit?

I suppose so, if a PD could figure out who you are from your posts. BKN is on here, but someone said that other PDs read but don't post.

 

[deleted109597]

Yes, there is only so much anonymnity that you can do on these boards.
Even though I try to be nice, every now and then you say things that could be used against you. Thus, every forum has a different screen name for me, and I don't put up my blog links. At least not until I get a spot.
Then I won't care who I piss off. 🙂

 

[SoCuteMD]

Yes, there is only so much anonymnity that you can do on these boards.
Even though I try to be nice, every now and then you say things that could be used against you. Thus, every forum has a different screen name for me, and I don't put up my blog links. At least not until I get a spot.
Then I won't care who I piss off. 🙂

I tried really hard to stay anonymous - until this summer no one knew what state I lived in. Now some people do, but hopefully I generally conduct myself in a respectable fashion and I try to make sure people know I'm joking when I make an off-color joke.

 

[Apollyon]

I tried really hard to stay anonymous - until this summer no one knew what state I lived in. Now some people do, but hopefully I generally conduct myself in a respectable fashion and I try to make sure people know I'm joking when I make an off-color joke.

Well, I know your name and birthdate (actually, forgot the birthday), but I haven't told (and I ain't tellin') anyone.