What is an Intra-Aortic Balloon Pump (IABP)?

sometimes our patients hemodynamics and cardiac function is not adequate or at risk of failure and just using medications alone is not going to be enough in these cases we need to support hemodynamics with mechanical means which brings us to the intra-aortic balloon pump or iabp in this lesson we'll talk about what exactly a blue pump is and how it works for our patients so let's go ahead and get started [Music] all right you guys welcome back to another video lesson from icu advantage my name is eddie watson and my goal with this channel is to

give you guys the confidence to succeed in the icu by making these critical care topics easy to understand i truly hope that i'm able to do just that for you and if i am i do invite you to subscribe to the channel below when you do make sure you hit that bell icon and select all notifications that way you never miss out when i release a new lesson and to test your knowledge at the end of this lesson make sure and head on over to icuadvantage.com or follow the link down the lesson description to take

a quiz and test your knowledge as well as be entered into a weekly gift card giveaway also don't forget that the notes for this lesson as well as all the others are available exclusively to the youtube and patreon members which you can find links to join both of those down below as well alright so let's go ahead and get into our lesson here and let's start off talking about what exactly is the intra-aortic bloom pump or iabp as the name suggests an intra-aortic balloon pump is at its most basic a balloon that sits in the

aorta that is run by a pump essentially we have a special catheter that is going to be inserted into our patient's aorta and at the end of the catheter there is a balloon that is going to inflate and deflate and you can actually see an example of the balloon in action here you can see it inflating and deflating and this is all taking place inside our patient's aorta this catheter is then attached to an external console that controls the inflation and deflation by filling that balloon with helium as well as our monitoring and settings the

inflation and deflation of the balloon in the aorta is going to happen in synchrony with our patient's heartbeat now it uses a process that we call counter pulsation to produce its desired effects and what this means is when the heart contracts the balloon deflates and when the contraction is done the balloon then inflates there are triggers for these events which i will talk about more in just a minute as well as in much more detail in the next lesson in the series so on that subject of counterpulsation there are a couple benefits that our patients

will get from this counterpulsation so first off when the heart's no longer ejecting blood that we are in diastole at this point that this is when the balloon is going to inflate now this inflation helps to augment the diastolic pressure meaning it increases the arterial pressure when it inflates it does this by displacing that volume of blood that the balloon takes up which is anywhere from 25 to 50 ml and there's two benefits that we get from this augmentation first is it's going to help to increase the systemic arterial pressure helping to support our patient's

hemodynamics now secondly and probably most importantly with our uses for the balloon pump is the displacement of blood flows retrograde back up the remaining part of the aorta and helps to perfuse the coronary arteries now these coronary arteries are going to be perfused during diastole as the heart is relaxed this augmentation increases the blood pressure and perfusion pressure of these arteries helping to ensure good perfusion of the cardiac muscle now the next benefit of this counterpulsation comes when the patient's heart begins to contract and we are in systole that this is when the balloon is

now going to deflate now this deflation occurs during the isovolumetric contraction of the heart this is essentially where the heart is beginning to contract but the pressure in the ventricle has not overcome the central aortic pressure and thus that aortic valve has not opened yet the deflation of the balloon at this time lowers that central aortic pressure so you can think of this almost like creating a vacuum in the aorta right before the heart starts contracting this has the effect of reducing the afterload or the pressure that that heart must contract against and doing this

decreases the workload of the heart and thus decreases our myocardial oxygen demand this also allows the heart to contract a greater volume of blood as it has less resistance to that contraction therefore combined together we're augmenting hemodynamics and decreasing myocardial oxygen demand while also increasing myocardial perfusion both of which can be helpful for a struggling heart now knowing this though it is imperative that our patient does have a moderately functioning left ventricle as the balloon pump only assists with these contractions if the right ventricle is not functioning the balloon pump is not going to be

of benefit here that said i have heard of using the balloon pump in the pulmonary artery to support the rv but it's not something that i've personally seen now also this is not to say that the right ventricle doesn't benefit from a balloon pump the rv still receives the increased perfusion of those coronary arteries from the diastolic augmentation as well as the improvement in our left ventricle function reduces left atrial and pulmonary artery pressure reducing the afterload of the rv now if the lv has completely failed the balloon pump is not going to be effective

and so other forms of support such as temporary vads or va ecmo would be needed at this point i do plan to cover vads in a future lesson as well as i do have a series on ecmo that i'm going to link to up above if you want to check that out all right so now let's move on and talk about the insertion and positioning of our boom pump now typically our balloon pump is going to be inserted via either the left or right femoral artery up through the common iliac artery and then into the

descending aorta it's going to travel retrograde up the aorta and rest with the tip of the balloon resting just before the aortic arch about one to two centimeters from the left subclavian artery with the bottom of the balloon just above the renal arteries insertion is often going to take place in the cath lab but this is something that can be done at the bedside with the aid of a portable fluoroscopy c arm now the positioning of the balloon pump is vital not only to the proper functioning of the hemodynamic augmentation but also to prevent other

complications and so here's an x-ray image showing the proper positioning of the balloon pump so you can see the balloon here and the tip of the balloon right here is about one to two centimeters below the aortic knob at roughly the level of the crina that you can see here we also want it in between the second and third intercostal space and this is going to be our ideal positioning on what we want to see for this balloon to be in the right spot now if the balloon is mispositioned too high we risk impacting blood

flow to the left arm as well as to the head by blocking these arteries coming off the aortic arch here we also risk throwing clots and emboli upwards leading to a cva or stroke and so here is an x-ray of a balloon that is positioned too high now once again you can see the balloon here but now the tip of the balloon here is up into the aortic knob and well above the carina here and finally if the balloon is positioned too low we're not going to achieve as much afterload reduction as well as we

risk impeding blood flow to the kidneys so here is another x-ray this time with a position that is too low you can see the balloon here and then the tip that is far below the aortic knob and the carina now in addition to the femoral approach we can also use the subclavian or axillary artery to introduce the balloon into the aorta for this we would use the left subclavian or the left axillary artery as using the right would have to go through the first branch off the aortic arch the brachiocephalic artery which also feeds the

right common carotid and risks decreasing perfusion to the brain now the landmarks iv the balloon placement still lie one to two centimeters below the left subclavian artery and above the renal arteries just this time the tip would be near the renal arteries and then the base would be just below the subclavian artery now this approach is better tolerated by the patient as they're going to be able to sit up and even ambulate the femoral approach though is the most common approach and especially during an emergency placement this is the one that we're going to go

with so now that you understand the basics about how the balloon pump works let's actually talk about why we use it and when we don't so first let's take a look at our indications and our first indication is going to be for myocardial infarction now this is probably going to be the most common use especially when the patient has impairment to the cardiac output the diastolic augmentation helps to increase that perfusion and oxygen delivery to the ischemic cardiac muscle as well as the reduction in afterload decreases that workload of the heart decreasing that myocardial oxygen

demand both of these are essential post mi especially for patients who are awaiting more definitive treatment such as going for surgery for a cabbage now the next indication is going to be for cardiogenic shock and the goal here is actually to augment hemodynamics by increasing aortic pressure as well as reducing afterload making it easier for the heart to contract which is our problem with cardiogenic shock once again i'm going to link to a lesson up above here that i did specifically talking about cardiogenic shock now this indication though is actually something that's almost exclusively used

in the united states there is a mixed consensus of studies when it comes to the benefit of a balloon pump in cardiogenic shock and i know places like europe where the balloon pump is actually not authorized for this use now when available though a vad such as an impella or a tandem heart is going to be more often used here but sometimes especially where the balloon pump is the only thing available we still do use it for this purpose another indication is gonna be for heart failure and so here we can use a bloom pump

to help offload the heart for patients with acute on chronic heart failure now this is only a temporary measure but it can help to rest the heart and allow recovery from that acute phase of failure now another one of our indications is going to be for high risk pci once again the offloading of the heart during high risk pci for patients who have multivessel disease and significant inclusions can be beneficial especially from that increased coronary perfusion the impeller is also often used to assist for these procedures as well so you kind of have a couple

options that you might see another indication is going to be weaning from bypass now here the balloon pump can be used with a hypokinetic heart coming off of cardiopulmonary bypass the weakened heart can be rested using the balloon pump before it has to resume full duty again and then another indication is actually going to be the offloading of the left ventricle for patients who are on va ecmo and so sometimes with va ecmo we don't get enough ejection of blood from the left ventricle which can lead to dilation of that ventricle this is often due

to the flow of blood that's coming back up the aorta retrograde from the ecmo itself making it harder for an already weakened heart to contract and eject that blood here a balloon pump can help to reduce that afterload and thus decreasing the opening pressure required to eject the blood from the lv helping to offload it once again something like an impeller can also be used for this purpose as well and so with the indications out of the way let's actually talk about some of our contraindications and there are a few situations in which a balloon

pump is not going to be appropriate to use the first of these is going to be patients who have aortic insufficiency or aortic regurgitation so if the patient has that incompetent aortic valve that just does not fully close then the increase in pressure from that diastolic augmentation would just flow retrograde right back into the left ventricle now the bloom pump is also going to be contraindicated in patients who have aortic dissection or aneurysm so any type of aortic dissection or aneurysm is really going to be contraindicated as we would not want to introduce the balloon

catheter into this aorta another contraindication is going to be for patients who have severe peripheral artery disease or pad now due to the pretty large size of the sheath and the size of the balloon catheter that we're going to be impeding perfusion distally from our insertion site so patients who have decreased blood flow from pat would be at risk for limb ischemia by having this large catheter in place now one option that does exist for these patients would be pre-treating this site with stenting prior to the insertion another contraindication is going to be in sepsis

so hopefully this goes without saying as we would not want to introduce a foreign object into the aorta with a systemic infection going on and then finally the last contraindication i want to talk about is going to be our coagulopathies so patients who would not be able to receive anticoagulation would potentially be contraindicated as full anticoagulation with heparin is usually going to be required when the balloon pump is in place all right so that was the basics of what an intra-aortic balloon pump is why it is that we use it and kind of how it

is that it works now in the next lesson we're going to take a look at the different pressures and waveforms that we see with the balloon pump to try and help you guys kind of understand a little bit more in depth about how it is that the balloon pump works so make sure you guys do stay tuned for that lesson coming out next week otherwise though i really hope that you did enjoy this particular lesson if you did please leave me a like down below it really goes a long way to support this channel as

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description like i said make sure you guys stay tuned for the next lesson in this series otherwise check out a couple awesome lessons i'm gonna link to right here as always thank you guys so much for watching have a great day