By Kathleen M. Weil, RN, BSN, MS
(Article reprinted from July Nursing2007, Volume 37, Issue 7.)
A CRITICALLY ILL patient needed an intra-aortic balloon pump (IABP) to provide circulatory support. When the pump's helium tank was low, a nurse switched the pump off for 30 minutes to replace the tank. At 2:30 a.m. the following day, the pump alarm sounded several times. The pump was shut off, and the patient was given heparin and blood products. At 8:40 a.m., the physician removed the intra-aortic balloon (IAB) catheter without difficulty but found that no balloon membrane material was left on the catheter. The patient was immediately taken to the OR for surgery to remove the balloon membrane but later died.
What went wrong?
Intra-aortic balloon pump counterpulsation is frequently used as therapy for patients with refractory left ventricular heart failure or for other indications. Benefits of IABP therapy include increased cardiac output, coronary blood flow, and systemic perfusion pressure and decreased afterload and myocardial oxygen demands.
Letting an IAB remain dormant for longer than 15 minutes is hazardous, not only because the patient loses valuable cardiac support, but also because blood becomes trapped within the folds of the deflated balloon, promoting the formation of clots. The IAB in this case was allowed to remain dormant twice.
What precautions can you take?
As a nurse, you can help mitigate complications from IABP therapy. Suggested device management and precautions include the following:
- Frequently monitor the patient's physiologic responses to IABP therapy such as cardiac output, cardiac index, systemic vascular resistance, blood pressure, stroke volume, central venous pressure/right atrial pressure, and pulmonary capillary wedge pressure.
- Frequently check pump activity, helium level, driveline, and catheter.
- Replace empty helium tanks within 15 minutes—the sooner, the better. Keep extra helium tanks nearby to minimize the time the IAB is dormant.
- Ensure that additional fully operational pumps are readily available in case of an emergency. If an alarm sounds, check the patient first, then the pump. Considered a high-priority alarm, a helium leak alarm indicates a potentially serious condition warranting immediate attention. If you can't quickly identify the cause of the alarm, obtain another pump console. If the alarm continues to sound, notify the physician immediately. The balloon may have ruptured, requiring immediate removal.
- If pump operation can't be restored within 15 minutes, the balloon becomes dormant. You must manually inflate and deflate the balloon optimally every 5 minutes; at a minimum, at least several times per hour. To reduce the risk of thrombus formation, continue this until a new pump is in place or the balloon is removed. Follow the IAB product instructions to check for blood in the driveline before starting manual inflation and deflation.
- Blood in the driveline or catheter can indicate that the IAB has ruptured. Notify the physician, who must remove a ruptured IAB immediately.
- Never inject air into the central (female luer fitting) lumen; you could introduce an air embolus into the patient's circulation.
- If your patient has problems with either the IAB or the pump, quarantine the device after it's removed and notify your biomedical engineering department so that the device can be returned to the manufacturer for examination and evaluation.
- Always follow the standards of clinical practice and your hospital's policies and procedures when you care for a patient receiving IABP therapy.
Although you need to support the adverse event– reporting policy of your health care facility, you may voluntarily report a medical device that doesn't perform as intended by contacting MedWatch at 1-800-FDA-1088 (fax: 1-800-FDA-0178) or online at MedWatch.