Iabp
Iabp
Iabp
Counterpulsation Applied
An Introduction to Intra-Aortic Balloon Pumping
ABT-TG 5/05
i
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
1. Pr ogr am Schedul e
4 Hour Cour s e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
8 Hour Cour s e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Pr ogr am Descr i pt i on 3
3. Par t i ci pant Behavi or al Obj ect i ves 4
4. Anat omy and Physi ol ogy as Rel at ed t o Count er pul sat i on Ther apy 5
5. Myocar di al Oxygen Bal ance 15
6. Pr i nci pl es of I nt r a- Aor t i c Bal l oon Count er pul sat i on
General Concepts ..................................................................................................................19
Balloon Inflation: Hemodynamics ............................................................................................21
Balloon Deflation: Hemodynamics ..........................................................................................22
Clinical Correlates of IAB Pumping ..........................................................................................23
7. I ndi cat i ons f or t he I nt r a- Aor t i c Bal l oon Pump
Indications ............................................................................................................................25
Contraindications ..................................................................................................................26
8. Compl i cat i ons of Bal l oon Pumpi ng ............................................................................27
9. Nur si ng Car e
Introduction ..........................................................................................................................29
IAB Catheter Insertion ............................................................................................................30
Insertion Competency Checklist ..............................................................................................35
Care of the Central Lumen ......................................................................................................37
Sample Flow Sheet ................................................................................................................39
Weaning from the Intra-Aortic Balloon Pump ..........................................................................41
Removal of the Balloon Catheter..............................................................................................42
Transporting a Patient with an IABP ........................................................................................44
Air Transport ........................................................................................................................45
10. El ement s of Ti mi ng
Introduction ..........................................................................................................................47
Inflation Timing......................................................................................................................49
Deflation Timing ....................................................................................................................51
Errors in Timing ....................................................................................................................53
Timing Three..........................................................................................................................54
Timing Exercises ....................................................................................................................55
Arrhythmia Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Tabl e of Cont ent s
ii 2005 Arrow International, Inc. All rights reserved. CRB-05-0174
11. Aut oCAT
Series/KAAT II PLUS
2 balloon material
ArmorGlide
hydrophilic coating
50cc 9Fr. Intra-Aortic Balloon
(1) 6" introducer sheath, with or without sideport
(2) .025 175cm guidewires
30cc 7Fr. and 40cc 8Fr. Intra-Aortic Balloon
(2) 6" introducer sheaths, with and without sideport
(2) .025 175cm guidewires
NarrowFlex
2 balloon material
Kink resistant and pushable
(2) 6" introducer sheaths, with and without sideport
(2) .030 175cm guidewires
30cc and 40cc 8Fr. Intra-Aortic Balloon
pre-mounted hemostasis device
Ultra8
2 balloon material
ArmorGlide
hydrophilic coating
(2) 6" introducer sheaths, with and without sideport
(2) .025 175cm guidewires
30cc and 40cc 8Fr. Intra-Aortic Balloon
fits through an 8Fr. Sheath
pre-mounted hemostasis device
UltraFlex
Series
thin walled stainless steel central lumen
Cardiothane
2 balloon material
Kink resistant and pushable
(2) 6" PTFE introducer sheaths, with and without sideport
(2) .025 175cm guidewires
30cc and 40cc 7.5Fr. Intra-Aortic Balloon, uses an 8Fr. Sheath
50cc 9Fr. Intra-Aortic Balloon, uses a 9Fr. Sheath
pre-mounted hemostasis device
FiberOptix
Series
Ultra8
and UltraFlex
Sensors
embedded in the tip for use with AutoCAT
2 WAVE
pump consoles
Available in 30cc and 40cc balloon volumes for both styles, 50cc only in UltraFlex
2 WAVE
only)
A. Slide blue fiberoptic connection in the IABP
B. Insert calibration key (black key)
C. Verify light bulb change from blue to green
D. Describe how to do a manual zero
4. Balloon Preparation
A. Place IAB guidewire on the field
B. Attach one-way valve to Gas lumen (do not remove until IAB is in position)
C. Pull vacuum on IAB
D. Remove IAB from the tray (immediately prior to insertion)
E. Remove the packing stylet (if present)
F. Flush IAB central lumen with heparinized NS solution before insertion
5. Arterial Pressure Source (Fiber optic IAB uses AutoCAT
2 WAVE
only)
A. To zero Fiberoptic source manually:
a) Press AP select to highlight fiber optic
b) Press soft key under FOS ZERO
B. To calibrate Fiberoptic source, if FOS was not zerod prior to insertion and MAP value is erroneous:
a) Press AP select to highlight fiber optic
b) Press soft key under FOS CAL
c) Adjust FOS MAP to actual MAP (from another AP source)
C. To zero Fluid Transducer:
a) Press AP select to highlight Xducer
b) Open stopcock to air and off to patient
c) Press soft key under TRANSDUCER ZERO (DO NOT press CAL key)
d) Close stopcock
6. Identify proper IAB positioning
A. 2nd to 3rd Intercostal Space (anterior ribs) on Fluoro/X-ray
B. Left radial (or ulner) pulse present
C. Urine output present (if Foley in place)
ARROW INTERNATIONAL
Intra-Aortic Balloon Insertion
Procedure Competency Checklist
Name:_____________________________________________ Date:_________________
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Insertion Competency Checklist
36
9. Nur si ng Car e of t he I nt r a- Aor t i c Bal l oon Pump Pat i ent ( cont i nued)
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Care of the Central Lumen
37
9. Nur si ng Car e of t he I nt r a- Aor t i c Bal l oon Pump Pat i ent ( cont i nued)
Nursing Care Considerations
A. Care of the Central Lumen
The central lumen of the IAB catheter was designed for guidewire insertion and pressure
monitoring. Use of the central lumen for blood samples should be discouraged.
1. Use a standard arterial pressure monitoring set-up to monitor pressure through the
central lumen.
2. Use of heparin in the flush bag should be in accordance with standard
hospital guidelines.
3. A 3cc/hour continuous flush is recommended to maintain line patency.
4. Aspirate and discard 3cc of blood prior to connecting the flush tubing.
5. If unable to aspirate blood from the central lumen consider the line clotted. Attach a
standard dead end plug and DO NOT attempt to use the central lumen during the course of
therapy.
6. Avoid flushing and blood sampling from the central lumen to decrease the risk of
embolization or formation of thrombus. If hospital policy or patient situation warrants
manipulation of the central lumen, the pump console should be placed in STANDBY to
prevent accidental embolization to the aortic arch.
7. Ensure that the pressure monitoring set-up and tubing are free of air bubbles.
8. The use of in-line filters may dampen the arterial pressure waveform and, therefore, should
not be used.
9. Arterial pressure line set-up should be changed in accordance with hospital guidelines.
B. Potential for Inadequate Circulation
Pulse checks to lower extremities
Pulse checks to upper extremitiesIAB too high
Monitor urine outputIAB too low
C. Potential for infection R/T invasive lines
D. Potential for skin breakdown R/T immobility
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Care of the Central Lumen
38
9. Nur si ng Car e of t he I nt r a- Aor t i c Bal l oon Pump Pat i ent ( cont i nued)
E. Potential for impaired gas exchange R/T atelectasis
F. Potential for injury R/T hematological abnormalities
G. Family and patient anxiety and stress
H. Control of arrhythmias
PARAMETERS
Time
Heart Rate
Rhythm
Mode (AutoPilot
/Operator)
Trigger
Assist Ratio
IAB Volume
Systole
Diastole
MAP
Asst Systole
AUG/PDP
Asst Diastole
Asst MAP
CIRCULATION ASSESSMENT
LT Radial Pulse
DP Pulse
PT Pulse
Insertion Limb
Color L/R
Temp L/R
Sensation L/R
Calf Circumference
Ankle/Brachial Index
I NTRA- AORTI C BALLOON PUMP FLOW SHEET
Date: __________________________ Insertion Site: __________________________ FR: ___________________ CC: ___________________
INITIALS SIGNATURE SIGNATURE INITIALS
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Sample Flow Sheet
39
LEGEND: PULSES PS = PALPABLE STRONG PD = PALPABLE DIMINISHED D = DOPPLER O = ABSENT
COLOR/SENSATION N = NORMAL D = DIMINISHED C = CYANOTIC M= MOTTLED
LIMB TEMP W= WARM C = COOL N = NUMB O = ABSENT
BAEDP/ADIA
PAEDP/DIA
PDP/AUG
APSP/ASYS
PSP/SYS
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Sample Flow Sheet
40
LATE DEFLATION EARLY DEFLATION LATE INFLATION EARLY INFLATION
DATE: TIME: MODE: TRIGGER:
DATE: TIME: MODE: TRIGGER:
DATE: TIME: MODE: TRIGGER:
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Weaning from the Intra-Aortic Balloon Pump
41
9. Nur si ng Car e of t he I nt r a- Aor t i c Bal l oon Pump Pat i ent ( cont i nued)
Weaning from the Intra-Aortic Balloon Pump
The time for weaning and the speed with which weaning can be accomplished are dictated by
the patients hemodynamic status. Those patients requiring the IABP because of profound
cardiogenic shock will probably wean more slowly than those needing balloon assistance for
instability due to low cardiac output syndrome following cardiac surgery.
There are two methods of weaning which may be used independently or in conjunction with one
another. Weaning can be accomplished by decreasing the frequency and/or volume of balloon
inflation. Weaning by decreasing the frequency is accomplished by decreasing the frequency of
assistance from one balloon inflation per cardiac cycle to 1:2, 1:3, 1:4, and 1:8. Weaning can
also be accomplished by decreasing the volume delivered to the balloon.
Any concerns that the patient may not be tolerating weaning should be directed immediately
to the physician.
Do not reduce the volume delivered to the balloon less than 2/3 the capacity of the balloon,
i.e. a 40cc balloon should not have the volume reduced to less than 28cc.
General recommendations when weaning:
1. Monitor the patients hemodynamic data to establish a baseline for analysis of response to
weaning, and carefully monitor the patient during weaning.
2. Throughout the weaning period, monitor the patients vital signs including but not
limited to:
ECG
Heart rate
Blood Pressure
Urine output
Mentation
Distal perfusion
Cardiac output/index
It is suggested that IABP support may be discontinued if the following clinical picture
is present:
1. Signs of hypoperfusion due to low cardiac output syndrome are absent.
2. The urine output can be maintained above 30ml per hour.
3. The need for positive inotropic agents is minimal. The cardiovascular system remains
stable in the low dose range.
4. The heart rate is less than 100 beats per minute.
5. Ventricular ectopic beats are fewer than 6 per minute, not coupled and unifocal.
6. The cardiac index remains equal to or greater than 2 l/min/m2 and does not decrease
by more than 20%.
7. The index of LVEDP (PCWP, PADP) does not increase to greater than 20% above
pre-weaning level.
8. Absence of angina.
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Weaning from the Intra-Aortic Balloon Pump
42
9. Nur si ng Car e of t he I nt r a- Aor t i c Bal l oon Pump Pat i ent ( cont i nued)
The inability to meet the above weaning criteria shows an intolerance to the withdrawal of
mechanical support. The operator should return to the previous step in the weaning
process and the physician notified in the event of weaning intolerance. A slow patient
weaning protocol can be successful in those cases where IABP support has been prolonged
or where the cardiovascular reserve is small.
3. When the patient no longer requires IABP support, press the OFF key in the PUMP
STATUS section of the keypad to stop pumping, then remove the IAB according to your
hospital policies and procedures.
4. After each use, clean and disinfect the IABP and its accessories and perform the
Operational Checkout Procedure, according to the operators manual.
For specific recommendations for weaning the patient on the Arrow IABP pump, refer to your
operators manual.
Removal of the Balloon Catheter
43
9. Nur si ng Car e of t he I nt r a- Aor t i c Bal l oon Pump Pat i ent ( cont i nued)
Removal of the Balloon Catheter
Removal of a percutaneously inserted balloon catheter can be done quickly and safely without
an operative procedure.
The procedure for removal of a percutaneous balloon is as follows:
1. Explain to the patient and family the nature of the procedure and what to expect.
2. Remove all anchoring ties and sutures.
3. Disconnect the balloon from the console. (Note: the patients blood pressure collapses the
balloon membrane, eliminating the necessity to aspirate the balloon with a syringe.
However, in some situations it is standard practice to reattach the one-way valve and
aspirate with a 60cc syringe. Should blood be aspirated into the tigon tubing during this
procedure, a radiographic examination of the IAB should be done to rule out entrapment.)
4. Remove the cuff from the sheath connector. While holding the sheath with one hand, the
balloon catheter is slowly withdrawn with the other hand until resistance is met. This
resistance means the balloon material is entering the end of the sheath.
ANY UNDUE RESISTANCE TO COMPLETE WITHDRAWAL SHOULD BE
IMMEDIATELY NOTED AND SURGICAL REMOVAL SHOULD BE CONSIDERED.
5. Apply firm pressure to the femoral artery immediately below the insertion site.
6. Remove the balloon and sheath simultaneously.
NEVER ATTEMPT TO WITHDRAW THE BALLOON BACK THROUGH THE SHEATH.
THIS PRACTICE CAN SEVERELY DAMAGE AND FRAGMENT THE BALLOON
MATERIAL.
7. Allow proximal bleeding for 1-2 seconds to encourage extravascular loss of thromboembolic
material.
8. Apply firm digital pressure to the femoral artery immediately above the insertion site.
Release pressure below the insertion site to encourage backbleeding for 1-2 seconds.
9. Apply firm pressure to the insertion site to provide hemostasis (30-40 minutes or more if
heparinized), and then apply a pressure dressing. A 5 to 10 pound sandbag can be used as
per hospital policy. Follow hospital policy guidelines for sterile wound care.
In cases where a leak in the IAB is known or suspected, extreme caution must be exercised
during removal. If resistance is met during step 4 (above), the percutaneous removal procedure
should be discontinued and surgical removal via arteriotomy employed.
Post removal care includes the continual assessment of circulation to the cannulated leg.
Monitoring and recording of peripheral pulses and the circulatory status of the cannulated
extremity should be done every hour for the first 24 hours post-removal. The patient should not
be allowed to flex the hip greater than 30 degrees for several hours to ensure a solid, organized
clot. The patient should also avoid the Valsalva maneuver for the first 24 hours. Coughing
exercises should not be done too vigorously and the insertion area splinted during coughing.
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Transporting a Patient with an IABP
44
9. Nur si ng Car e of t he I nt r a- Aor t i c Bal l oon Pump Pat i ent ( cont i nued)
Transporting a Patient with an IABP
1. Inform ambulance or air transport company that you are transferring a patient with:
a. IABP
b. Ventilator
c. Number of Infusion Pumps
d. Be sure transport vehicle or aircraft is large enough to accommodate all equipment
e. Ask if vehicle is equipped with an inverter to supply power to IABP
2. Confirm that bed at accepting facility is ready.
3. Verify clean ECG skin and AP transducer signals on IABP screen.
4. Check IABP batteryOn the KAAT II PLUS
1, AutoCAT
1 and AutoCAT
2 Series of
pumps, Battery Charged LED should be lit. On the TransAct
, KAAT II PLUS
, ACAT
Series, AutoCAT
1 and AutoCAT
2 WAVE
Series IABPs contain a pressure transducer inside the helium gas shuttle circuit. This
transducer senses the above mentioned changes in barometric pressure and gas expansion
and contraction, causing activation of alarms. These alarms will result in venting the system
and referencing the transducer to current atmospheric pressure. The IABP can then be
re-purged with the appropriate helium volume and pressure. The TransAct
and AutoCAT
1
Series of IABPs will automatically adjust for these changes.
Procedures During Flight for all IABP consoles:
1. Maintain alarms in ON position at all times.
2. Balloon gas volume expansion and contraction may result in alarm conditions (High
Baseline or Kinked Line during ascent and Helium Loss or Gas Loss during
descent.)
3. Both alarms result in the pump going to OFF position and venting the system.
4. Observe alarm condition on the screen/strip. The screen of the IABP console should be
placed for continual visual observation of pump performance as well as allow access for
adjustments, if required.
5. Press Reset, then Pump On.
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Air Transport
46
9. Nur si ng Car e of t he I nt r a- Aor t i c Bal l oon Pump Pat i ent ( cont i nued)
Introduction
47
10. El ement s of Ti mi ng
Introduction
The precise timing of balloon inflation and deflation is essential to achieve the hemodynamic
effects that increase coronary blood flow and decrease the workload of the heart. This section
relates the cardiac cycle to the waveform changes caused by balloon inflation and deflation. The
landmarks that will identify proper timing are discussed. Timing examples from various arterial
sites are discussed to inform the reader of the inherent time delays from the different locations
used for monitoring. Timing exercises will allow the reader to practice timing skills.
Timing is set and changed using two separate controls that move the timing markers to the left
and right. The inflate control is moved to the left to adjust the inflate time to occur earlier and
to the right to occur later. The deflate control operates in a similar manner: moved to the left for
earlier deflation, to the right for later deflation.
The efficiency of intra-aortic balloon pumping depends on the accuracy of the inflate and
deflate timing settings. It is imperative that the operator fully understand the hemodynamic
signs of proper timing and the adverse effects of improper timing.
Even if your IABP adjusts and sets timing automatically, timing assessment should be done per
hospital policy.
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Introduction
48
10. El ement s of Ti mi ng ( cont i nued)
Arterial Pressure Waveform Landmarks
The IABP is a volume displacement device that affects the cardiovascular system in a
mechanical manner. In order to evaluate the timing of inflation and deflation, the physical
characteristics of the unassisted and assisted arterial pressure waveform must be assessed.
Timing of the IABP is always performed using the arterial pressure waveform as the guide.
Before one may appreciate the changes that occur with balloon inflation and deflation, an
assessment of the arterial pressure morphology is necessary.
AVO = Aortic valve opens. Beginning of systole.
AEDP = Aortic end diastolic pressure (DIA or diastolic pressure).
PSP = Peak systolic pressure (SYS or systolic pressure) 65-75% of stroke
volume has been delivered.
DN = Dicrotic notch. Signifies aortic valve closure and diastole. The last 25-35% of stroke
volume is delivered by this point.
The onset of systole first begins with the IVC phase. The IVC phase occurs milliseconds before
the upstroke on the arterial pressure waveform. The aortic valve opens when the pressure in the
LV exceeds the pressure in the aorta. Rapid ejection occurs and the ventricle delivers 65-75% of
its stroke volume. The pressure generated is the peak systolic pressure (PSP or SYS). After the
Peak Systolic Pressure, flow velocity declines until the pressure in the ventricle falls below the
pressure in the aorta, and the aortic valve closes (DN). The blood in the aorta flows to the
periphery in the runoff phase. The cycle then repeats itself.
The important landmarks of the arterial pressure waveform are shown in Figure 11.
Identification is necessary for proper timing of inflation and deflation. When intra-aortic
balloon pumping is begun, the assist interval is set on 1:2 (the IAB inflates and deflates every
other systole). This is done so that landmarks can be identified and the effects of inflation and
deflation can be compared to the baseline hemodynamic status.
Figure 11. Arterial Pressure Waveform Landmarks.
PSP/SYS
DN
AVO
AEDP/DIA
Inflation Timing
49
Inflation Timing
Inflation goal: Inflation effect achieved by:
Increase myocardial oxygen supply Increasing CPP
Increase systemic perfusion pressure Increasing systemic pulse pressure/rate
To accomplish the goals of inflation, the balloon must be inflated at the onset of diastole. The
dicrotic notch is the landmark for this on the arterial pressure waveform and inflation should
occur just prior to this point. The result of properly timed inflation is a pressure rise, peak
diastolic pressure (PDP) or augmentation (AUG), during diastole. The PDP/AUG influences the
gradient for coronary artery perfusion. While it may not only be a reflection of timing, the
PDP/AUG should be higher than the PSP/SYS unless:
1. the patients stroke volume is significantly higher or lower than the balloon volume
2. balloon is positioned too low
3. severe cases of hypovolemia
4. balloon is too small for patients aorta
5. low SVR
6. improper timing
7. catheter partially kinked, in sheath, not unwrapped
The reference point for absolute timing is the aortic root. It is not possible in the critical care
unit to monitor the aortic root pressure, therefore we measure the pressure in the descending
aorta via the central lumen of the balloon. Because the monitoring site is not the aortic root,
there are time delays between the actual physiological events and the monitoring of those events.
Propagation of a pressure wave takes much the same pattern as a ripple in a pond.
There is a larger transmission delay in the fluid filled transducer system than with the fiber
optic AP sensor. This may result in timing waveform differences between AP monitoring sites.
10. El ement s of Ti mi ng ( cont i nued)
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Inflation Timing
50
10. El ement s of Ti mi ng ( cont i nued)
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
What does this mean in terms of setting IABP timing?
Inflation timing should be set to occur 40-50 milliseconds (msec) early to compensate for the
delay. Forty msec is the same as one very small block on the horizontal axis on standard ECG
paper. Therefore, the inflation point should be set to occur one small block ahead of the DN on
the ECG paper. Correct inflation timing is illustrated in Figure 12.
DN = Dicrotic Notch. Symbolizes the beginning of diastole.
PDP = Peak Diastolic Pressure. Also called diastolic augmentation (DA).
When using the radial artery as the monitoring point for cardiovascular pressures, the time
delay will be approximately the same as for the central lumen pressure line. The increased
amount of blood volume involved when transducing a femoral arterial site necessitates an
increase in time delay to 120 msec (3 small blocks).
Figure 12. Correct Inflation Timing.
DN
PDP/DA
Deflation Timing
51
10. El ement s of Ti mi ng ( cont i nued)
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Deflation Timing
Deflation goal: Deflation effect achieved by:
Decreased myocardial oxygen demands Afterload reduction
Increased stroke volume Decreasing aortic pressure
Accomplishing the goals of deflation requires the assessment of several pressures on the 1:2
assisted arterial pressure waveform. Deflation timing does not have the benefit of absolute
landmarks but entails assessment of pressure responses.
Balloon deflation during the IVC phase of systole causes a fall in pressure immediately
preceding ventricular ejection. This fall is represented by the balloon aortic end diastolic
pressure (BAEDP) or assisted diastole (ADIA). (See Figure 13.) For effective afterload
reduction, the BAEDP/ADIA must be lower than the patients own unassisted aortic end
diastolic pressure (AEDP). The following systole (assisted systole) benefits from the effects of
afterload reduction as the left ventricle does not have to generate as high a pressure to eject
stroke volume and is therefore lower than the patients own PSP/SYS. The result of properly
timed balloon deflation should be:
1. BAEDP < AEDP (ADIA < DIA)
2. Assisted PSP < PSP (ASYS < SYS)
Aside from improper timing, poor afterload reduction may be caused by:
1. Balloon not inflated to full volume causing a decrease in volume displacement
2. Compliant aortic wall which allows for only small changes in volume
3. Improper balloon placement
4. Partial obstruction of gas lumen
BAEDP/ADIA Balloon aortic end diastolic pressure or assisted diastole. Fall in end
diastolic pressure caused by balloon deflation.
Assisted Systole (ASYS) The systole following a balloon inflate/deflate cycle.
(Reduced peak systolic pressure)
Figure 13. Correct Deflation Timing.
BAEDP/ADIA
Assisted
Systole
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Errors in Timing
52
10. El ement s of Ti mi ng ( cont i nued)
Errors in Timing
Inflation or deflation timing errors can be made in two ways: too early or too late. Two of these
errors, early inflation and late deflation, are considered potentially risky to the patient. Late
inflation and early deflation are considered suboptimal, as the patient may not receive the full
benefits of IAB pumping. Although not risky in themselves, late inflation and early deflation
may cause further deterioration of myocardial status due to the lack of benefit.
The IAB has inflated before the aortic valve has closed (during systole) causing premature
closure of the aortic valve and reduction of SV. The hemodynamically unstable patient cannot
afford to lose any forward CO and an impediment of only 10% may cause deterioration.
Figure 14 shows early inflation. Assess the position of the DN by the assisted systole. One can
see that inflation occurs too far before (early) the DN.
During the diastolic phase, there is blood flow from the aorta to the periphery. As a result,
the volume of blood in the aorta will decrease following aortic valve closure. If the balloon is
inflated after the aortic valve closes, there is not as much blood volume available for
displacement, resulting in a lower pressure increase. The major effect of late inflation is a
suboptimal increase in coronary perfusion. Many times the PDP/AUG is the same as PSP/SYS
as well as the DN being visible. See Figure 15.
Figure 15 shows late inflation. Assess the position of the DN by the assisted systole. One can
actually see the DN where it should not be seen. Inflation occurs after (late) the DN.
Figure 14. Early Inflation.
Figure 15. Late Inflation.
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Errors in Timing
53
10. El ement s of Ti mi ng ( cont i nued)
When properly timed, the balloon should deflate during IVC. In early deflation, the balloon is
deflated before IVC so that the corresponding reduction in aortic pressure occurs too soon to be
of benefit. By the time the aortic valve opens, pressure in the aorta has equilibrated back to
baseline so that the ventricle is ejecting against the same pressure as it was without the balloon.
(The equilibrating aortic pressure, at heart rates less than 90, can be seen as a shelf just prior to
the assisted systole.) The net effect is that afterload reduction is not present, and the workload
of the heart is therefore not decreased. See Figure 16.
Figure 16 shows early deflation. In the evaluation of the pressure landmarks, there is no
reduction in the assisted systolic pressure (no afterload reduction effects).
PSP = ASSISTED PSP (SYS = ASYS)
Figure 16. Early Deflation.
Early Deflation
During late deflation, the balloon is inflated (or partially so) at the beginning of ventricular
ejection. The left ventricle now has to force its contents out of the aorta against the resistance of
the inflated balloon. The result is an increase in the workload of the ventricle and impedance of
SV. The hallmark of this timing error is a BAEDP/ADIA that is higher than AEDP/DIA as seen in
Figure 17.
Figure 17 shows late deflation. In the evaluation of the pressure landmarks there is an increase
in the BAEDP/ADIA.
BAEDP > AEDP
ADIA > DIA
Figure 17. Late Deflation.
Late Deflation
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Timing Three
54
10. El ement s of Ti mi ng ( cont i nued)
Figure 18.
The Timing Three
1. Inflation
Just Prior to the Dicrotic Notch (DN)
If > 40ms beforeEARLY INFLATION
If dicrotic notch exposedLATE INFLATION
2. Deflation:
BAEDP < PAEDP ADIA < DIA
BAEDP = Balloon Aortic End Diastolic Pressure (ADIA)
PAEDP = Patient Aortic End Diastolic Pressure (DIA)
If BAEDP/ADIA is higherLATE DEFLATION may be occuring
3. Deflation:
Assisted Systole (APSP/ASYS) < Peak Systole (PSP/SYS)
SYS/PSP = Peak Systolic Pressure
ASYS/APSP = Assisted Peak Systolic Pressure
If both pressures are equalEARLY DEFLATION can be suspected or afterload reduction
not required
PDP/AUG
110
APSP/ASYS
90
PSP/SYS
95
55
2
3
1
PAEDP/DIA
DN
BAEDP/ADIA
PAEDP/DIA
70
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Timing Exercises
55
10. El ement s of Ti mi ng ( cont i nued)
Timing Exercises
The augmented arterial pressure waveform becomes familiar after the operator has practiced
identification of pressure landmarks. The evaluation of the pressure waveform should be an
orderly process. Use of the Timing Three will greatly aid in the diagnosis of proper/improper
timing. The speed of evaluation will increase as the operator gains experience and is exposed to
patient situations. To gain mastery, the operator must PRACTICE, PRACTICE, PRACTICE.
These timing exercises are included to give the learner the opportunity to develop their own
process of analysis and gain familiarity.
1. Improper Timing
Hemodynamic Effect
2. Improper Timing
Hemodynamic Effect
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Timing Exercises
56
10. El ement s of Ti mi ng ( cont i nued)
3. Improper Timing
Hemodynamic Effect
4. Improper Timing
Hemodynamic Effect
5. Improper Timing
Hemodynamic Effect
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Timing Exercises
57
10. El ement s of Ti mi ng ( cont i nued)
6. Improper Timing
Hemodynamic Effect
7. Improper Timing
Hemodynamic Effect
8. Improper Timing
Hemodynamic Effect
Timing Exercises
58 2005 Arrow International, Inc. All rights reserved. CRB-05-0174
10. El ement s of Ti mi ng ( cont i nued)
9. Improper Timing
Hemodynamic Effect
10. Improper Timing
Hemodynamic Effect
Bonus Question: Any guesses on what is happening here?
Timing Exercises
59 2005 Arrow International, Inc. All rights reserved. CRB-05-0174
10. El ement s of Ti mi ng ( cont i nued)
Answers to Timing Exercises
1. Timing Assessment: Inflation optimal
Deflation early
Hemodynamic Effect: Poor afterload
reduction
2. Timing Assessment: Inflation early
Deflation optimal
Hemodynamic Effect: Premature closure
of the aortic valve
causes decreased
CO, increase
preload
3. Timing Assessment: Inflation optimal
Deflation optimal
Hemodynamic Effect: Timing is set for
maximum benefit.
4. Timing Assessment: This is a 1:1 assist
interval, therefore,
cannot assess timing
accurately.
5. Timing Assessment: Inflation optimal
Deflation late
Hemodynamic Effect: Balloon inflated
during systole
which increases
oxygen demands
and afterload
6. Timing Assessment: Inflation early
Deflation early
Hemodynamic Effect: Decreases CO by
early valve closure
and has poor
afterload reduction.
7. Timing Assessment: Inflation late
Deflation optimal
Hemodynamic Effect: Little increase in
CPP
8. Timing Assessment: Inflation late
Deflation late
Hemodynamic Effect: Little increase in
CPP and increased
afterload
9. Timing Assessment: Inflation late
Deflation early
Hemodynamic Effect: Little increase in
CPP and poor
afterload reduction.
10. Timing Assessment: Inflation early
Deflation late
Hemodynamic Effect: Greatly decreased
CO by premature
aortic valve closure
and increased
afterload. Oxygen
demands greatly
increased, increase
preload.
11. There has been a heart rate change. The
original rate was 100 which slowed to 80.
Deflation on the fourth complex is early
after which it is corrected. This is an
example of the automatic timing circuits
readjusting to a rate change without
operator intervention. The compensation
is automatic, occurs in one beat and is
accurate for heart rate changes of 20%.
Arrhythmia Timing
60 2005 Arrow International, Inc. All rights reserved. CRB-05-0174
10. El ement s of Ti mi ng ( cont i nued)
Arrhythmia Timing on the IABP
If the patient develops an irregular rhythm conventional timing algorithms may have difficulty
maintaining consistent appropriate inflation/deflation. "Real Timing" (true R wave deflation) or
"Arrhythmia Timing" modes may result in more efficent deflation timing. Inflation timing is set
as usual in these modes; however, deflation of the balloon is automatic once the next systolic
cycle is identified. The major benefit is having the full period of diastole augmented to enhance
perfusion and minimizing the potential negative effects of early and/or late deflation.
For the ACAT
Inflation Timing
Windkessel Aortic Valve Equation (WAVE
2 WAVE
IABP
in AutoPilot
mode when the Fiber Optic signal is selected. The fiber optic arterial pressure
signal is converted to an aortic flow signal by the pump. The aortic flow waveform is then
used to set inflation of the balloon in synchrony with Aortic Valve closure on a beat to
beat basis.
Compare inflation to the most unassisted beat Dicrotic Notch.
38msec delay
10. El ement s of Ti mi ng ( cont i nued)
Operation
62
10. El ement s of Ti mi ng ( cont i nued)
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Operation
63 2005 Arrow International, Inc. All rights reserved. CRB-05-0174
The AutoCAT
MODE
In AutoPilot
mode the console selects the ECG source, AP source, trigger, and timing.
1. Console scans all available ECG leads continuously. If the current lead selected is
lost or noisy, the console will select another available lead. If another lead is
significantly better for triggering than the current lead, the pump will change
leads. If the clinician desires, he/she can change the ECG lead, source, or gain.
2. AP source is selected by the console but can be changed by the clinician. On the
AutoCAT
2 WAVE
2 Ser i es Oper at i on
Trigger Modes
64
Trigger Modes
It is necessary to establish a reliable trigger signal before balloon pumping can begin. The
computer in the IAB console needs a stimulus to cycle the pneumatic system which inflates
and deflates the balloon. The trigger signal tells the computer that another cardiac cycle has
begun. In most cases it is preferable to use the R wave of the ECG as the trigger signal.
Back-up options are the arterial pressure waveform and pacer spikes.
AutoPilot
automatically selects the best available trigger. If control of the trigger mode is
desired, select Operator mode.
ECG Pattern
Pattern analyzes the height, width and slope of a positively or negatively deflected QRS
complex. The width of the R wave must be between 25-135msec. Widened QRS complexes
may not be recognized, such as bundle branch blocks. Rejection of pacer spikes is
automatic. This is AutoPilot
will only choose this trigger if there are no QRS complexes or arterial pressure
waveforms seen but pacer spikes are present.
AutoPilot
will NEVER
choose this trigger.
To access trigger modes the pump must be in Operator mode.
1. Press the TRIGGER key.
2. Select the desired trigger mode by pressing the
softkey under that trigger.
Aut oCAT
or Operator mode.
If in AutoPilot
will
override the manual selection.
1. To change input source press ECG SELECT twice.
2. To change lead, press ECG SELECT once. Press key under desired LEAD label.
To select the alternate lead II/AVL, press the key under the desired lead again.
To switch gain mode press key under desired label. DECREASE/INCREASE
GAIN keys can be used with AUTO or MANUAL GAIN. If AUTO is selected,
the GAIN change is only valid until lead is changed.
Note: It is highly recommended to use ECG skin leads when AP fiber optic is selected.
SELECT LEAD OR PRESS ECG SELECT
AGAIN TO SELECT MONITOR
5 lead ECG cable
Aut oCAT
2 WAVE
IABP.
2. In use when FIBER OPTIC is selected on the keypad.
B. Transducer Cable
1. In use when XDUCER is selected on the keypad.
C. Monitor Cable
1. In use when MONITOR is selected on the keypad.
TRANSDUCER
FIBER OPTIC SENSOR
A.
B.
C.
MONITOR
Aut oCAT
or Operator mode.
If you select an alternate AP source while the fiber optic
sensor is connected to the pump, AutoPilot
will return to
FIBER OPTIC after one minute.
1. To change input source press AP SELECT twice.
2. To change scale, set AP alarm, zero or calibrate, press AP SELECT once.
Press key under desired label to select function.
AP SCALING
AUTO is the preset.
To set scale manually press AP SCALING once.
Press AP SCALING AUTO to select MANUAL scaling.
Press MANUAL SCALES.
Press soft key under desired scale.
Aut oCAT
IAB tubing disconnected from Check all IAB connections for leak.
Operator console Reconnect and/or tighten as needed.
Gas line tubing and IAB catheter Tighten connection.
not tightly connected at catheter
bifurcation
Leak at IAB connection or in Verify tight connections at all drive
Tygon tubing between console and line tubing connection points.
catheter insertion point
Other helium leak. Check for blood Perform leak test. Replace or repair
in tubing. If blood is observed, IAB as needed.
remove and replace IAB. If no
blood is observed, perform leak test.
Large Helium Leak
High Pressure
Operation Mode Possible Cause(s) Corrective Action
AutoPilot
FiberOptix
1. Select alternate
(AutoCAT
2 WAVE
only)
AP sensor cable Replace IAB. Select an
broken alternate AP source.
CAL key not inserted Insert CAL. Change
or corrupted IAB catheter. Use
alternate AP source.
Aut oCAT
Replace FiberOptix
sensor contact.
AP sensor partially Disconnect AP
connected FiberOptix
sensor.
Verify "click" is heard
when sensor is connected.
AP FOS Sensor AutoPilot
AP FiberOptix
The AutoCAT
2 from AC
mode power source. Check
circuit breaker position
located in helium
compartment.
Circuit breaker Turn on circuit breaker.
turned OFF
Available Battery Power AutoPilot
2 Series IABP
Name: ________________________________________________________________________
Instructor: _______________________________________________ Date: _______________
Skill Observed Completed with Completed
Assistance without Assistance
AUTOPILOT
MODE
Initial Set-up
1. Establish Power
a. Plug Power Cord to Wall Outlet ______ _________________ _________________
b. Press Power On Switch ______ _________________ _________________
2. Connect Patient ECG
a. Skin Cable ______ _________________ _________________
b. Phono-Phono Cable (Slave) ______ _________________ _________________
3. Verify Trigger Acceptance
a. Assist Marker on ECG ______ _________________ _________________
b. Flashing Heart and Heart Rate ______ _________________ _________________
4. Connect Arterial Pressure
a. Transducer Cable ______ _________________ _________________
b. Phono-Phono Cable (Slave) ______ _________________ _________________
c. FOS (if available) ______ _________________ _________________
5. Connect IAB Catheter
a. Verify IABP Volume Setting ______ _________________ _________________
6. Initiate Pumping ______ _________________ _________________
7. Change Assist Interval (Starts in 1:1) ______ _________________ _________________
Recorder
1. Record Timing Strip ______ _________________ _________________
2. Change Recorder Paper ______ _________________ _________________
ECG
1. Adjust ECG Gain ______ _________________ _________________
2. Change ECG Source ______ _________________ _________________
Arterial Pressure
1. Zero FOS ______ _________________ _________________
2. Zero Arterial Pressure Transducer ______ _________________ _________________
3. Change AP Scale ______ _________________ _________________
4. Set AP Alarm (optional) ______ _________________ _________________
Assess Balloon Pressure Waveform
Characteristics ______ _________________ _________________
Aut oCAT
IABP
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Operation
90
ACAT
1 PLUS enables use of Phono -to- Phono cable for pacer triggers.
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Use of the IABP During CPR
92
ACAT
)
Select appropriate source for ACAT
AP automatically
selected based on which cable is connected.
Trigger Pattern
Assist Ratio 1:2
Timing safe
IAB Volume full volume
Alarms ON
Arrow International 24 Hour Intra-Aortic Balloon Product Hotline:
1-800-447-IABP (4227)
International/Worldwide: 617-389-8628
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Balloon Pressure Waveform
94
ACAT
Series.
* Pumping will resume automatically with ACAT
Series only
THE PUMP WILL:
go to PUMP OFF
deflate the IAB
initiate an audio alarm
display an alarm message on the screen
freeze the waveform display
activate the recorder to print the last
5 seconds of both the AP and balloon
pressure waveforms (7 sec. for ACAT
1)
THE PUMP WILL:
go to pump STDBY (system not
vented to atmosphere)
deflate the IAB
initiate an audio alarm
display an alarm message
THE PUMP WILL:
display an advisory message
audible alarm (Class 3 Alarm)
THE PUMP WILL:
display message only without an
audible alarm (Class 4 alarm)
Alarms
100
ACAT
) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3. Phono-Phono (ACAT
1 PLUS) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C. Adjust ECG Gain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D. Connect Arterial Pressure _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
1. Phono-Phono _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2. Transducer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E. Initiate 4 beat purge _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
F. Initiate Pumping _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2. Timing, Identify and Correct
A. Early inflation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
B. Late inflation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C. Early deflation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D. Late deflation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3. Change Assist Interval _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4. Set Up for Pacemaker Detection/Rejection _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(I.D. appropriate ECG cable)
5. Recorder
A. Program:
AP, BPW _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
AP _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date/Time _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
B. Change Paper _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
6. Zero Arterial Pressure Transducer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
IABP Skills Checklist
102
ACAT
Oper at i on
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Figure 31
Trigger Modes
104
Aut oCAT
MODE
In AutoPILOT mode the console selects the ECG source, AP source, trigger, and
timing.
1. Console scans available ECG leads. If the currently selected lead is lost, the console
will select the next clear ECG lead.
2. AP source is selected by the console but can be changed by
the operator.
3. If trigger is lost, console will select alternate trigger.
4. The console continuously assesses correlation of IAB diameter to patients aortic
diameter. If the IAB is found to be too large for the patients aorta, the console will
decrease the IAB volume to correct this condition.
5. All control keys and knobs, whose functions are adjusted by the console in
AutoPILOT mode, will not function when this mode
is selected.
If, at anytime, the operator prefers to take control of trigger,
ECG source, timing, etc. this can be accomplished by selecting OPERATOR mode.
OPERATOR MODE
This is the mode of operating all other models of intra-aortic balloon
pumps use. The operator makes all choices regarding ECG source,
AP source, trigger, timing, and IAB volume.
1. Once timing is set the console will automatically adjust timing for changes in
heart rate and rhythm.
Use of the IABP During CPR
105
Aut oCAT
will go
to AP trigger. If no AP waveform detected, the pump will automatically look for the ventricular
pacer spike of a V pacer or AV pacer.
When the pump is in OPERATOR mode, the ECG trigger key can be used to toggle between
triggering on the R-wave of the ECG and the V spike of a V or AV paced rhythm.
AP
The systolic upstroke of the arterial pressure waveform is the trigger event. A 14mmHg minimum
pulse pressure is required initially then 7mmHg thereafter. Every 64th beat is unassisted when in
1:1 assist and assessed by the console to ensure proper trigger. AP trigger may be used when
ECG triggering is not possible. To avoid late deflation, set the deflation point to occur prior to
the systolic upstroke. AP triggering is not recommended for use with irregular rhythms.
INT
An internally generated signal provides asynchronous assist. It may be set at 40, 60 or 80 assists
per minute. Should the system detect an R-wave while in internal trigger mode, an audible
alarm is sounded and the message ECG DETECTED will appear on the monitor screen.
WARNING: DO NOT USE THE INTERNAL TRIGGER MODE IN THE PRESENCE OF ANY
INTRINSIC CARDIAC ACTIVITY; SERIOUS COMPETITIVE HEMODYNAMICS WILL
RESULT. Available in Operator Mode only.
Initiation of Pumping
106
Aut oCAT
Mode when
no ECG trigger can be
obtained.
ARRHYTHMIA Message only Irregular cardiac rhythm If the rhythm is irregular,
TIMING or irregular triggering. treat patient accordingly.
Ensure the trigger signal is
clear; pump not triggering
on artifact.
If desired, the automatic
afib timing can be
overridden by pressing
AFIB TIMING OFF.
AVL FAILURE Audible tone, message, AVL not functioning Call for service. Try to
deflate balloon; stop properly re-initiate pumping by
pumping powering down and back up.
BALLOON Audible tone, message, No pressure in balloon Check gas tubing
DISCONNECT deflate balloon; stop line or balloon line not connections at console or
pumping connected. at balloon connection.
GAS ALARMS OFF Call for service if all
Mode: Message only connections are tight and
alarm condition persists.
CALL SERVICE Unable to start Computer failure Call for service. Try to
pumping, display re-initiate pumping by
message. powering down and back up.
CHECK Active in OPERATOR Pumping switched from Reminder to assess timing.
TIMING Mode only. Message. AUTOPILOT mode to Adjust as needed.
OPERATOR mode.
Assist interval set to Press ASSIST FREQ to
short to fully inflate 1:2 to evaluate timing.
balloon. Readjust timing.
ECG Message and beep tone Cardiac activity (ECG) Switch trigger mode
DETECTED every 5 seconds. detected while pumping according to patients
in INTERNAL trigger. rhythm. Readjust timing.
FILL FAILURE Audible tone, message, Failure to fill to Press ASSIST key again.
deflate balloon; stop 6-10mmHg during Check for adequate supply
pumping fill state. of helium. If alarm persists,
operate in GAS ALARMS
GAS ALARMS OFF OFF override mode until
Mode: None another console available.
Alarms
113
Aut oCAT
IABP
Name: __________________________________________________________
Instructor: _________________________________ Date: ______________
Skill Observed Completed Completed
With Assistance Without Assistance
AUTOPILOT
MODE
Initial Set-Up
1. Establish Power
a. Plug Power Cord to Wall Outlet
b. Press Power On Switch
c. Verify/Select Operation Mode
2. Connect Patient ECG
a. Skin Cable
b. Phono-Phono Cable (Slave)
3. Verify Trigger Acceptance
a. Assist Marker under ECG
b. Flashing Heart and Heart Rate
4. Connect Arterial Pressure
a. Transducer Cable
b. Phono-Phono Cable (Slave)
5. Connect IAB Catheter
6. Initiate Pumping
7. Change Assist Interval (Starts in 1:1)
Recorder
1. Recorder Timing Strip
2. Change Recorder Paper
Arterial Pressure
Zero Arterial Pressure Transducer
Set MAP Alarm (Optional)
Aut oCAT
Oper at i on
2005 Arrow International, Inc. All rights reserved. CRB-05-0174
Trigger Modes
The trigger is the event the pump uses to identify the onset of the cardiac cycle (systole). The
pump must have a consistent trigger in order to provide patient assist. If the selected trigger
signal can no longer be detected, counterpulsation will be interrupted.
R-WAVE this mode uses the slope of the QR segment to detect the triggering point and reject
pacer spikes. R-wave triggering is the recommended mode, whenever possible.
PEAKS this mode utilizes either the R-wave or the pacing spike as the trigger. PEAKS is
generally used for patients with wide QRS complexes as in fixed-rate ventricular pacing.
WARNING: DO NOT USE PEAKS TO TRIGGER FROM ATRIAL OR AV SEQUENTIAL
PACER SPIKES AS PREMATURE INFLATION IN THE CARDIAC CYCLE WILL OCCUR.
A/V PACE this mode uses the ventricular spike of the AV pacer to detect the triggering point.
AV PACE should only be used in the presence of 100% AV sequential pacing (fixed rate).
AP (PRESSURE) this mode uses the systolic upstroke to detect the trigger event. A 14mmHg
minimum pulse pressure is required. AP trigger may be used when ECG triggering is not
possible. To avoid late deflation, set the deflation point to occur prior to the systolic upstroke.
AP triggering is not recommended for use with irregular rhythms.
INTERNAL An internally generated signal provides asynchronous assist. To decrease the
internal assist ratio the wean ratio may be utilized. Should the system detect an R-wave while in
the internal trigger mode, an audible alarm is sounded and the message ECG DETECTED will
appear on the monitor screen. WARNING: DO NOT USE THE INTERNAL TRIGGERING
MODE IN THE PRESENCE OF ANY INTRINSIC CARDIAC ACTIVITY; SERIOUS
COMPETITIVE HEMODYNAMICS WILL RESULT.
Use of the IABP During CPR
118
Tr ansAct