IABP Removal

[BJRN76]

I wanted to post a question to the board and get a feel for what is being done in other institutions. I work in busy CCU unit. We routinely care for IABP patients. We have a new cardiologist on staff who thinks that the bedside nurse should D/C the IABP's when ordered without a physcian present or potentialy even in house . Currently our policy is to have a physcian D/C pumps. Our nurses do have a lot of autonomy, more than any other CCU I've been in. So I'm wondering if this is common practice in other CCU's or if we are getting into murky waters. Thanks for your input.

[justanurse]

IABP = Intra-Aortic Balloon Pump

This device is a near ventilator size machine attached to an arterial line placed into the patient's femoral artery. On the end of the line is a balloon that is rhythmically inflated and deflated with helium. This is timed just right by the machine to correspond with the patient's heart rhythm. As the balloon inflates it pushes blood back against the aortic valve and into the cardiac arteries (increasing blood flow to the heart) and down the aorta (increasing blood flow to the rest of the body). The balloon has to be positioned just right by the cardiologist (or other specially trained Dr) so that it does not occlude the renal arteries or the left subclavian artery.

Hope this helps!

[delirium]

thanks very much for your explanation, it helps a lot.

i appreciate that you've taken the time to explain it to me.

take care,

msp

[Andie CCURN]

At my facility the MD who puts it is takes it out. The RN responsibilites are to have ACT ready usuallly

[booklady]

It's very important that you check with your State Board to see their view on this. I have done classes for Datascope Balloon Pumps and they do not endorse that RN's d/c IABP's because of the rare but real danger of balloon entrapment. THis happens if there is a small leak in the the balloon, the helium reacts with the blood that leaks into the circuit, and hardens to a cement like substance. Worst case scenario, can rip the aorta when the catheter is withdrawn. Hence the need for a physician present. (Of course my favorite smart-mouth cardiologist remarked,"What difference does it make if I'm there or not, the patint's going to die anyway!") Seriously, some hospitals do not even allow the physician to D/C the IAPB unless a surgery team in house. So the issue is not hemostasis, because if you're like us , we D/C 9 and 10 sheaths all the time, the issue is the entrapment.

[olympiad27]

I have never worked anywhere where it was the RNs responsibility to remove the IABP catheter . Currently where I work it is always removed by the physician, or his mid- level practitioner (ie. PA, CNS or NP) who has been trained to do so by the physician in most cases. This skill falls under the category of advanced practice in my opinion and should not be performed by an RN.

[Kat63]

In my CCU (a 10 bed unit) we do not pull IABPs, the cath lab staff comes to floor and performs an ACT and if it is within range (

[wendyssmile]

I work in a combination CCU and CTICU. On our surgical pateints the nurse practitioners d'c the IABP's. If it is a CCU patient the IABP is d/c'd by the cath lab fellow or the CCU fellow. I would not want to be responsible for pulling the IABP. Also it is just another thing added to your day that you do not have time for !

[CTnuse]

Wow that is really murky water. I work in a Cardiothoracic ICU and we see our fair share of balloons. Our surgeons always d/c the balloon, hold pressure for ~5 minutes (sometimes using the Syvek Patch) then pass the responsibility to the PA/NP on duty.

I would hate the responsibility, I onceheard of an incident where the balloon was entraped and not only was the balloon d/c'd but the femoral artery was too!!!

I worked too hard and long for my license and do not want that liability.

Good luck in your research.

Denise

[BABYGIRL_RN]

PULLING IABP CATHETERS IS OUT OF THE SCOPE OF NURSING CARE. A DR OR PA CAN REMOVE IABP ONLY. THE NURSE'S JOB IS TO HOLD PRESSURE FOR 30 PLUS MINUTES AND TO MONITOR FOR POST REMOVAL COMPLICATIONS. NURSES WHO PULL IABP CATHETERS ARE PUTTING THEIR SELF AT RISK OF LOSING THEIR LICENSE. IF SOMETHING GOES WRONG, THE DR IS NOT GOING TO TAKE YOUR SIDE AND STATE, I TOLD THAT NURSE TO REMOVE THE PT'S IABP CATH. YOU REALLY NEED TO CHECK WITH YOUR STATE'S BOARD OF NURSING. BE VERY CAREFUL IN FOLLOWING "CRAZY" ORDERS FROM DR.

[pattylynn15]

I work in a very busy CCU. Staff nurses do not remove IABP catheters, and we are very happy not to do so. Admittedly, 99% of the time everything goes smoothly. But we have seen a few cases where everything went very bad, very fast.

One case in point was when the wire in the center of the catheter was broken on insertion and we did not know it. The CT surgeon went to remove the catheter, and ended up doing a cutdown at the bedside to save the patient from a catheter embolism in his aorta/femoral artery.

If you are an advanced practice RN on an invasive cardiology (or surgical cardiology) service, have been trained in IABP removal, and have medical/surgical staff available during removal, it would be another story. But it is risky business when you have no backup.

As always, you need to check with your state's standards of practice guidlines in order to see what you are and are not allowed to do under your license in your state.

[heartsmart]

For 21 years it has never been my job or responsibility and shall remain that way. I have seen TOO many problems from improper removal, bleeding, clots, immediate death from aortic laceration, femoral laceration, not to mention strokes and perminent loss of limbs & Black toes eeekkkky. IT IS NOT my job......... nor do I wish to loose my license. The CV surgeon or interventional Cardiologist are the ones who should remove them. Nothing in your scope of practice says you are covered, now if the patient pulls the thing out or climbs out of bed you best be there or it's your butt in the sling and notify the MD ASAP and yes you should know immediately what to do. GET HELP? LOTS OF IT>Turn IABP to standby, Check out the site, ect. CXRAY, Check pulses, urine output heart rate, ect. Level of acuity is another scope of care that needs to be addressed. IABP's at our facility are 1:1.sometimes 2:1 if they are particularly unstable with numerous gtts to titrate post op CABG or in acute cardiogenic shock. But our DR.s are close by also. Successful outcomes are important to all of us. DR.s hold pressure as long as it's necessary and if there are problems they direct the intervention. I like my job but clearly know what limitation it has. The same for pulling chest tube. If you've seen one bleeding and part of the new graft come out with the chest tube you realize the risk is not yours.. NURSE not MD. It is your job to check pulses, document clearly what is or isn't present, cms ect. and telling the MD if it changes ASAP. We are responsible for the outcome if something changes and following up with the MD. This does not mean waiting for the next shift to do it because it might mean you get out late. Things happen that we can and cannot control. Knowing the difference keeps your patients safe and with a good outcome. We are not Gods, but Goddesses will do!!!!!!!!!!! Tell you what I've seen and heard all kinds of rasons. Still not my job. All though how many surgeons actually let it back bleed out the clots or hold pressure below first then above the clear the clots. Always remind them to do this. Save the toes. Pink is pretty!!!!!!!!!!

[MIS]

Our facility has similar guidelines for pulling IABP's. Physician pulls pump after ACT levels are less than 150 and holds manual pressure for 5min and then the nurse steps in and finishes, usually holding pressure for 20-30min. Whether or not we use a fem-stop varies from doc to doc.