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Counterpulsation: What Kind of Counter is that?

CCU Article   (4,804 Views 6 Replies 1,159 Words)
by Esme12 Esme12, ASN, BSN, RN (Moderator) Nurse

Esme12 is a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

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Counterpulsation is life saving treatment for the sick and failing weak heart. The use of the intra-aortic balloon pump in the ICU on the critically ill patient has saved many lives. How does this work? Why does this work? Who thought of this crazy idea? Timing is everything but it isn't the time on the clock you are concerned with.

Counterpulsation: What Kind of Counter is that?

Well...it is not in your kitchen....

Counterpulsation : count-er-pul-sa-tion (kown'ter-pÅ­l-sÄ'shÅ­n), A means of assisting the failing heart by automatically removing arterial blood just before and during ventricular ejection and returning it to the circulation during diastole; a balloon catheter is inserted into the aorta and activated by an automatic mechanism triggered by the ECG. (Farlex Partner Medical Dictionary)

The intra-aortic balloon pump (IABP) was introduced the in the late 1960s by Dr. Adrian Kantrowitz as a simple yet effective device to increase coronary perfusion. The IABP is a balloon that sits in the aorta approximately 1-2cm below the origin of the left subclavian artery and is inserted via the femoral artery.

Because it is easy to insert, the IABP is the most widely used form of mechanical circulatory support. Dr. Kantrowitz not only invented the intra-aortic balloon pump he also invented the L-VAD and an early version of the internal pacemaker. He also performed the first pediatric heart transplant in 1967. Inventions: Intra-Aortic Balloon Pump | Thayer School of Engineering at Dartmouth

The principle of the IABP (intra-aortic balloon pump) in simple with the primary goal is to improve the ventricular performance of the failing heart by facilitating an increase in myocardial oxygen supply and a decrease in myocardial oxygen demand.

The first uses of the IABP were used for surgical patients; the pump can now be used along with interventional cardiology procedures and medical therapy (medications).

Some indications for its use include

  • Failure to wean from cardiopulmonary bypass.
  • Cardiogenic shock.
  • Heart failure.
  • Acute heart attack.
  • Support during high-risk percutaneous transluminal coronary (balloon) angioplasty, rotoblator procedures, and coronary stent placement.

The balloon inflation in diastole and deflation in early systole causes 'volume displacement' of blood within the aorta, both proximally and distally. The intra-aortic balloon, by inflating during diastole, displaces blood volume from the thoracic aorta leads to a potential increase in coronary blood flow and displacing the blood distally increases blood flow to the distal extremities and organs. In systole, as the balloon rapidly deflates, this creates a dead space, effectively reducing afterload for myocardial ejection and improving forward flow from the left ventricle.

There are several contraindications to using the IABP. For example: patients with aortic regurgitation because it worsens the magnitude of regurgitation. IABP insertion should not be attempted in case of suspected or known aortic dissection because inadvertent balloon placement in the false lumen may result in extension of the dissection or even aortic rupture. Similarly, aortic rupture can occur if IABP is inserted in patients with sizable abdominal aortic aneurysms. Patients with end-stage cardiac disease should not be considered for IABP unless as a bridge to ventricular assist device or cardiac transplantation.

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IABP device placement should be avoided in patients with severe peripheral vascular disease. Percutaneous femoral IABP device insertion is contraindicated in the presence of bilateral femoral-popliteal bypass grafts. Uncontrolled sepsis and bleeding diathesis are relative contraindications to the placement of IABP device.

http://ceaccp.oxfordjournals.org/content/9/1/24.full.pdf

Accurate timing of the pump is imperative for maximal assistance. ICUFAQs-Intra-Aortic Balloon Pump Review

Correct timing of balloon inflation and deflation during the cardiac cycle is vital to ensure optimal effects of counterpulsation minimizing potentially harmful effects related to mistiming. Most commonly the ECG waveform is used to trigger balloon inflation and deflation. The arterial pressure waveform is an alternative technique that may be useful if either the ECG trace is poor or there are cardiac arrhythmias. Present day machines allow either method to be easily selected. The balloon starts to inflate at the onset of diastole. This corresponds to the middle of T wave on the ECG waveform and the dicrotic notch of the arterial pressure trace. As aortic valve closure has occurred balloon inflation causes a sharp upstroke on the arterial pressure waveform followed by a tall peak which represents the assisted diastolic pressure. Deflation occurs at the onset of systole immediately before opening of the aortic valve. This corresponds with the peak of the R wave on the ECG trace and the point just before the upstroke of systole on the arterial pressure trace. As the balloon deflates, the assisted aortic end-diastolic pressure dips down to create the second deep wave, usually U shaped on the arterial pressure waveform. IABP timing in relation to the cardiac cycle is monitored by display of arterial pressure waveform.

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Improper timing can increase the hearts workload and further stress the failing heart. The balloon is set to inflate after the aortic valve closure (which corresponds to the dicrotic notch on the arterial waveform) and deflate immediately before the opening of the aortic valve (which corresponds to the point just before the upstroke on the arterial pressure waveform). IABP timing refers to inflation and deflation of the IAB in relation to the cardiac cycle. The cardiac cycle is monitored by continuous display of the arterial pressure waveform. As the balloon inflates at the onset of diastole, a sharp and deep 'V' is observed at the dicrotic notch Balloon inflation causes augmentation of diastolic pressure and a second peak is observed. This peak is referred to as diastolic augmentation. Diastolic augmentation is ideally higher than the patient's systolic pressure except when reduced stroke volume causes a relative decrease in augmentation. Depending upon the patient's hemodynamic status, the balloon is programmed to assist every beat (1:1) or less often (1:2, 1:4, or 1:8)

Principles of intra-aortic balloon pump counterpulsation

The intra-aoritc balloon pump may appear to be a sophisticated video game, with pretty colors on a screen, but is a life saving adjunct in the care of the sick and failing heart. Counterpulsation is a valuable method of temporary mechanical circulatory support that attempts to create more favorable balance of myocardial oxygen supply and demand by using the concepts of systolic unloading and diastolic augmentation that saves cardiac muscle by allowing it to rest and increasing coronary perfusion by increasing the blood flow down the coronary arteries.


Resources

Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL Jr. Initial clinical experience with intraaortic balloon pumping in cardiogenic shock. JAMA. 1968 Jan 8;203(2):113-8. PubMed PMID: 5694059.

Unverzagt S, et al. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD007398. doi: 10.1002/14651858.CD007398.pub2. Review. PubMed PMID: 21735410.

Thiele, H. et al. Intra aortic balloon support for myocardial infarction with cardiogenic shock. NEJM 2012 Oct 4;367(14):1287-96.

35 years experience, my specialty is critical care/ED/Trauma Flight and being Mom to 2 teenage children and one spoiled Weimaraner.

5 Followers; 4 Articles; 146,156 Visitors; 20,896 Posts

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NRSKarenRN has 40 years experience as a BSN and specializes in Vents, Telemetry, Home Care, Home infusion.

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Thank you for this info --learned something new today!

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tnbutterfly is a BSN, RN and specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

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Thank you for this very informative article!!

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16,379 Visitors; 1,026 Posts

Very informative. Thanks for sharing your thoughts.

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calivianya specializes in ICU.

35,255 Visitors; 2,418 Posts

Thanks for the info! We don't get balloon pumps on my ICU so I feel like I will miss all those questions when I take CCRN. This is a good resource. I will be back to read it again.

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DosmoRN has 30 years experience and specializes in SCI and Traumatic Brain Injury.

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WOW! what a great new life saving device! Lots of new things since I retired from nursing.

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delphine22 has 5 years experience and specializes in Quality, Cardiac Stepdown, MICU.

7,526 Visitors; 304 Posts

Just took a class on IABPs (don't yet work on a unit that has them though). Very fascinating. We spent a good amount of time examining the waveforms to see if the balloon is inflating early or late, or deflating early or late.

Late inflation or early deflation are certainly not optimal, but they are not necessarily causing harm to the patient. However, early inflation and late deflation can cause serious harm. The rep had a good way to remember this: "You don't want to be too early for your shift or leave too late."

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