Help RE: IABP

The tip of the catheter (the "root" line) should be about 1 cm distal to the left subclavian artery. That is most easily established by echo cardiogram, not sure what other folks do.

You transduce the distal tip of the IABP catheter tip and, in the vast majority of patients, have a radial or some other arterial pressure as well. We just have a pressure bag on the catheter so there is no need for routine flushes.

So to clarify -- is the tip of the arterial line alongside the tip of the balloon? We only get IABP so few times a year. We always place our hep bag in a pressure bag but again I've gotten various responses in that I should manually flush every hour no matter what. One nurse even told me that I should place the balloon pump on stand by prior to manually flushing and reasoning was that "if you manually flush while the balloon is inflating, you're just pushing that heparin back into the coronary arteries." I'm getting confused with different answers here. And I've looked up our policies and procedures and it says nothing about manual flush however all the heart nurses on my unit manually flush (maybe because of how it was done the old way?)

The tip of the catheter (the "root" line) should be about 1 cm distal to the left subclavian artery. That is most easily established by echo cardiogram, not sure what other folks do.

You transduce the distal tip of the IABP catheter tip and, in the vast majority of patients, have a radial or some other arterial pressure as well. We just have a pressure bag on the catheter so there is no need for routine flushes.

So to clarify -- is the tip of the arterial line alongside the tip of the balloon? We only get IABP so few times a year. We always place our hep bag in a pressure bag but again I've gotten various responses in that I should manually flush every hour no matter what. One nurse even told me that I should place the balloon pump on stand by prior to manually flushing and reasoning was that "if you manually flush while the balloon is inflating, you're just pushing that heparin back into the coronary arteries." I'm getting confused with different answers here. And I've looked up our policies and procedures and it says nothing about manual flush however all the heart nurses on my unit manually flush (maybe because of how it was done the old way?)

The terms "root line" and "arterial line" are sometimes used synonymously. The very tip of the balloon catheter has a hole in it and that is where the pressure is measured. Patients very often have a standard radial A-line as well, and a blood pressure is measured there too.

Like I said, a pressure bag keeps the catheter lumen patent so routine flushing isn't necessary, but if you did flush it you wouldn't need very much volume at all and the concentration of heparin, I would imagine wouldn't need to be more than 10 units per cc, if that.

The theoretical concern about flushing the coronary arteries is, IMO, misplaced. When a surgeon puts someone on the heart-lung machine, he puts a 20 fr catheter right into the ascending aorta and gives a bolus of 100 cc of crystalloid that doesn't hurt the patient at all.

But if that is what folks do at your place, it's easy enough to pause the pump for a few seconds, flush and then resume normal function.

I've gotten different responses from our senior nurses, but I wanted to know what your guys' typical practice is: For the heparin flush going in the root line, do you manually flush every hour? And if so, do you place the machine on standby prior to flushing or no? And where is the tip of the root line on the balloon? Is the art line at the distal end where the balloon tip is or is the art line's tip (inside the pt) located elsewhere? Tried to look info in our policy but no information found regarding manually flushing the root line. If anyone has any recent evidence based study they'd like to share, please feel free. If it helps, I'm pertaining to the Autocat 2 WAVE machine. Thanks guys!

Your facility should have a policy regarding flushing of balloon pumps. The fact that yours doesn't address flushing tells me that your institution doesn't recommend hourly flushes. I have worked for institutions that flushed, and for institutions that did not. Anecdotally, I didn't notice any big difference in complications between the institutions that flushed and the institutions that didn't.

If you DO flush, you should place your balloon pump on standby while flushing for ten seconds, then restart the pumping. The reason for placing your balloon pump on standby is the possibility of dislodging a clot or fibrin and flushing it forward. The heparin in your flush bag should not be a consideration, because you're going to have a heparin level either way.

The tip of the balloon should be between the second and third intercostal spapce on CXR. Many institutions require daily CXRs. If your balloon is malpositioned, the radiologist will call back at 6 PM to tell you -- after 12 hours of ineffective pumping and risk of complications. Get into the habit of looking at the CXR yourself so you can alert the provider early if there's an issue. It will take you a while to get used to looking at the CXR and what you are seeing.