This 67-year-old male was admitted to the Intensive Care Unit 6 hours ago following emergency coronary artery bypass grafting. He has remained hypotensive (mean arterial pressure of 60 mmHg) and oliguric, despite adequate fluid loading to a right atrial pressure of 15 mmHg and an adrenaline infusion at 20 mg/min. A recent transoesophageal echocardiogram demonstrates global severe systolic dysfunction and no evidence of pericardial tamponade.
You have been asked to consider inserting an intra-aortic balloon pump by the attending team.
Consider your approach and preparation for this procedure.
Procedure station: Candidates were expected to provide a systematic approach to the principle of insertion, management and removal of an Intra-Aortic Balloon Pump catheter. Nineteen out of twenty-eight candidates passed this section.
Indications for IABP insertion:
No choice but pump
Probably harmless, but probably not useful
Totally experimental
(Ideally, you'd have an IABP as a prop to hand to the candidate, so they can fiddle with it physically. The picture of my own expired IABP is included here for convenience).
This is an intra-aortic balloon pump catheter.
Its major features are:
Generally speaking, the IABPs are sized according to height.
By Seldinger technique, of course. There is a sheathed and unsheathed version of this procedure
Two main ways of checking the position:
Absolute contraindications
Relative contraindications
Common complications
Rare complications
There is early balloon inflation and early balloon deflation.
Early balloon inflation results in
Early balloon deflation results in
Two main schools of thought:
Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.
Insertion of the IABP: a manual by MAQUET
Ranucci, Marco, et al. "A Randomized Controlled Trial of Preoperative Intra-Aortic Balloon Pump in Coronary Patients With Poor Left Ventricular Function Undergoing Coronary Artery Bypass Surgery." Critical care medicine (2013). 2013 Nov;41(11):2476-83.
Theologou, Thomas, et al. "Preoperative intra aortic balloon pumps in patients undergoing coronary artery bypass grafting." Cochrane Database Syst Rev 1 (2011).
Ohman, E. Magnus, et al. "Use of aortic counterpulsation to improve sustained coronary artery patency during acute myocardial infarction. Results of a randomized trial. The Randomized IABP Study Group." Circulation 90.2 (1994): 792-799.
Moulopoulos, Spyridon D., Stephen Topaz, and Willem J. Kolff. "Diastolic balloon pumping (with carbon dioxide) in the aorta—a mechanical assistance to the failing circulation." American heart journal 63.5 (1962): 669-675.
SOROFF, HARRY S., et al. "Assisted circulation II. Effects of counterpulsation on left ventricular oxygen consumption and hemodynamics." Circulation 27.4 (1963): 722-731.
Chen-yang, Jiang, et al. "Anticoagulation therapy in intra-aortic balloon counterpulsation: Does IABP really need anti-coagulation?." Journal of Zhejiang University SCIENCE A 4.5 (2003): 607-611.
Cooper, Howard A., Elissa Thompson, and Julio A. Panza. "The role of heparin anticoagulation during intra-aortic balloon counterpulsation in the coronary care unit." Acute Cardiac Care 10.4 (2008): 214-220.
Chin, Chee Tang, et al. "The impact of anticoagulation during intra-aortic balloon counterpulsation pump placement on in-hospital outcomes in 18,875 patients undergoing cardiac revascularization." Circulation. Vol. 122. No. 21. 530 WALNUT ST, PHILADELPHIA, PA 19106-3621 USA: LIPPINCOTT WILLIAMS & WILKINS, 2010.
Yutani, Chikao, et al. "CEREBRO‐SPINAL INFARCTION CAUSED BY ATHEROMATOUS EMBOLI." Pathology International 35.4 (1985): 789-801.
Ho, A. C., et al. "Stroke after intraaortic balloon counterpulsation associated with mobile atheroma in thoracic aorta diagnosed using transesophageal echocardiography." Chang Gung medical journal 25.9 (2002): 612-616.
Kvilekval, Kara HV, et al. "Complications of percutaneous intra-aortic balloon pump use in patients with peripheral vascular disease." Archives of Surgery 126.5 (1991): 621.
Rius, Jordi Bañeras, et al. "Resolution of Shock-Induced Aortic Regurgitation With an Intraaortic Balloon Pump." Circulation 124.4 (2011): e131-e131.
Ferguson, James J., et al. "The current practice of intra-aortic balloon counterpulsation: results from the Benchmark Registry." Journal of the American College of Cardiology 38.5 (2001): 1456-1462.
Alderman, James D., et al. "Incidence and management of limb ischemia with percutaneous wire-guided intraaortic balloon catheters." Journal of the American college of Cardiology 9.3 (1987): 524-530.
Pennington, D. Glenn, et al. "Intraaortic balloon pumping in cardiac surgical patients: a nine-year experience." The Annals of thoracic surgery 36.2 (1983): 125-131.
Cruz-Flores, Salvador, Alan L. Diamond, and Enrique C. Leira. "Cerebral air embolism secondary to intra-aortic balloon pump rupture." Neurocritical Care 2.1 (2005): 49-50.
HIROOKA, KAZUNOBU, et al. "Helium Gas Embolism caused by a Ruptured Intraaortic Balloon." Japanese Journal of Intensive Care Medicine 27.9 (2003): 867-871.
Mitchell, Simon J., et al. "Cerebral arterial gas embolism by helium: an unusual case successfully treated with hyperbaric oxygen and lidocaine." Annals of emergency medicine 35.3 (2000): 300-303.
Chockalingam, Anand, et al. "Dynamic left ventricular outflow tract obstruction in acute myocardial infarction with shock cause, effect, and coincidence." Circulation116.5 (2007): e110-e113.
Bavin, Terry K., and Marjorie A. Self. "Weaning from intra-aortic balloon pump support." AJN The American Journal of Nursing 91.10 (1991): 54-59.