Page 328 - ACCCN's Critical Care Nursing

Cardiac Surgery and Transplantation 305

usually undertaken if indicated and according to specific
BOX 12.1 Effects of intra-aortic balloon hospital protocol (no literature available to support sys-
counterpulsation temic heparinisation).
Hourly assessments of peripheral perfusion (colour,
Balloon inflation warmth, movement, sensation) should be performed to
● increased aortic diastolic pressure (augmented, or balloon- identify potential deficits. Dorsalis pedis and posterior
assisted peak diastolic pressure, BAEDP) tibialis pulses should be palpated and may sometimes
● increased mean arterial pressure require examination with a Doppler probe. Deficits
● increased myocardial perfusion and oxygen supply should be promptly reported and consideration given
● increased cerebral and systemic perfusion to catheter removal or reinsertion on the contralateral
limb. When pulses cannot be demonstrated, the limb
Balloon deflation should be assessed for the development of compartment
● decreased afterload syndrome. At times the viability of a limb must be
● increased stroke volume and cardiac output weighed against the potential survival benefit of IABP to
● decreased LV congestion, decreased PCWP, decreased the patient.
pulmonary congestion
● decreased left ventricular workload
● decreased systolic pressure Prevention and Treatment of Bleeding
● decreased myocardial oxygen demand Significant bleeding is uncommon, but blood loss may
51
● decreased duration of isovolumetric contraction occur from the femoral arterial access site. In addition
to physical factors at the insertion site, contributors to
bleeding include heparinisation, thrombocytopenia from
the physical effect of the pump on platelets, and/or other
anticoagulants or antiplatelet agents used for the primary
50
catheter size. Limb ischaemia remains the commonest disease. Regular observation should be made of the inser-
serious complication, especially in patients with existing tion site for bruising or external bleeding, as well as
51
vasculopathy, providing impetus to the development of other possible sites of bleeding due to heparinisation.
smaller catheters, which have now reached 7.5 French Treatment includes pressure at the insertion site (includ-
gauge. Additional complications, such as bleeding, ing the use of sandbags), reinforcement of dressings,
catheter migration, thromboembolism, insertion-site and/or topical procoagulant agents. Monitoring of coagu-
vascular damage, thrombocytopenia and device-related lation status and haemoglobin should be undertaken
problems such as timing inaccuracy, device failure and and blood or blood products may (uncommonly) be
gas leaks, also occur but are less common. These are required.
described below.
Prevention of Immobility-related
NURSING MANAGEMENT Complications

Prevention of complications, as well as optimisation of The need for immobilisation of the patient, and in par-
the impact of counterpulsation, form the major compo- ticular the leg, is often overemphasised, and may heighten
nents of nursing care of a patient being treated with IABP. the risk of atelectasis, pressure area development and
Thorough understanding of the impact of the presence of venous stasis and thrombosis. Sensible limitation of leg
the balloon, as well as the beneficial and detrimental movement is advised, but patients can generally still
effects of counterpulsation, is essential. move in bed, and should still be turned 2-hourly for pres-
sure relief as long as the insertion site is adequately pro-
Maintenance of Limb Perfusion tected and supported. The femoral access limits flexion at
The use of smaller-gauge catheters has reduced the poten- the hip beyond 30 degrees, which may also hamper effec-
tial for obstruction of arterial flow past the catheter to the tive chest physiotherapy and increase the risk of atelecta-
lower limbs, as has the trend to sheathless insertion. sis and pneumonia.
Nevertheless, the threat of limb ischaemia remains an Migration of the balloon catheter towards the aortic
important issue in patient care, as IABP is most com- arch or towards the abdominal aorta may cause com-
monly undertaken in patients with atherosclerosis, promised perfusion to left arm (occlusion of left sub-
potentially involving the lower limbs, even in the absence clavian artery), kidneys (renal arteries) or abdominal
of overt peripheral vascular deficits. Identification of viscera (superior mesenteric artery). Therefore, neuro-
patients at risk (known claudication, chronically cold feet vascular observation of upper limbs, urine output and
and peripheral vascular diseases) may be useful to ensure bowel sounds are part of nursing management of patient
appropriate vigilance and prompt intervention where with IABP in situ.
necessary. Peripheral perfusion may also be compromised
by arterial embolisation should thrombi develop on
the catheter. Although catheter materials are non- Weaning of IABP
thrombogenic, the risk of thrombi formation remains Weaning of intra-aortic balloon pumping therapy is gen-
and is heightened if periods of catheter stasis (interrupted erally undertaken once the patient has stabilised, is free
pumping) are encountered. Systemic heparinisation is of ischaemic signs and symptoms and is on minimum or