ClinicalArticle

Nursing Care of Patients Receiving

Intra-aortic Balloon
Counterpulsation
Mary Beth Reid, RN, PhD, APRN-BC, CCRN, CEN
Damon Cottrell, RN, MS, APRN-BC, CCNS, CCRN, CEN

I ntra-aortic balloon counterpul-

sation (IABC) was introduced into
clinical settings in 1967 for the treat-
ated with IABC are essential. In this
article, we describe the indications
for using IABC, potential complica-
Displacement of blood, proximally
to the aortic root and coronary arter-
ies and distally to the systemic circu-
ment of cardiogenic shock.1 IABC is tions and the nursing care required, lation, results in elevation of the
now used for more than 100 000 potential risk factors for complica- diastolic pressure (Figure 1). Defla-
patients each year in the United tions, and education of patients and tion occurs at the end of diastole just
States.2 In the past 3 decades, IABC their families about IABC. before the onset of the heart’s isovol-
has assumed a prominent role in umetric contraction (Figure 2). The
the treatment of patients with a fail- Intra-aortic Balloon displacement of the blood that occurs
ing heart; the intra-aortic balloon Counterpulsation during inflation decreases the work-
catheter is the most widely used left To initiate IABC, a polyurethane, load of the left ventricle by decreasing
ventricular assist device.3 nonthrombogenic catheter is inserted, the systolic and aortic end-diastolic
Patients receiving IABC require most commonly into the femoral pressure or afterload. Thus, the mean
the same intense and expert nursing artery, and threaded upward so that pressures are elevated and tissue
care required by all critically ill the distal tip of the catheter is in the perfusion is improved.
patients. In addition, specialized man- thoracic part of the aorta just distal
agement is required to reduce the risk to the origin of the left subclavian Indications for Using IABC
of complications and to minimize artery. The proximal end of the Although IABC was originally
the morbidity associated with IABC. catheter is connected to a balloon designed to assist patients in cardio-
These acutely ill patients require nurs- pump console that forces helium genic shock, the indications for IABC
ing care based on specialized knowl- into and out of the balloon, inflating have expanded during the past 30
edge and skill. Prompt recognition and deflating the balloon. years because of continued research,
and treatment of the sometimes life- Inflation occurs during the dias- the ease of catheter insertion, the
threatening complications associ- tolic or resting phase of the heart. increased availability of the technol-
ogy, and a decrease in the size of the
Authors pump console.4 Table 1 lists many
Mary Beth Reid is a clinical nurse specialist in the intensive care unit at Presbyterian indications for IABC.
Hospital of Plano in Plano, Tex. The most common indication
Damon Cottrell is a clinical nurse specialist for cardiology/telemetry at Providence for use of IABC is low cardiac output
St. Vincent Medical Center in Portland, Ore. due to left ventricular dysfunction.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Low cardiac output can result from
Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
mechanical complications due to

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 commonly used Limb Ischemia
Aorta to relieve myo- Limb ischemia is the most fre-
cardial ischemia quent complication of IABC.3 The
Heart in such conditions primary causes are obstruction of a
as impending or small or diseased femoral artery by
acute myocardial the catheter, distal formation of a
infarction or thrombus from direct arterial injury
unstable refrac- during insertion of the catheter, and
Inflated intra-aortic
balloon catheter tory or postin- thromboembolism.3
Kidneys farction angina.7 Critical care nurses must complete
It has also been an extensive peripheral vascular
indicated for assessment before the intra-aortic
hemodynamic balloon (IAB) catheter is inserted
support during and should continue reassessments
and after proce- throughout the remainder of the
dures such as patient’s stay in the hospital because
Renal angiography and long-term complications related to
arteries angioplasty, for decreased perfusion to the extremity
weaning from are not unusual. Nurses should start
cardiopulmonary by assessing the skin’s color and
Figure 1 Catheter with inflated balloon.
bypass, and as a temperature, observing for indica-
bridge to and tions of poor perfusion and arterial
after heart trans- insufficiency such as cyanosis, mot-
plantation.8,9 tling, pallor, or coolness of each
Aorta
extremity. Then they should palpate
Potential Com- the femoral, popliteal, dorsalis pedis,
Heart
plications and and posterior tibial pulses while
the Nursing marking the sites bilaterally with a
Care Required permanent marker before the IAB
When moni- catheter is inserted. Because 8% to
Deflated intra-aortic toring patients 10% of persons in the general popu-
balloon catheter receiving IABC, lation do not have a palpable dorsalis
Kidneys
critical care pedis pulse,10 the absence of this pulse
nurses must be should be documented before the
alert for the pos- IAB catheter is inserted. The pulses
sible occurrence are recorded on the assessment form
of complications by using numerical values to indicate
throughout the the quality:
process. Table 2 0 = no pulse,
Renal
arteries lists potential 1 = thready pulse,
complications 2 = weak pulse,
attributed to 3 = normal pulse, and
Figure 2 Catheter with deflated balloon. IABC, including 4 = bounding pulse.
the nursing care A portable Doppler ultrasound
acute myocardial infarction or from and treatment for each. Each compli- device should be used to determine
left ventricular failure resulting in cation is addressed in more detail in the presence or absence of distal
congestive heart failure.5,6 IABC is the following sections. pulses that are difficult to palpate,

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 Table 1 Indications for use of intra-aortic balloon counterpulsation
sure to obtain the index11 (Table 3).
Ideally, the IAB catheter is inserted
Low cardiac output states due to left ventricular dysfunction, such as into the leg that has the higher ankle-
Right ventricular failure brachial index. Measurements of the
Refractory left ventricular failure
Ventricular septal defect ankle-brachial index can be useful in
Ventricular aneurysm monitoring changes in blood flow to
Papillary muscle rupture with mitral valve regurgitation
Mechanical complications due to acute myocardial infarction
the limb, detecting the presence of
acute ischemic changes, and moni-
Relief of myocardial ischemia in
Impending or acute myocardial infarction toring progression of peripheral vas-
Unstable refractory angina or angina after a myocardial infarction cular disease.
Ischemia related to intractable ventricular dysrhythmias after myocardial infarction
Maintaining body temperature,
Hemodynamic support during and after procedures, such as
Support and stabilization during coronary angiography and angioplasty
cardiac index, and systemic vascular
Prevention of acute restenosis in percutaneous transluminal coronary angioplasty resistance near normal levels is essen-
Weaning from cardiopulmonary bypass tial to promote maximum perfusion
Cardiac support for high-risk general noncardiac surgical patients
of the affected limb. Nitroglycerin
As a bridge to heart transplantation and after transplantation because of
cardiovascular deterioration from rejection can be applied topically to the limb
in an attempt to increase blood flow
if the limb becomes ischemic.4 In most
especially the dorsalis pedis and pos- examination that provides objective cases, removal of the IAB catheter
terior tibial pulses. In addition, any baseline data for later comparison resolves the ischemia; rarely a partial
neurological deficits or impairments with subsequent measurements. It or full amputation is necessary when
of the lower extremities should be is a simple, painless, and objective irreversible, massive necrosis due to
documented before the IAB catheter method of detecting vascular changes prolonged ischemia occurs.
is inserted.
Acute ischemia of the limb may
produce the “6 P’s”: pain, pallor, Acute ischemia of the limb may produce
pulselessness, poikilothermia (cold), the “6 P’s”: pain, pallor, pulselessness,
paresthesia, and paralysis. Circula-
tion checks of the femoral, popliteal, poikilothermia (cold), paresthesia, and
dorsalis pedis, and posterior tibial paralysis.
pulses should be completed every 15
minutes for the first hour after the
catheter is inserted, every 30 minutes in the lower limb associated with the Compartment Syndrome
for the second hour, then every hour patient’s subjective complaints. Critical care nurses must be alert
for 2 hours, and then every 4 hours In order to measure the ankle- for changes that can lead to com-
thereafter until the catheter is brachial index, the blood pressure cuff partment syndrome. Compartment
removed. Bilateral capillary refill is put around the ankle above the syndrome is a condition in which
should be recorded in seconds. malleolus. When the dorsalis pedis increased pressure within a closed,
Circulation checks include using pulse has been located via Doppler unyielding fascial space reduces cap-
Doppler imaging to locate an impal- imaging, the cuff is inflated in the illary blood flow to the point that
pable pulse; comparing both lower usual manner until the Doppler sig- the viability and function of the tis-
extremities to detect differences or nal is no longer heard. As the cuff is sues enclosed in the fascia are at risk.
changes in color, temperature, and slowly deflated, the systolic pressure The increase in pressure is due to
sensation; and using an ankle-brachial is recorded when the signal returns. increases in fluid pressure plus the
index to provide a more quantitative The brachial systolic pressure is contribution of cells, fibers, gels,
measurement of circulation. The measured in the same manner and and matrices. Compartment syn-
ankle-brachial index is a noninvasive divided into the ankle systolic pres- drome can be triggered by any con-

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dition that reduces capillary blood
flow, such as difficulty of insertion of
the catheter further reducing blood
flow within small vessels, preexisting
peripheral vascular disease, vasopres-
sive drugs, lengthy periods of immo-
bilization, and thrombosis.12 When
an event occurs that affects the micro-
vasculature, the result is diffuse
ischemia within the compartment.
Deep throbbing pain or pressure,
paresthesia, and paralysis localized
in the involved compartment are
common complaints. The earliest
objective findings of compartment

Table 2 Nursing care and treatment of potential complications of intra-aortic balloon counterpulsation
Potential
complication Nursing care Treatment
Limb ischemia Before insertion of catheter, complete an extensive peripheral vascular assessment, noting Physician may order that
Risk factors topical nitroglycerin be
Skin color and temperature applied to the lower
Capillary refill extremity
Peripheral pulses (palpate and mark), recording quality of pulse Physician may have to
Ankle-brachial index remove catheter
Any neurological deficits or impairments in sensitivity or movement
During intra-aortic balloon counterpulsation, assess
Distal pulse every 15 minutes for 1 hour after catheter insertion, every 30 minutes for
1 hour after that, every hour for the next 2 hours, and then every 4 hours until the
catheter is removed
Ankle-brachial index every 4 hours
After removal of the catheter, assess
Distal pulses every 4 hours until patient is discharged (instruct patient and patient’s
family to inform physician of any peripheral circulatory changes in lower extremity)
Notify physician immediately if any changes in the extremity occur
Compartment Assess patient for Surgeon performs
syndrome Throbbing pain or pressure, paresthesia, or paralysis localized in the extremity with the compartmental
catheter decompression
Swollen, tense localized area of extremity (pulse may or may not be affected)
Pallor in feet when lower extremity is elevated 45°
Increase in level of creatine phosphokinase
Increase in pressure measured directly
Notify physician immediately if any of these changes occur
Dissection of Monitor patient for Surgeon repairs dissection
aorta Intense ripping or tearing pain in back or abdomen with an increase in abdominal girth
Peripheral pulses becoming unequal or absent with decreases in blood pressure,
cardiac output, and urine output
Decrease in hematocrit
Evidence of mediastinal enlargement on chest radiograph
Notify physician immediately if any of these changes occur
Dislodgment of Assess patient for Prevention is the best
plaque or Signs and symptoms similar to those of compartmental syndrome or limb ischemia treatment
emboli with neurological compression Supportive care
Signs and symptoms of cerebrovascular accident
Changes in the electrocardiogram indicative of an acute myocardial infarction
Respiratory failure due to pulmonary emboli
Notify physician immediately if any of these changes occur
Catheter Secure catheter with tape and document position of catheter: length from insertion site to Physician repositions the
migration proximal end catheter or removes it
Assess patient for changes in and inserts a new one
Upper extremity pulses, color, temperature, sensitivity, and motion
Level of consciousness, unilateral neurological deficits
Decrease in urine output
Elevate head of bed to no more than 30°
Instruct patient to keep leg straight (may need to use long leg or knee immobilizer) to
prevent hip flexion
Notify physician if patient complains of back, flank, or abdominal pain associated with
nausea and vomiting
Continued

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 Table 2 Continued
Potential
complication Nursing care Treatment

Bleeding Initially monitor the insertion site every 15 minutes for 1 hour after the catheter is Nurse applies pressure to
inserted, every 30 minutes for the next hour, then every hour for 2 hours, and after that catheter insertion site
every 4 hours for bruising or tenderness until hemostasis is
Monitor laboratory values for decreases in hematocrit, hemoglobin level, platelet count, achieved
prothrombin time, partial thromboplastin time, and activated clotting time Nurse covers insertion site
Assess patient for increase in heart rate and decrease in blood pressure with compression bandage
Notify physician if patient complains of back, flank, or abdominal pain unrelieved by and sandbag if more
changing patient’s position or if distal pulses decrease or are absent compression is needed
Physician may order
replacement blood
products
Balloon Assess catheter for brown flecks or blood every 2 hours Physician removes catheter
rupture Assess patient for poor augmentation with inflation by femoral artery
Report any “gas leak” alarms on console cutdown
Notify physician immediately if any of these changes occur
Infection Assist with maintaining asepsis during insertion of catheter Prevention is the best
Scrupulously use aseptic technique when manipulating or changing tubing and during all treatment
dressing changes Physician may order
Monitor patient for increase in white blood cell count, increase in body temperature, blood antibiotics
cultures that show growth of microorganisms, and redness, warmth, swelling, or
drainage at insertion site
Skin Reposition patient by log rolling every 1 to 2 hours; provide back rubs Prevention is the best
breakdown Use heel and elbow protectors treatment
Assess bony prominences for changes in color
Obtain and use pressure-relieving devices such as low-air-loss beds
Assist patient to maintain adequate hydration and nutritional status
Keep patient clean and dry

inserted into the compartment, the other compartments. Elevation

Table 3 Ankle-brachial index
Index Indication
>1 Normal
0.88-0.99 Mildly abnormal
0.40-0.79 Claudication
<0.40 Ischemia
syndrome are a swollen, palpably
tense compartment, reflecting
increased intracompartmental pres-
sure. The compartment pressure may
be high enough to cause nerve and
muscle damage but not so high as to
occlude the artery and obliterate
peripheral pulses.
Direct measurement of the pres-
sure in the compartment is a more
sophisticated method of quantify-
ing the increase in compartmental
pressure. A needle or catheter is
allowing direct measurement of the
pressure. Normal capillary perfusion
pressure is 25 mm Hg. Normal mus-
cle tissue pressure is 0 to 12 mm Hg.
When tissue pressure exceeds capil-
lary perfusion pressure, the capillar-
ies collapse. A compartment pressure
of greater than 30 mm Hg is an indi-
cation of compartment syndrome that
requires quick intervention, whereas
a pressure of 70 mm Hg or higher
requires acute surgical fasciotomy to
avoid contractures or rhabdomyolysis
with acute renal failure.12
The anterior and lateral compart-
ments are most often affected by
chronic exertional compartment
syndrome.12 The posterior compart-
ment is deeper and does not respond
as well or as quickly to fasciotomy as
in the level of creatine phosphoki-
nase is also used as an indicator of
muscle ischemia in acute compart-
ment syndrome. Early detection and
surgical decompression of the
affected area are crucial to avoid per-
manent damage of muscles and
nerves and to increase the chances
for functional recovery of the limb.
The limb should be kept elevated at
the level of the heart, and the patient’s
hydration should be maintained at
adequate levels. Mannitol has been
used in some cases of compartment
syndrome.12
Dissection of the Aorta
Dissection of the aorta is a seri-
ous complication of IABC that can
be caused by trauma due to difficulty

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inserting, repositioning, or moving
the catheter.4 Dissection occurs when
the catheter causes a tear in the inti-
mal wall of the aorta. The pressure
within the aorta forces blood between
the vascular layers. This forceful
lengthwise channel of blood can strip
the intimal layer from the adventitial
layer along the aorta, resulting in
obstruction of arterial branches along
the path of the dissection or rupture
of the aorta leading to catastrophic
hemorrhage.
Signs and symptoms of aortic
dissection (Table 2) include patients’
reports of a ripping or tearing pain
in the back or in the abdomen radi-
ating to the back or chest. The periph-
eral pulses may be unequal, or blood
pressure may vary between the right
and left extremities. Peripheral pulses
may decrease on one or both sides.
Once the IAB catheter is inserted,
cardiac output and renal function
may decrease. Other indications of
aortic dissection include decreases
in blood pressure and hematocrit,
signs and symptoms of shock, and
an increase in abdominal girth. A
chest radiograph will show medi-
astinal enlargement. Aortic dissec-
tion is an emergency complication
commonly managed by surgical
intervention.
Dislodgment of Plaque or Emboli
Complications arising from dis-
lodgment of plaque or emboli in the
femoral artery or aorta can occur at
any point during IABC and result in
an obstruction somewhere in the
vasculature. Emboli that decrease
capillary blood flow to the extremi-
ties could result in compartment
syndrome, which has many of the
same signs and symptoms as limb
ischemia with symptoms of nerve
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compression. Emboli making their
way to the cerebral circulation may
cause an occlusion that evolves into
neurological signs and symptoms of
a cerebrovascular accident. Emboli
that become lodged in the coronary
arteries can lead to an acute myocar-
dial infarction. Respiratory failure
can occur if the emboli travel to the
pulmonary artery. Prevention of this
complication is key. Treatment gener-
ally consists of supportive care. Main-
tenance of ventilation, oxygenation,
and anticoagulation with close mon-
itoring are extremely important.
Catheter Migration
After the IAB catheter is inserted,
interventions to monitor for and
prevent migration of the catheter are
undertaken. The IAB catheter is
positioned high in the aorta so that
the lower end of the balloon does
not compromise perfusion to the
celiac, superior mesenteric, or renal
arteries (Figure 1). On a chest radi-
ograph, the proper position of the
catheter is 2 cm below the origin of
the left subclavian artery, or between
the second and third ribs and above
the renal arteries.2
Migration of the IAB catheter
during counterpulsation is a concern.
Once inserted, the catheter should
be taped securely, and the length of
the catheter from the insertion site
to the proximal end should be marked
for reference. The patient should be
instructed to lie flat, keeping the
affected leg still and straight; a long
leg or knee immobilizer can be used
if necessary. The catheter may migrate
as much as 1 to 4.5 cm when the
patient sits up.2 The head of the bed
should be elevated to no more than
30°, and flexion of the patient’s hip
should be avoided.
Inward migration of the IAB
catheter creates the potential for
occlusion of the subclavian or the
carotid artery. Such occlusion will
result in unequal or absent radial
pulses and dampening or loss of the
arterial waveform in the radial artery.
The upper extremities must be
assessed and documented before the
catheter is inserted. The patient’s
hands and extremities should be
assessed for color, temperature, sen-
sitivity, and motion along with the
rate and rhythm of the radial pulses
bilaterally. If the carotid artery
becomes occluded, changes will be
apparent in the patient’s level of con-
sciousness, mental alertness, and
orientation, or the patient may have
unilateral neurological deficits. Out-
ward migration of the IAB catheter
may result in occlusion of the renal
artery. Indicators of renal artery
occlusion include the patient’s report
of abdominal, back, or flank pain,
fever, nausea, vomiting, or anorexia,
followed by a decrease in renal out-
put. The treatment for balloon migra-
tion is for the physician to reposition
the catheter if possible or to remove
the catheter and insert a new one.
Bleeding
Another potential complication
that can occur during any part of
IABC is systemic or local bleeding.
Thrombocytopenia from the use of
anticoagulants in patients requiring
IABC reduces the risk for throm-
boembolic complications but can
increase the risk of bleeding. Throm-
bocytopenia also can be a result of
platelet destruction due to the
mechanical trauma that occurs dur-
ing the inflation of the IAB catheter
against the wall of the aorta. Hemo-
globin level, hematocrit, platelet
count, prothrombin time, and par-
tial thromboplastin time must be
monitored closely for changes that
could indicate bleeding or the poten-
tial for bleeding.
Indications of bleeding may be
manifested as bruising or a hematoma
at the insertion site or by an increase
in the girth of the thigh. The patient
may not initially be hypotensive, but
becomes tachycardic and has a
decrease in hemoglobin level and
hematocrit. Retroperitoneal bleeding
may be manifested by the patient
becoming hypotensive and com-
plaining of back, flank, or abdominal
pain unrelieved by changes in posi-
tion. The pulse distal to the catheter
may be absent because of blood loss,
a situation that requires immediate
surgical intervention.
Several factors can be checked in
an effort to avoid bleeding complica-
tions when the IAB catheter is
removed. Prothrombin and partial
thromboplastin times should be less
than 1.5 times the control; the acti-
vated clotting time should be greater
than 200 seconds; and administra-
tion of anticoagulants should be
stopped 1 to 4 hours before the
catheter is removed. The physician
should apply pressure above and
below the site of insertion while
removing the sheath and the catheter
simultaneously, usually allowing the
insertion site to bleed vigorously for
1 to 2 seconds to remove any clots at
the site. The physician may choose
to deploy a vascular hemostasis
device.13
The extremity must be evaluated
closely for signs of ischemia for 24
hours after the catheter is removed.
Once the IAB catheter is removed,
pressure should be applied to the
puncture site for 20 to 30 minutes
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continuously, or until hemostasis is
achieved. Then a 4.5-kg (10-lb) sand-
bag and a compression bandage can
be applied for 2 hours. The patient
should be instructed to remain on
bed rest for a minimum of 8 hours
after removal of the catheter and to
avoid exercising the extremity so as
to prevent bleeding. Treatment for
bleeding includes administration of
platelets, packed red blood cells, and
other blood products as needed.
Balloon Rupture
Blood or brown flakes in the IAB
catheter are indications of balloon
rupture. When the catheter balloon
ruptures, immediate recognition of
the rupture and removal of the IAB
catheter are crucial. If the gas leak is
only a small pinhole, the catheter
may not contain any blood. The bal-
loon pump may indicate a “gas leak”
or augmentation with inflation of
the catheter may be poor. Whether
blood appears in the catheter, the
same grievous potential exists for a
gas embolus or for entrapment of
the IAB catheter. When the balloon
ruptures, it fills with blood that
forms a clot and the balloon cannot
deflate completely. As a result, the
catheter cannot simply be pulled
out. Treatment for an entrapped
balloon is usually surgical removal;
however, the clot can be dissolved
with a fibrinolytic agent, allowing
the physician to aspirate the liquid
blood and remove the catheter by
femoral artery cutdown.14
Infection
The second most frequent com-
plication of IABC is infection at the
catheter insertion site, which is man-
ifested by fever, local infection, and
bacteremia.15 Indications of infection
CRITICALCARENURSE Vol 25, No. 5, OCTOBER 2005 47
are the same as with any invasive
catheter: elevation of body tempera-
ture; elevation of white blood cell
count; warmth at the site, with red-
ness, swelling, and drainage; blood
cultures that show growth of microor-
ganisms; and indications of sepsis.
The primary goal of critical care
nurses is prevention of infection.
Scrupulous aseptic technique must
be exercised throughout the inser-
tion procedure, during manipulation
of the catheter, and when redressing
the insertion site.
Skin Breakdown
Because of their restricted mobil-
ity, chronic disease, impaired sensory
perception, and altered tissue perfu-
sion, patients receiving IABC are
prime candidates for development
of pressure ulcers. These patients
generally have limited mobility
because of mechanical ventilation,
deep sedation, chemical or physical
restraints, immobilizing devices, and
hemodynamic instability. The mere
presence of the IAB catheter in the
femoral artery exposes patients to a
decrease in tissue perfusion to the
affected extremity.
Pressure-reducing or pressure-
relieving devices such as low-air-loss
beds that are designed to maintain
low interface tissue pressure would
reduce or eliminate interface pressure
to a level below that of capillary clos-
ing pressure. Patients should be
repositioned every 1 to 2 hours to
promote skin integrity. Ensuring
adequate nutrition and hydration
also assists in protecting the skin’s
integrity.
Risk Factors for Complications
Thoroughness when obtaining a
patient’s medical history is essential
for recognizing factors that can pre-
dispose patients to the development
of complications related to IABC.
Information from patients’ medical
histories can assist critical care
nurses in determining which patients
are more likely to have complications
related to IABC. Table 4 lists factors
that put patients at greatest risk for
development of such complications.
Lower limb ischemia is more likely
to develop in women than in men
when the IAB catheter is inserted via
the femoral artery.3,16 This increased
risk for peripheral vascular compli-
cations is often attributed to the dif-
ferences between men and women
in the diameter of the femoral artery.
The smaller diameter in women
increases the chance for compro-
mised blood flow and the risk of
thrombosis.16
Preexisting peripheral vascular
disease is a major, if not the main,
risk factor for the development of
vascular complications associated
with IABC.9 Predisposing factors to
peripheral vascular disease include
diabetes mellitus, cigarette smoking,
hypertension, hypercholesterolemia,
advanced age, and obesity.3,16 Because
of the peripheral vascular disease
associated with diabetes mellitus,
the incidence of lower limb ischemia
is as much as 6 times higher in dia-
Table 4 Risk factors for complica-
tions of intra-aortic balloon counter-
pulsation
Female sex
Preexisting peripheral vascular disease
Advanced age
Diabetes mellitus
Cigarette smoking
Hypertension
Obesity
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betic patients than in nondiabetic
patients when an IAB catheter is
inserted in the femoral artery.16 The
patient’s lower extremities should be
assessed for signs of poor perfusion
such as loss of leg hair, thickened
toenails, pallor, and shiny skin.
Major ischemia of the lower limb
in patients receiving IABC is 3 times
more likely in cigarette smokers
than in nonsmokers.16 Hypertensive
patients have a higher incidence of
vascular complications than do nor-
motensive patients.16 Other estab-
lished risk factors such as obesity,
low cardiac index, elevated systemic
vascular resistance, and the use of
vasopressors are related to the devel-
opment of lower limb ischemia.16
Education of Patients and
Their Families About IABC
Educating patients and patients’
families about IABC is important to
prepare them for the limitations the
patients will experience and to reduce
anxiety. Helping patients and their
families understand the basics of
IABC and why the patients’ mobility
is limited increases compliance.
The limitations that patients will
experience while receiving IABC
should be explained. If the catheter
is inserted via the femoral artery, the
patient will be on complete bed rest
with the head of bed raised to no
more than 30°. Patients should be
taught how to apply an immobilizer
to maintain extension of the limb
that has the catheter insertion site.
Patients must be turned at least every
2 hours to prevent skin breakdown
and promote comfort.
Nurses should explain to
patients and patients’ families that
bleeding may occur at the catheter
insertion site. Patients should be
told to put pressure on the insertion
site when coughing or sneezing and
to notify the nurse immediately if
they experience pain in the lower
back or a sudden burning, pain, or
wetness at the insertion site.
Patients and their families
should be instructed to immediately
report symptoms indicative of
peripheral circulatory changes (eg,
tingling, numbness, coldness, pallor,
and pain) to a nurse while in the
hospital and to a physician after dis-
charge from the hospital.
Once home, patients should
know that if any pain in the extrem-
ity occurs when walking (claudica-
tion) or while at rest, especially at
night, a physician should be noti-
fied. Patients and their families must
understand that such a change is
serious and requires immediate eval-
uation and treatment to prevent
possible tissue damage. Patients and
their families must be taught how to
inspect the patients’ feet daily for
redness or ulcers, especially on the
toes or around any pressure points,
and patients should be instructed to
wear shoes loose enough to avoid
pressure points on the feet. Patients
and their families should understand
that any of the preceding changes,
even if seemingly insignificant, must
be brought to the attention of a
physician immediately.
Conclusion
Since the initial introduction of
IABC in 1967 for the treatment of
cardiogenic shock, the IAB catheter
has become the most widely used
left ventricular assist device. IABC is
not accomplished without risk to
patients; therefore, practitioners
must weigh the risks against the
benefits before using IABC. Nurses
caring for these critically ill patients
must be aware of potential problems
and, through assessment, recognize
those patients who are at high risk
for possible complications of IABC.
Critical care nurses must be vigi-
lant and skilled in assessing circula-
tion in the lower extremity. Frequent
and thorough assessment of the
extremities is essential before, during,
and after IABC. Because of the poten-
tial for long-term vascular complica-
tions related to the use of IABC, the
peripheral vascular assessment should
continue for at least several days after
the IAB catheter is removed. It should
become a part of each patient’s annual
physical examination, especially if the
patient has preexisting peripheral vas-
cular disease.
With the broadened use of IABC,
prevention, recognition, and man-
agement of complications must be
the focus of care. The importance of
the nursing assessment and appro-
priate interventions to minimize
morbidity associated with IABC can-
not be overemphasized. Because of
the high mortality rate, the acuity of
these cases, and the complexity of
their management, critical care nurses
must fully understand the nursing
care and potential complications
related to caring for patients receiv-
ing IABC. As more research is per-
formed and outcomes evaluated, the
data will accumulate and practice
can be adjusted to prevent complica-
tions related to IABC.
References
1. Kantrowitz A, Tjonneland S, Freed PS,
Phillips SJ, Butner AN, Sherman JL Jr. Initial
clinical experience with intra-aortic balloon
pumping in cardiogenic shock. JAMA.
1968;203:135-140.
2. Bolooki H. Clinical Applications of the Intra-
Aortic Balloon Pump. 3rd ed. Armonk, NY:
Futura; 1998.
3. Ferguson JJ III, Cohen M, Freeman RJ Jr, et
al. The current practice of intra-aortic bal-
loon counterpulsation: results from the
Downloaded from http://ccn.aacnjournals.org/ by AACN on October 21, 2019
Benchmark Registry. J Am Coll Cardiol.
2001;38:1456-1462.
4. Stavarski D. Complications of intra-aortic
balloon pumping. Crit Care Nurs Clin North
Am. 1996;8:409-421.
5. Davidson J, Baumgariner F, Omari B, Mil-
liken J. Intra-aortic balloon pump: indica-
tions and complications. J Natl Med Assoc.
1998;90:137-140.
6. Goran SF, Johantgen M. Heart failure. In:
Kinney MR, Dunbar S, Brooks-Brunn JA,
Molter N, Vitello-Cicciu J, eds. AACN Clini-
cal Reference for Critical Care Nursing. 4th ed.
St Louis, Mo: CV Mosby; 1998:429-460.
7. Cook L, Pillar B, McCord G, Josephson R.
Intra-aortic balloon pump complications: a
five-year retrospective study of 283 patients.
Heart Lung. 1999;28:195-202.
8. Arafa OE, Pedersen TH, Svennevig JL, Fosse
E, Geiran OR. Intraaortic balloon pump in
open heart operations: 10-year follow-up
with risk analysis. Ann Thorac Surg.
1998;65:741-747.
9. Scherr K, Jensen L, Koshal A. Mechanical
circulatory support as a bridge to transplan-
tation: toward the 21st century. Am J Crit
Care. 1999;8:324-339
10. Dorland’s Illustrated Medical Dictionary.
29th ed. Philadelphia, Pa: WB Saunders Co;
2000.
11. Brown MM, Fitzgerald C, Morse K, Doyle J.
Cardiovascular surgery. In: Kinney MR,
Dunbar S, Brooks-Brunn JA, Molter N,
Vitello-Cicciu J, eds. AACN Clinical Reference
for Critical Care Nursing. 4th ed. St Louis,
Mo: CV Mosby; 1998:383-428.
12. Swain R, Ross D. Lower extremity compart-
ment syndrome: when to suspect acute or
chronic pressure buildup. Postgrad Med.
1999;105:159-162, 165, 168.
13. Chadwo HL, Hauptman RE, Strizik B, et al.
Vasoseal after intra-aortic balloon pump
removal: a pilot study. Catheter Cardiovasc
Interv. 2000;50:495-497.
14. Cipriani L, Baldereschi G, Boncinelli L,
Marchionni N. Vascular entrapment of a
ruptured intra-aortic balloon: a case report
of successful removal without surgery.
Cathet Cardiovasc Diagn. 1998;44:218-219.
15. Crystal E, Borer A, Gilad J, et al. Incidence
and clinical significance of bacteremia and
sepsis among cardiac patients treated with
intra-aortic balloon counterpulsation
pump. Am J Cardiol. 2000;86:1281-1284,
A9.
16. Cohen M, Dawson M, Kopistansku C,
McBride R. Sex and other predictors of
intra-aortic balloon counterpulsation-
related complications: prospective study of
1119 consecutive patients. Am Heart J.
2000;139:282-287.
CRITICALCARENURSE Vol 25, No. 5, OCTOBER 2005 49
Nursing Care of Patients Receiving: Intra-aortic Balloon Counterpulsation
Mary Beth Reid and Damon Cottrell
Crit Care Nurse 2005;25 40-49
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