Interpreting the arterial pressure waveform in the intra-aortic balloon-pumped patient.

This paper reviews arterial pressure waveforms and contrasts the differences in waveforms imposed by intra-aortic balloon counterpulsation. It explores questions regarding blood pressure interpretation and offers guidelines for practice.

Improving the accuracy of pulmonary artery catheter measurements.

Pulmonary artery pressures and arterial pressures are important hemodynamic measurements utilized in clinical management decision making for critically ill patients. Studies have demonstrated a concerning rate of measurement error, often due to technical errors. Zeroing, leveling, and dynamic response testing are essential components of assuring the quality of measurements. This article describes a multilevel approach to assuring the accuracy of measurements. It includes the physics underlying each of these principles, criteria for judging the efficacy of the dynamic response, and clinically applicable methods for measuring the natural frequency and damping coefficient of pressure monitoring systems.

Nursing care of the intraaortic balloon catheter's inner lumen.

An inner lumen exists within the intra-aortic balloon for the purpose of introducing a guidewire to facilitate balloon insertion. This inner cannula also can be used for continuous arterial pressure monitoring. However, special precautions are necessary when utilizing this port for arterial monitoring as compared to a conventional radial arterial line. The proximal tip of this arterial pressure monitoring source rests within the proximal aorta in close proximity to the trifurcated vessels coming off the aorta. The possibility of a clot dislodging and entering the trifurcated vessels. Because of the inner lumen's small size and location, special guidelines need to be followed for its care and maintenance. This paper reviews physiological specific to the intraaortic balloon's inner cannula and recommends practice guidelines regarding heparinized or nonheparinized flush solutions, flushing of the inner lumen, and troubleshooting a damped inner cannula arterial waveform.

Clinical nurse specialist: role restructuring to advanced practice registered nurse.

This article recognizes challenges facing the traditional clinical nurse specialist (CNS) role and supports the merger of the nurse practitioner (NP) and the CNS into a hybrid advanced practice registered nurse (APRN). A historical review of each role is presented, with justification for role merger. The focus of the article is to present a personal account of this author's successful reengineering of a traditional cardiovascular CNS role to conform to a new state and institutional APRN model and ultimately to better serve a population of post-myocardial infarction patients.

Maximizing cardiopulmonary resuscitation in patients with intra-aortic balloon pumps.

Improved hemodynamics and blood flow have been reported in patients with IABPs who experience cardiopulmonary arrest and require CPR. The following research questions, however, remain unanswered: Is there a more effective method of using IABP to prevent cardiac arrest and the need for CPR? Is the timing of balloon inflation and deflation the same for patients undergoing CPR as it is for patients who do not require CPR? Would earlier or later inflation or deflation further enhance cerebral or systemic blood flow? What are the most effective ways for healthcare staff to maintain competency skills in CPR in patients with IABPs?

Cardiovascular clinical specialist: insights and inspirations.

Dr Quaal presents an account of her career as a cardiovascular clinical specialist from an early inspiration role model to the mentors who had an impact on her professional development. Insights and inspirations that form the conceptual framework for this article include preparatory pearls of wisdom, the stimulus of adversity, experiencing fulfillment, salient lessons learned, and viewing the journey of life with new eyes. Insights and inspirations originated from mentors ranging from a small Midwestern town upbringing to Baragwanath Hospital in South Africa. Dr Quaal reflects on nearly 25 years as a cardiovascular specialist and pays tribute to all who mentored her with their personal and professional wisdom.

Maintaining competence and competency in the care of the intra-aortic balloon pump patient.

Care of the IABP patient requires specialized knowledge and skill. Two methods exist for verifying the nurse's ability to safely care for this patient population. Competence and competency testing approach this task from two different aspects; the former assesses the nurse's potential knowledge and skills and later verifies the nurse's ability to perform and apply knowledge, skill, and standards of care in an actual "mock run" situation. Both aspects should be included in an IABP training program.

Intra-aortic balloon pumping in the community hospital setting.

A community-hospital IABP program provides potentially lifesaving treatment for patients with lethal cardiac problems. Similar to the rapidly growing number of other community hospitals with IABP programs, Landmark Hospital in Rhode Island has successfully implemented this modality of cardiac care, once limited to tertiary care facilities. Although the challenges the community hospital faces when establishing an IABP program and maintaining clinical competency are unique, IABP in the community hospital is a proven treatment modality that decreases mortality rates.

Caring for the intra-aortic balloon pump patient. Most frequently asked nursing questions.

IAB counterpulsation poses specific nursing issues and challenges. The patient's arterial pressure reference points are expanded to five components as opposed to the usual systole and diastole. It is, therefore, crucial that procedures be developed that address issues such as computation of mean arterial pressure and documentation and titration of drips through the use of the 5 waveform components of the IABP patient. Peripheral vascular assessment is most important because of the potential for compromised flow. The ankle/arm index can be used as an objective measurement to quantify perfusion. Balloon inflation during diastole normally generates the highest pressure point in the counterpulsation cycle. Various factors can lower the magnitude of augmentation, and these need to be included in troubleshooting assessments.

Intra-aortic balloon counterpulsation timing.

Intra-aortic balloon counterpulsation is a product of an endeavor begun more than 3 decades ago. First the concept, then applications of inflating a nonthrombogenic balloon within the aorta during diastole were explored. The intra-aortic balloon is timed to inflate with aortic valve closure. Two options are available for deflation timing: (1) conventional timing, where deflation is estimated to be completed at some point during isovolumetric contraction, prior to ejection; and (2) R wave deflation, also known as real timing, where deflation is triggered by each QRS complex to occur during isovolumetric contraction or early systole. Although clinical implementation of both conventional and real timing was introduced in 1968, limited information about these methods of deflation is currently available. This article elucidates the differences between these models and suggests implications for clinical practice and further research.

Quality assurance in hemodynamic monitoring.

Patient care management decisions frequently are based, at least in part, on hemodynamic indices. Accuracy in repeated measurement of hemodynamic parameters is therefore critical. It can be achieved only through a program of quality assurance (QA), which should include the following factors: static, dynamic, and validation of pulmonary artery wedge pressure (PAWP). The static QA factor consists of establishing an accurate reference point from which all subsequent measurements are made. The hemodynamic monitoring system must be able to transmit pulsating physiologic pressures to the transducer with high fidelity, which is validated via the dynamic response or "square wave" test and damping coefficient. Other QA aspects that are used to validate the accuracy of PAWP include catheter placement into lung zone 3 capillary and comparison of capillary to arterial blood gases. Measurement error also can be introduced because of varying methods to quantify the ana-log pressure waveforms, such as end-expiratory or pressure averaging techniques. This paper explores each of these domains within a framework of quality assurance.

Effect of increased intra-aortic balloon pressure on catheter volume: relationship to changing altitudes.

OBJECTIVE: To evaluate the effect of intra-aortic balloon membrane response under increasing intracatheter pressure by indexing these data to associated barometric pressures that occur with changes in altitude. DESIGN: A static compliance test was performed to assess the effect of internal pressure on intra-aortic balloon compliance (simulating helium gas within the intra-aortic balloon affected by barometric pressure). Testing consisted of incrementally increasing pressure within eight percutaneous intra-aortic balloons from four leading manufacturers. SETTING: The University of Utah Department of Mechanical Engineering Laboratory. PATIENTS: No patients were involved. This study was a bench test lab study. INTERVENTIONS: No patient interventions were utilized. RESULTS: Results for all trials showed a curvilinear relationship between intracatheter pressure and balloon volume. Clinically significant balloon expansion data were obtained, with manufacturer variation observed at moderate-to-high pressures. CONCLUSIONS: Based on the results of this study, recommendations for operation of intra-aortic balloon pumps during altitude ascent and descent are proposed, from which individual institutional protocols may be developed.

Centrifugal ventricular assist devices.

A centrifugal ventricular assist device (VAD) uses centrifugal force to propel blood through nonocclusive pumpheads. Blood is diverted from either the right atrium or left atrium to a disposable pumphead. Then kinetic energy is added to blood contained within the VAD by rotating it at high speed. Centrifugal force generates energy which causes the blood to rise from the pumphead's base, thus forcing a return flow direction. Centrifugal VAD design has been used to sustain myocardial function when patients could not be weaned from cardiopulmonary bypass and as a bridge to transplantation. Interaction between centrifugal VAD and human hosts are complicated and multisystemic. Therefore a multidisciplinary VAD support team is most efficacious. A case study, nursing diagnoses, and care plan provide a comprehensive overview of nursing management for this patient population.

Air transport of the patient requiring intra-aortic balloon pumping.

Air transport of the IABC patient requires a high level of skill and competence. The nurse caring for the IABP patient must be experienced in balloon pumping in a variety of settings (catheterization laboratory, operating room) and during unstable hemodynamic conditions, such as occur with arrhythmias, pacemakers, severe cardiogenic shock, and cardiac arrest. The nurse must be trained in all aspects of console operation and troubleshooting. Evanston Hospital, Evanston, Illinois, examined its experiences in ground transportation of 50 IABP patients over a 5-year period. The hospital has put forth several important principles that we have incorporated into our recommendations for air transport of the IABC patient: 1. Transport personnel should be completely familiar with the function of the IABP console; capable of handling bleeding at the balloon site, should it occur; capable of delivering intravenous medications, CPR, and ACLS; and proficient in operation of the ventilator, hemodynamic monitoring, and aerohemodynamics. 2. All patients must be stabilized before transfer. Appropriate management of hemodynamic instability and/or respiratory distress should be undertaken prior to beginning transport. 3. Medical personnel delivering care must transfer patients into and out of transport vehicles with minimal interruption of IABP. 4. Health-care professionals present during transport should be thoroughly familiar with the patient's medical status and anticipated complications. This article was not intended to teach basic principles of intra-aortic balloon pumping; rather its purpose was to discuss those characteristics of balloon pumping that are unique to flight transport and how they impact on balloon pumping. Console operation should follow manufacturer's recommendations. Table 3 summarizes features of the Aries, Datascope, Kontron, and Mansfield transport balloon pumps. Manufacturers and aircraft suppliers should be consulted for specific balloon-pump operating instructions, prior to assuming responsibility for care of the air-transport IABC patient. Well-established care plans and protocols for IABP have been published previously. Documentation of balloon-pump function during air transport is important, and can be an addenum to a standard ICU flowsheet (Fig. 4). The patient who presents at a community hospital with accelerating angina, complications following cardiac catheterization or myocardial infarction, emergency cardiac structural defects, or as a potential cardiac transplantation candidate may require institution of IABC as a life-saving intervention. Once the patient is stabilized, transport to a tertiary-care hospital that can provide advanced cardiac therapies is a logical trajectory.(ABSTRACT TRUNCATED AT 400 WORDS)

The pill electrode. New technology as an adjunct to nursing assessment of patient arrhythmias.

The value of esophageal electrocardiography (ECG) in differential diagnosis of complex arrhythmias has been well known for the past half century. However, until recently, the technique was not widely used primarily because of the patient discomfort associated with esophageal placement of nasogastric tubes containing the ECG electrodes. With the advent of the pill electrode and development of appropriate recording methodology, interest in and use of esophageal electrocardiography has increased dramatically. In this article, the authors review the historic development of the pill electrode, recording technique, and current case studies in which the technique of pill electrode esophageal ECG monitoring facilitated differential diagnosis of complex arrhythmias.