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Perf tech III > test 3 > Flashcards

test 3 Flashcards

1
Q

What is one of the main uses for the intra-aortic balloon pump?

A
  • cardoigenic shock
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2
Q

Miocardial infarctions effect on the systolic phase

A
  • a decrease in CO and SV -> hypotenstion -> decrease coronary perfusion pressure -> ischemia -> progressive myocardial dysfunction -> death
  • a decrease in CO and SV -> decrease in systemic perfusion -> compensatory vasoconstriction (increase in afterload) -> progressive myocardial dysfunction -> death
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3
Q

Miocardial infarctions effect on the diastolic phase

A
  • an increase in left ventricular end diastolic pressure ending up in pulmonary congestion -> hypoxia -> ischemia -> progressive myocardial dysfunction -> death
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4
Q

what is the intra-aortic balloon pump considered

A
  • Cardiac ASSIST Device: Patient must be ejecting blood

- won’t keep a patient alive on its own

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5
Q

intra-aortic balloon pump components

A

1) Gas cylinder (He)
2) Gas supply unit
3) Monitoring system
4) Control unit
- duel lumen = gas and blood compartment

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6
Q

IABP Treatment for:

A

 Cardiogenic shock postmyocardial infarction - bridge to reperfusion therapies
 Acute myocardial ischemia / Unstable angina
 Acute cardiac defects - bridge to emergent surgery
 Bridge to transplant/assist device implant
 Perioperative support of high-risk cardiac and general surgical patients
 Weaning from CPB
 Stabilize high-risk patient for PTCA (balloon that clears out plaque from the coronaries), stent placement & angiography
 Pharmacologically intractable ventricular arrhythmias
 Septic Shock*

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7
Q

Contraindications - Absolute

A

 Thoracic or abdominal aortic aneurysm
 Dissecting aortic aneurysm
 Severe aortic insufficiency - regurgitation
 Major coagulopathies (bleeding is major problem)
 Underlying brain death
 End-stage diseases
 Advanced or terminal neoplastic disease

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8
Q

Contraindications - Relative (at the surgeon or caregivers choice)

A

 Severe aortic or femoral atherosclerosis

 Symptomatic peripheral vascular disease

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9
Q

Intra-Aortic Balloon Insertion Sites

A

1) both right and left femoral artery (main insertion sites)
2) abdominal aorta
3) ascending or descending aorta (will have to leave chest open)
4) right subclavian

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10
Q

how does the balloon inflate?

A
  • Base to tip
  • As balloon expands, it displaces the same amount of blood pushing it toward the tip.
  • designed to be put in retrograde
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11
Q

Percutaneous Insertion Seldinger Technique: Step 1

A
  • after palpating the artery, the physician inserts an 18 gauge angiographic needle through the skin and into the artery
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12
Q

Percutaneous Insertion Seldinger Technique: Step 2

A
  • The physician removes the stylet from the angiographic needle, and inserts the guidewire through the needle and into the artery.
  • The guidewire is advanced up into the descending aorta so the tip of the wire is above the bifurcation of the aorta
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13
Q

Percutaneous Insertion Seldinger Technique: Step 3

A
  • The physician removes the angiographic needle from the artery, and then placing a dilator on the guidwire, advances the dilator into the artery.
  • The dilator is removed and replaced with the sheath-dilator assembly
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14
Q

Percutaneous Insertion Seldinger Technique: Step 4

A
  • The dilator portion of the dilator-sheath assembly is removed.
  • Physician removes the central lumen stylet from the balloon, places the balloon catheter over the guidewire, then advances the balloon catheter through the sheath and into the artery.
  • The balloon is then advanced into the proper position within the descending aorta
  • Use TEE to make sure the tip of the balloon is right where you want it
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15
Q

Arterial Cut-Down (Surgical)

A
  • done in the femoral artery
  • make incision and expose femoral artery
  • make incision in it
  • insert the balloon
  • get it into the right position
  • put a flexible graft onto the outside of the vessel and secure that down to prevent any bleeding
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16
Q

Benefits of doing a surgical insertion

A
  • Direct visualization
  • Less vessel trauma
  • Less catheter kinking
  • Applicable for patients with peripheral vascular disease
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17
Q

Risks of doing a surgical insertion

A
  • Bleeding
  • Thromboembolism
  • Infection
  • Increased insertion time
  • Requires surgical removal
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18
Q

Benefits of doing a percutaneous insertion

A
  • Increased speed of insertion
  • Performed throughout hospital
  • Less bleeding
  • Decreased incidence of distal thromboembolism
  • Decreased risk of infection
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19
Q

Risks of doing a percutaneous insertion

A
  • Lack of vessel visualization
  • Potential increased vessel trauma
  • Increased chance of thromboembolism during removal
  • Increased chance for dissection
  • Not applicable for patients with peripheral vascular disease
20
Q

Proper Balloon Position

A
  • the tip of the balloon should be at the junction of the aortic arch and the descending aorta
  • about 1 to 2 cm below the left subclavian artery
  • on X-ray
    - top of the balloon at the center of the second intercostal space
    - bottom of the balloon should be at the L1 vertibrae
21
Q

What is possible if the balloon is too low

A
  • could occlude their renal ateries resulting in no renal blood flow which leads to renal failure
22
Q

How occlusive is the balloon in the aorta

A
  • want it to be 80 to 90% of the diameter of the patients aorta
  • not completely occlusive or could result in:
    - damage to aorta
    - block blood flow
    - platelet activation
23
Q

Goals of Balloon Pump Treatment

A 
- increase supply and decrease demand
 Increase cardiac output
 Decrease myocardial work
 Decrease myocardial oxygen demand
 Decrease myocardial ischemia
- all done by volume displacement
24
Q

Inflate the balloon during

A
  • diastole
25
Q

Deflate the balloon during

A
  • systole
26
Q

Balloon Counterpulsation

A
  • Generation of a balloon pulse that is synchronized to occur opposite the cardiac cycle.
     Heart creates pulse during systole
     Balloon creates pulse during diastole
27
Q

Goal of Counterpulsation

A

 Inflate balloon during diastole

 Deflate balloon before ventricular ejection (during isovolumetric contraction => right at the peak of R wave)

28
Q

Purpose of Trigger Logic

A
  • Synchronizes the patient’s cardiac cycle of systole and diastole with the balloon pump’s cycle of deflation and inflation
29
Q

Trigger Logic

A

 Tells pump console when the patient’s heart has entered systole
 Provides starting point for timing logic
 Provides mechanism to ensure that balloon will not be inflated during systole
 Triggering information HAS to be provided by the patient

30
Q

Triggering Options

A

 Electrocardiogram
 Senses the rate at which the ECG voltage changes
 Usually upstroke of R wave satisfies the criteria
 What if the patient has a pacemaker => pacer spikes will do the trick
 Pressure (if patient doesn’t have and EKG like during CPR)
 Senses the rate at which the arterial blood pressure changes
 Internal (patient doesn’t have either)

31
Q

Optimize ECG Triggering

A

 Maximize amplitude of R wave
 Do not need (or want) a diagnostic ECG
 Minimize amplitude of other waves
 Avoid electrical interference

32
Q

Establishing Optimal ECG Trigger

A

 Skin preparation
 Use silver-silver chloride electrodes
 Consider lead placement

33
Q

Where to connect the IABP to get an EKG reading

A
  • add to anesthesias monitor using a slave cord to trigger off of that
34
Q

Where to connect the IABP to get an EKG reading when the case is over

A
  • put the 4 to 5 leads on and switch the balloon back over
35
Q

Optimize Pressure Triggering

A

 You can measure patients aortic pressure from the tip of the balloon (internal lumen)
 Prevent catheter whip
 Prevent over damping of
waveform

36
Q

Fiber-optic (at the tip) IAB catheters

A

 Automatic in vivo calibration
 Every 2 hours
 Instantaneous signal transmission
 Consistent and accurate arterial blood pressure waveform

37
Q

Purpose of Timing Logic

A
  • Used to set the precise inflation and deflation points
38
Q

Timing Logic

A

 Separate controls for setting inflation and deflation
 Act as timers
 Affected by trigger source
 Set inflation point first, then set deflation point
 Changing inflation point will affect timing of deflation point
 Proper timing can ONLY be verified by looking at the patient’s arterial waveform (have to compare it to the patients native arterial waveform)

39
Q

Effects of Balloon Inflation on the Proximal Compartment

A

 Increased perfusion pressure at the coronary ostia
 Increased diastolic pressure in the aortic root
 Coronary blood flow may increase
 Collateral coronary circulation may open
 Increased perfusion to head vessels

40
Q

Effects of Balloon Inflation on the Distal Compartment

A

 Increased peripheral runoff
 Increased systemic perfusion
 Magnitude of effect depends on position of balloon tip (toward head or toward legs)

41
Q

Effects of Balloon Deflation

A

 Rapid reduction in aortic pressure
 10 to 15 mmHg decrease in pressure (afterload)
- decreases pressure in the aorta so the aortic valve opens earlier

42
Q

Isovolumic Contraction

A
  • using the IABP reduces this phase
  • This is where 90% of the oxygen consumption occurs
  • therefore reduces the oxygen consumption
43
Q

Effects of Decreased Afterload

A

 Cardiac work is decreased
 Maximum tension developed by ventricle reduced
 Myocardial oxygen consumption is decreased
 Balance between myocardial oxygen supply and demand may be restored

44
Q

Factors that effect the demand

A
  • DECREASING THE LV WALL TENSION
  • myocardial contractility will increase the demand
  • heart rate will increase the demand
    - the heart is ejecting faster and less time for diastole so the filling is reduced
  • we reduce the afterload so decreasing LV wall tenstion by using the IABP
45
Q

Factors that effect the supply

A
  • INCREASING DIASTOLIC BLOOD PRESSURE AND DECREASING LV INTRAMURAL PRESSURE
  • myocardial O2 uptake
  • LV intramural pressure
    - when intramural pressure is greater you have less blood flow down the coronaries and putting a greater pressure on the coronaries
    - it is reduced by using the IABP
  • coronary flow
  • Diastolic BP
    - we are augmenting with the IABP (when it deflates we are raising the diastolic P)
46
Q

Endocardial viability ratio

A

= Diastolic pressure time index (supply) / time tension index (area under LV systolic curve or demand)

  • the goal is to increase the ratio
  • anything less than 0.7 is severe myocardial ischemia

Perf tech III (55 decks)

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