What are the appropriate settings for the Intra-Aortic Balloon Pump (IABP) during a code, specifically regarding ratio mode, augmentation, and trigger mode?

IABP Management During Cardiac Arrest

During a cardiac arrest, the IABP should be set to 1:1 ratio mode with maximum augmentation and pressure trigger mode to optimize coronary perfusion and reduce left ventricular afterload. 1

IABP Settings During Code

• Set the IABP to 1:1 ratio mode to provide maximum hemodynamic support during cardiac arrest 1
• Use maximum augmentation (highest balloon volume setting) to optimize diastolic augmentation and improve coronary perfusion 1, 2
• Switch to pressure trigger mode during cardiac arrest, as ECG triggering becomes unreliable during resuscitation 1
• Ensure invasive arterial pressure monitoring via an arterial line is in place to properly assess IABP effectiveness 1, 3

Rationale for Settings

• The 1:1 ratio provides counterpulsation for every cardiac cycle, maximizing coronary perfusion during the limited periods of cardiac output during resuscitation 1
• Maximum augmentation increases diastolic pressure, which has been shown to improve coronary blood flow and potentially augment cardiac output 4, 2
• Pressure trigger mode allows the IABP to synchronize with any blood pressure generated during chest compressions or spontaneous cardiac activity 1, 3

Integration with Resuscitation Efforts

• Continue high-quality CPR while the IABP is functioning, as the IABP requires some cardiac output or mechanical chest compressions to be effective 1
• Mechanical CPR devices may be used in conjunction with IABP to provide consistent chest compressions during prolonged resuscitation 1
• The IABP can help reduce left ventricular afterload and prevent ventricular distension during resuscitation efforts 1

Troubleshooting During Cardiac Arrest

• If there is poor augmentation during CPR, verify proper balloon positioning within the aorta 5
• Check for balloon membrane integrity and proper inflation volume if augmentation appears inadequate 5
• Ensure the IABP catheter is not kinked or partially obstructed 5
• Consider increasing preload through careful volume assessment if augmentation remains poor 5

Post-ROSC Management

• After return of spontaneous circulation (ROSC), maintain the IABP at 1:1 ratio initially 1
• Maintain mean arterial pressure above 90 mmHg or no more than 30 mmHg below baseline to ensure adequate coronary perfusion 1, 3
• Consider adding inotropic and/or vasopressor support if needed to maintain adequate perfusion while optimizing IABP function 5
• Perform echocardiography to evaluate ventricular function and response to IABP support 5

Escalation of Support

• For patients with refractory cardiac arrest despite IABP, early consideration of more advanced mechanical circulatory support is recommended 1
• IABP may be reasonable to use as a rescue treatment when initial therapy is failing for cardiac arrest that occurs during PCI 1
• Consider ECPR (Extracorporeal CPR) as an alternative or adjunct to IABP for cardiac arrest when initial therapy is failing 1

Contraindications and Limitations

• The IABP may be contraindicated in patients with aortic dissection, severe aortic regurgitation, or severe peripheral vascular disease 1
• Be aware that the hemodynamic benefits of IABP are diminished when the patient is in the semirecumbent position 6
• The IABP requires some degree of left ventricular function or mechanical chest compressions to be effective 7