Is reduction of intra-aortic balloon pump (IABP) augmentation recommended during cardiopulmonary resuscitation (CPR)?

Reduction of IABP Augmentation During CPR

During cardiopulmonary resuscitation (CPR), intra-aortic balloon pump (IABP) augmentation should be reduced or turned off to avoid interference with effective chest compressions and optimize coronary perfusion pressure.

Rationale for Reducing IABP Augmentation During CPR

• The primary goal during cardiac arrest is to maintain adequate coronary perfusion pressure (CPP), which is best achieved through high-quality chest compressions with minimal interruptions 1
• IABP inflation during chest compressions can potentially interfere with the hemodynamic effects of chest compressions, reducing their effectiveness 2
• Maintaining a high CPR fraction (time spent performing compressions) of at least 60% is recommended to optimize outcomes, and IABP cycling may interfere with this goal 1

Optimal IABP Management During CPR

• When cardiac arrest occurs in a patient with an IABP:

  • Temporarily reduce or turn off IABP augmentation during active chest compressions 2, 3
  • Focus on delivering high-quality CPR with proper depth (at least 5 cm), rate (100-120 compressions/min), and minimal interruptions 1
  • Minimize pre-shock and post-shock pauses in chest compressions as these significantly impact survival 1

• Recent experimental evidence suggests that if IABP must be used during CPR, it should be precisely synchronized with chest compressions for optimal effect 3, 4

  • Specifically, IABP inflation 0.15 seconds before mechanical chest compressions has been shown to significantly increase mean arterial pressure and carotid blood flow compared to standard timing 4

Monitoring During CPR with IABP

• Invasive arterial pressure monitoring via an arterial line is essential for proper assessment of CPR effectiveness and IABP function 2, 5
• When available, target a coronary perfusion pressure (CPP) >20 mmHg or arterial diastolic pressure >25 mmHg during CPR 1
• End-tidal CO2 monitoring should be used as a surrogate marker of CPR quality and cardiac output 1

Special Considerations

• For patients with refractory cardiac arrest despite conventional CPR and IABP:

  • Consider early implementation of more advanced mechanical circulatory support such as extracorporeal CPR (ECPR) if available 2, 6
  • Prolonged IABP use (>4 days) after cardiac arrest is associated with worse outcomes 6

• After return of spontaneous circulation (ROSC):

  • Resume IABP augmentation to reduce afterload and improve coronary perfusion 2
  • Target mean arterial pressure above 90 mmHg or no more than 30 mmHg below baseline 2, 5

Potential Pitfalls

• Failure to recognize when IABP is interfering with effective chest compressions 7
• Continuing maximal IABP augmentation during CPR may reduce the effectiveness of chest compressions by altering intrathoracic pressure dynamics 3
• Delayed consideration of alternative mechanical circulatory support in patients with refractory cardiac arrest despite IABP 6
• Improper timing of IABP inflation/deflation during the CPR cycle can diminish rather than enhance hemodynamic support 4

Conclusion

While IABP can provide valuable hemodynamic support in cardiogenic shock, during active CPR the priority should be on delivering high-quality chest compressions with minimal interruptions. Reducing IABP augmentation during CPR allows for optimal chest compression effectiveness and coronary perfusion pressure.