Should intra-aortic balloon pump (IABP) augmentation be reduced or continued during active cardiopulmonary resuscitation (CPR)?

IABP Augmentation During Cardiopulmonary Resuscitation

During active cardiopulmonary resuscitation (CPR), intra-aortic balloon pump (IABP) augmentation should be maximized and synchronized with chest compressions to optimize coronary perfusion pressure and improve outcomes. 1, 2

Rationale for Maximizing IABP Augmentation During CPR

• IABP inflation timed 0.15 seconds before mechanical chest compressions significantly increases mean arterial pressure and carotid blood flow compared to inflation after compression or chest compressions alone 3
• Synchronized IABP with mechanical chest compressions significantly improves return of spontaneous circulation (ROSC) rates (87.5% vs 25% in control groups) in experimental cardiac arrest models 2
• Maximum augmentation increases diastolic pressure, which improves coronary blood flow and potentially augments cardiac output during resuscitation efforts 1
• IABP use during CPR significantly increases diastolic blood pressure and coronary perfusion pressure, which are critical determinants of successful resuscitation 4

Optimal Timing of IABP During CPR

• IABP inflation should be synchronized with chest compressions, specifically timed to inflate on the upstroke and deflate on the downstroke of compressions 4
• Coronary perfusion pressure significantly increases when IABP inflation occurs 0.25 seconds before mechanical chest compressions compared to inflation at the time of compression 3
• Proper synchronization is essential - inflation timing has a significant impact on hemodynamic parameters during CPR 3, 2

Technical Considerations

• Invasive arterial pressure monitoring via an arterial line is essential for proper assessment of IABP effectiveness during CPR 1
• Continuous ECG monitoring must be implemented alongside blood pressure monitoring 1, 5
• When available, target a coronary perfusion pressure >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

Integration with Other Resuscitative Measures

• Focus on delivering high-quality CPR with proper depth (at least 5 cm), rate (100-120 compressions/min), and minimal interruptions 1
• IABP may be reasonable as a rescue treatment when initial therapy is failing for cardiac arrest that occurs during PCI 1
• Mechanical CPR devices may be used in conjunction with IABP to provide consistent chest compressions during cardiac arrest 1
• Consider early implementation of more advanced mechanical circulatory support for patients with refractory cardiac arrest despite IABP 1, 5

Post-ROSC Management

• After ROSC, maintain mean arterial pressure above 90 mmHg or no more than 30 mmHg below baseline to ensure adequate coronary perfusion 1, 5
• Continue IABP in patients with post-cardiac arrest myocardial dysfunction to reduce afterload and improve coronary perfusion 1
• Left ventricular unloading with IABP can prevent distension, ventricular stasis, and myocardial ischemia, potentially improving survival 1

Potential Complications and Considerations

• IABP may be contraindicated in patients with aortic dissection, severe aortic regurgitation, or severe peripheral vascular disease 1
• Unlike total resuscitative endovascular balloon occlusion of the aorta (REBOA), IABP maintains distal blood flow, which is an important advantage during prolonged resuscitation 2
• Monitor for signs of improved tissue perfusion including improved urine output, decreasing lactate levels, and improved mental status 5

By maximizing and properly synchronizing IABP augmentation during CPR, healthcare providers can significantly improve hemodynamic parameters and potentially increase the likelihood of successful resuscitation.