What are the immediate steps to take when an intra-aortic balloon pump (IABP) loses its trigger?

Immediate Steps for IABP Trigger Loss

When an intra-aortic balloon pump (IABP) loses its trigger, immediately switch from autoPilot mode to operator mode and verify arterial pressure waveform for timing while ensuring continuous hemodynamic monitoring. 1, 2

Initial Assessment and Immediate Actions

• Verify proper balloon positioning within the aorta using imaging or waveform analysis, as malposition can lead to inadequate augmentation 3
• Check for kinks or partial obstructions in the IABP catheter that may be affecting proper function 3
• Assess for balloon membrane integrity and proper inflation volume 3
• Evaluate the ECG signal quality, as poor quality signals are present in 37% of cases with incorrect timing 2
• Check for arrhythmias, which are present in 69% of cases with incorrect timing and can reduce diastolic time, limiting effective augmentation 3, 2

Trigger Source Management

• If ECG trigger is compromised, switch to pressure-based triggering using the arterial line waveform 1
• Ensure invasive arterial pressure monitoring via an arterial line for proper assessment of IABP effectiveness 1
• Consider using an external interface device (like BPI 202) that can process and simulate R wave signals for controlling IABP if available 4
• In cases of persistent trigger issues, manually adjust timing to synchronize with the cardiac cycle based on arterial waveform 3

Hemodynamic Optimization During Troubleshooting

• Maintain mean arterial pressure above 90 mmHg or no more than 30 mmHg below baseline to ensure adequate coronary perfusion 3
• Consider adding inotropic and/or vasopressor support if needed to maintain adequate perfusion while optimizing IABP function 3
• Monitor for signs of improved tissue perfusion including improved urine output, decreasing lactate levels, and improved mental status 3
• For patients with refractory hemodynamic instability despite IABP troubleshooting, early consideration of more advanced mechanical circulatory support is recommended 1

Special Considerations

• In patients with right ventricular failure, IABP can still be beneficial - optimize right ventricular preload and consider adding pulmonary vasodilators to reduce right ventricular afterload 3, 5
• For patients with mechanical complications of ACS, short-term mechanical circulatory support devices are reasonable for hemodynamic stabilization as a bridge to surgery 6
• Note that routine use of IABP in patients with cardiogenic shock and no mechanical complications due to ACS is not recommended due to lack of survival benefit 6

Monitoring During Troubleshooting

• Continuously assess hemodynamic parameters including cardiac output, mixed venous oxygen saturation, and end-organ perfusion 3
• Perform echocardiography to evaluate ventricular function and response to IABP support 3
• Monitor serum lactate levels, as levels >11 mmol/L in the first 10 hours of IABP support predict poor outcomes 5
• Watch for base deficit >12 mmol/L, mean arterial pressure <55 mmHg, urine output <50 ml/h for 2 hours, and high vasopressor doses (>0.4 mg/kg/min of epinephrine or norepinephrine) as these are predictors of poor outcomes 5

Prevention of Future Trigger Issues

• Consider alternative access sites (axillary, subclavian, or external iliac artery) for long-term IABP placement if femoral access is problematic 7
• Regularly check IABP timing every four hours by printing strips with the IABP frequency set to 1:2 to identify and correct timing discrepancies 2
• Be aware that even in autoPilot mode, inflation and deflation timing of the IABP is not always correct, with incorrect timing observed in approximately 16% of cases 2