What to do with the Intra-Aortic Balloon Pump (IABP) augmentation alarm when a patient codes?

IABP Management During Cardiac Arrest

When a patient with an IABP codes (cardiac arrest), you should maximize the IABP to full augmentation (1:1 ratio) and continue it during CPR to enhance coronary perfusion pressure and potentially improve outcomes. 1

Immediate Actions During Cardiac Arrest

Optimize IABP Settings

• Set the IABP to maximum augmentation (1:1 ratio) immediately to increase diastolic pressure and improve coronary blood flow during resuscitation efforts 1
• Switch to pressure-based triggering using the arterial line waveform if ECG triggering becomes unreliable during the chaotic rhythm of cardiac arrest 2
• Ensure the arterial line remains functional for proper IABP timing and assessment of coronary perfusion pressure 2, 1

Focus on High-Quality CPR

• Deliver compressions at proper depth (at least 5 cm) and rate (100-120/min) with minimal interruptions, as this remains the primary determinant of survival 1
• Maintain a CPR fraction of at least 60% - the IABP should augment, not interfere with, chest compressions 1
• Minimize pre-shock and post-shock pauses to maximize coronary perfusion time 1

Rationale for Continuing IABP at Maximum Augmentation

The physiologic basis for maintaining IABP during cardiac arrest is compelling: maximum augmentation increases diastolic pressure, which directly improves coronary blood flow and potentially augments cardiac output during CPR 1. The IABP may be reasonable as a rescue treatment when initial therapy is failing for cardiac arrest that occurs during PCI 1.

Monitoring During Resuscitation

• Target coronary perfusion pressure (CPP) >20 mmHg or arterial diastolic pressure >25 mmHg during CPR when arterial monitoring is available 1
• Use end-tidal CO2 monitoring as a surrogate marker of CPR quality and cardiac output 1
• Continuously assess the arterial waveform to ensure proper IABP timing and augmentation 2, 1

Post-ROSC Management

After return of spontaneous circulation:

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

Escalation Considerations

• For refractory cardiac arrest despite IABP and optimal CPR, consider ECPR (extracorporeal CPR) as an alternative or adjunct, particularly for cardiac arrest occurring during PCI 1
• Mechanical CPR devices may be used in conjunction with IABP to provide consistent chest compressions 1
• Early consideration of more advanced mechanical circulatory support is recommended for patients who remain unstable despite IABP 2, 1

Critical Caveats

Do not turn off or reduce the IABP during cardiac arrest - the alarm indicating low augmentation is expected during arrest due to loss of cardiac output, but the device should remain at maximum settings to provide whatever hemodynamic support is possible 2, 1. The alarm is a reflection of the patient's condition, not a reason to adjust the device downward.