Initiation of and weaning from IABP

IABP therapy must not be unnecessarily delayed, particularly following myocardial revascularization of the already impaired left ventricle. Inotropic support consisting of more than 10 g/kg/min of dopamine or equivalent, despite adequate left atrial pressure, will produce a significant increase in myocardial oxygen demand without an increase in myocardial oxygen supply. Initiation of IABP therapy before any significant myocardial necrosis occurs is more likely to result in a favorable outcome than further escalation of the inotropic support.

The exact timing of weaning from IABP therapy depends on many factors. However, as a rough guide, a patient with a mean arterial pressure greater than 70 mmHg, a cardiac index greater than 2.2 l/m2/min, and a pulmonary artery pressure below 18 mm Hg without any significant inotropic support should be considered for weaning. Weaning can be achieved by reducing either the inflation ratio or the balloon volume.

The method of removal depends on which method was used to insert the catheter. Heparin is stopped 1 h prior to removal. With the percutaneous method the IABP is turned off and a 50-ml syringe is used to evacuate the balloon gas. An assistant presses on the artery distal to the insertion site to minimize the chance of distal embolization. The catheter is pulled back until the balloon meets the sheath and the two are then pulled together. The artery is allowed to bleed for a few seconds to expel any thrombus, and then firm pressure is applied for at least 30 min or until the bleeding stops completely. A pressure dressing is applied and the patient is kept supine for 24 h.

Open removal is used if the open technique was used for the insertion or when problems are anticipated. The main advantage of this technique is that it allows embolectomy at the same time and a definitive repair of the artery.

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