1) Intra aortic Balloon Pump (IABP)

  • Mechanism

    • Polyethylene balloon filled with helium (low viscosity/diffusion).

    • Inflates in diastole → augments diastolic BP/coronary perfusion.

    • Deflates in systole → mild afterload reduction, ↓ workload/O₂ consumption.

    • Support: ~0.5–1 L/min.

  • Triggering & Settings

    • Triggers: ECG, pressure, pacing, or spontaneous.

    • Frequencies: 1:1 → 1:2 → 1:3 (wean often unnecessary in shock).

    • Augmented BP is not used to titrate vasoactives; use MAP.

  • Placement & Alarms

    • Commonly femoral; also axillary/brachial; confirm by CXR.

    • Alarms: low helium, gas leak, no trigger (switch ECG↔pressure).

    • Migration more common axillary; may need adjustment.

  • Rupture (Emergency)

    • Turn off, remove promptly (clotting risk), raise BP, 100% FiO₂/non-rebreather or ventilator, Trendelenburg.

  • Trials/Outcomes

    • IABP-SHOCK II (AMI shock): no outcome difference vs standard care.

    • Alt-SHOCK II (decomp HF): futility, notable bleeding/vascular/limb ischemia.

    • Guideline note (US): against routine use in AMI shock (context from talk).

2) Impella (example: CP)

  • Mechanism

    • Pigtail catheter pump in LV: unloads LV, ↓ LVEDP/volume, ↓ work/O₂ use.

    • Pumps to ascending aorta: ↑ MAP, forward flow, coronary perfusion.

    • Typical support ~3.5 L/min (CP); larger surgical version higher.

  • Access & Positioning

    • 14F sheath (femoral/axillary); peel-away + repositioning sheath.

    • Confirm with echo (parasternal long) and console waveforms (LV & aortic).

  • Complications/Management

    • Thrombus/heat if inadequate anticoagulation; device off → emergency removal/replacement.

    • Migration: adjust via locking hub under echo.

    • Vascular issues higher than IABP; mitigate tension/stitching.

  • Evidence

    • DANGER-Shock (STEMI shock, non-comatose): mortality reduction; higher complications; expertise required.

3) VA-ECMO (brief)

  • Pros: Strong peripheral perfusion, oxygenation, transportable cannulation.

  • Cons: Stroke/bleeding/vascular risks; ↑ afterload (ensure aortic valve opens; risk aortic thrombus).

  • Trial Mentioned: ECLS-Shock (AMI shock, high lactate/very sick): no outcome difference vs standard care.

  • Variant: LAVA-ECMO (LA drainage via septostomy) for indirect LV unloading.

4) Systems, Complications, Troubleshooting

  • Complications common: bleeding, limb ischemia, device migration, suction/chugging.

  • Mitigation: micropuncture, ultrasound/fluoro/angiography, anticoagulation, echo, invasive hemodynamics.

  • Shock Team & Workflow

    • Early recognition, early support, invasive hemodynamics, hub-and-spoke transfers, wean/escalate by protocol.

    • Multidisciplinary ICU collaboration essential.

5) Practical Pearls

  1. Titrate vasoactive drugs to MAP, not augmented BP.

  2. For hypotension/suction alarms: check position, volume, bleeding, RV failure, acidosis.

  3. When uncertain: re-review indication, imaging, hemodynamics, call for help.

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