Early Mobility of Patients in the CCU with Axillary Balloon Pump awaiting Advanced Heart Failure Therapies

Publico, Catherine MS, RN; Manalad, Anna Maika, BSN, RN, CCRN;Tinio, Girlie G. BSN, RN, CCRN; Laya, Haide BSN, RN; Fernandez, Ma Luthgarda, BSN, RN, CCRN; Nayden, Mary Grace, BSN, RN

Medicine, The Johns Hopkins Hospital, Baltimore, MD

Introduction

Heart failure is a debilitating condition marked by progressive left ventricular function decline. Alterations in organ perfusion occurs leading to poor quality of life. Treatments options for advanced heart failure patients typically include medication regiments including intravenous home inotropic support. When these supportive therapies became inadequate, heart transplantation becomes the only option. At any given time, there are over 3000 candidates awaiting heart transplant. Heart transplant allocation criteria places divides candidates into six statuses with the first two specifically for patients unable to leave the hospital and are on mechanical support including the intra-aortic balloon pump (IABP). IABPs are percutaneously implanted devices in patients as a bridge to transplant therapy. Operating on a counter pulsation, a cylindrical balloon implanted in the descending aorta deflates prior to systole and opening of the aortic valve and inflates in diastole at the closure of the aortic valve. Inflation and deflation of the balloon promotes coronary perfusion and helps offload left ventricular ejection, respectively. In prolonged use in patients awaiting transplant, standard femoral insertion of IABPs pose increased risk for complications including limb ischemia, pseudoaneurysm, bleeding, and amputations. (Quader et al., 2014). Wait time for donor availability is largely unpredictable and can take 40 days or longer. With femoral IABPs, patients are limited to no more than 30 degree head elevation, strict leg restriction on the affected extremity, and inability to get out of bed. This decreased mobility leads to systemic muscle deconditioning that subsequently leads to a decline of multiple body organ systems. (Parry, 2015). The novel approach of IABPs insertion via the axillary-subclavian artery addresses the complications of mobility in prolonged hospitalizations of transplant candidates by allowing for patient mobility 24 hours post insertion. (Macapagal, et al., 2017). Axillary IABPs (ax IABPs) have shown promise in allowing patients to safely mobilize during their prolonged hospitalization while maintain their status on the transplant list. In **, the first ax IABP was placed in a patient awaiting transplant at Johns Hopkins. Our goal with this presentation is to highlight the benefits of ax IABP insertion and to showcase the budding interdisciplinary collaboration in promoting safe patient mobility in pre-transplant patients.

Practice Question

Heart failure is a debilitating medical condition that affects 5.7 million adults in the United States (CDC, 2019). Intra aortic balloon pumps (IABP) are the bridge treatment when pharmacologic interventions prove inadequate for heart failure patients. IABPs are traditionally inserted through the femoral line which poses risks for infection and limiting mobility in pre-transplant patients thereby making these devices an under utilized therapy for patients requiring transplant. The recent innovation of axillary insertion of IABPs (axillary IABP) has seen a rise in pre-transplant use — In the Cardiac Care Unit (CCU), axillary IABPs allow for patients to safely mobilize while still benefiting from mechanical therapy during their extended hospitalization. Nurses, Physical Therapists, and Occupational Therapists play a vital role in the early stage of mobility to maximize the patient’s functional recovery. Early mobilization in the CCU requires careful assessment and management. The Johns Hopkins activity measure post acute care (JH AM-PAC) (Shumrock, Appel & Toonstra, 2015) was used in conjunction with JH highest level of mobility (JH-HLM) (Hoyer et al., 2016). Nevertheless, iabp has been associated with bleeding, infections, hematoma, thrombus,limb ischemia, etc. (De Jong et al., 2018). Hence, malpositioning of the Iabp,injury to the axillary artery and hemorrhagic shock are some of the challenges the ccu nurses are facing. It is crucial that CCU nurses must be alert for possible complications are well trained and knowledgeable with iabp.

Objectives:At the end of this poster presentation, the learner will be able to:1. Discuss the importance of early ambulation of patients in the

critical care with Ax IABP.2. Discuss ways to safely ambulate patients with Ax IABP

Does the placement of the device matter in terms of mobility optimization before surgery?

P – The population of focus are patients in the CCU that require intra-aortic balloon pump (IABP) supportive therapy.I – The intervention is the implementation of early mobility in patients that have intra-aortic balloon supportive therapy.C- Patients who have axillary placed IABP are compared to patients with femoral placed IABP in terms of mobility tolerance and progression.O- The outcome is patients who have axillary placed IABP will show greater mobility capability in comparison to patients with femoral placed IABP. Greater mobility will be evident through the patients’ activity tolerance and progression.

Level and Quality of Included Evidence SynthesisIt is evident that as technology and innovation continue to advance in the field of heart failure, nurses PT and OT will continue to collaborate to promote early mobilization and self-care. As the use of axillary IABP becomes more recognized, it is clear that early mobility protocol will improve patients’ functions, strengths, endurance and promotes self-care. It has psychological benefits as well—pre-transplant patients will have positive outlook for recovery.

Developing

Early ambulation with PT 24h post insertion starting with RN and MD then to unit staff and families.

Qday xrays

Goal q2 walks on unit c staff

Pain adequately addressed

Room planning for larger rooms on the unit to maintain positive outlook and mental health

Encourage weekly family gatherings in the unit

Transplant support from other recipients

Arm sling option for ambulation to minimize device dislodgement

References

Text Box

The group research was based on a systematic review of existing evidence that addresses a focused clinical question. This includes evidence based literature research, peer reviewed and from the last five years.

Seatch Strategy:Pubmed, EBSCO, CINAHL/Nursing, CDC and Medline(OVID) Keywords used: Axillary IABPs, Mobility, Critical Care,safe mobility, heart failure, Intra aortic balloon pump, mechanical circulatory support, activity measure post acute care, vascular complications, mobilizations, physical therapy.

REVIEW OF LITERATURE

Nwaejike, et al. (2017) retrospectively identified three cases of ax-IABP support for post-cardiac surgery (CABG) heart failure patients requiring prolonged mechanical circulatory support. In all three studies, ax-IABP supported patients were allowed early ambulation and aggressive physical therapy. Maximum daily-ambulated distance on these patients were from 400 feet to 2800 feet. Duration of IABP support was up to 43 days and these patients were subsequently discharged with no complications. Sufficient amount of literature reviews and the table outlined from literature reviews were compatible with the narrative report. The conclusion of the study is consistent that ax-IABP is practical with suitable safety profile that allows patient support for days to weeks while allowing for ambulation. Shumock, et al. (2015) presented a retrospective level I study on a patient with heart failure with ax-IABP as a bridge to left ventricular assist device (LVAD) implantation. Ax-IABP was implanted and patient was able to ambulate 182.88 m with a rolling walker on day 33 subsequently received his LVAD on day 40. Though a low quality survey and requires additional replicated results, the study was able to demonstrate a safe and feasible mobility for the patient with ax-IABP.

Hoyer, et al. (2016) utilized a sizeable group of 3352 patients in a retrospective quality improvement study to promote multidisciplinary mobility measured with JH-HLM and reduce length of hospital stay. This single research study design spanned 12 months within 2 general medicine units in a large teaching hospital. Limitations, such as ability to replicate results in a generalized setting with a different population, were noted. Nevertheless, findings consistently show how mobility in the acute hospital setting is feasible and can reduce hospital stay. Patients with improved JH-HLM mobility scores between admission and discharge increased from 32% to 45% with an adjusted median length of stay reduction of .40 - .57 days.

Between the years 2007-2013, Macapagal et al. (2017) and the team at Houston Methodist Hospital utilized the novel approach of ax IABP to safely mobilize their patients on average 1-2 days post device implantation. A nursing care protocol was developed that not only included increased mobility but also lab and assessment schedules to promote sleep. Small rate of complications of limb ischemia including bleeding, pain, and numbness were reported. Patients in the retrospective study were 100% mobile pre-transplant.

A follow up article was published by the same team (Macapagal, et al., 2019) explaining further results of ax-AIBP and mobility in pre-transplant patients. The clinical practice guidelines utilized in the 10 year span study was explained in detail. This article serves as a update to their previous paper (Macapagal, et al., 2017) and continues to support that ax-IABP allows for necessary early mobility which is of paramount importance to patients awaiting heart transplant.

De Jong, et al. (2017) reviewed 20 articles regarding complications resulting from IABP placement published from 1990 to March 2016. were compiled and included in the current 20 studies in this literature. The study involved 23,731 patients ages 63 and above, mostly male (76.7%) and had an average femoral IABP insertion of 8 hours and 6 days. This literature review identified limb ischemia as the most common complication post femoral IABP insertion. Furthermore, longer the IABP duration correlated with increased rates of developing vascular complications like ischemia, pseudoaneurysm, hematoma, bleeding or hemorrhage and even amputation. Patients had a higher risk for developing these complications when they have diabetes, hypertension and peripheral vascular disease.

Translation to PracticeCurrent practice in the CCU for promoting mobility and mental well-being for pre-transplant ax-IABP patients include the following: ambulation as early as 24 hours post insertion with RN/MD then progress to unit staff and family with a goal of BID walks, addressing any pain limiting mobility early, use of arm slings to protect the affected extremity per patient preference, relocation to larger rooms for increased in room mobility, daily morning chest x-rays for device verification performed post night shift, adjustments of nursing assessments/lab collection/imaging to promote sleep and energy for mobility, encouraging weekly family gatherings, and having the availability of support from post transplant patients.

Pictured are two CCU nurses replicating daily routines with ax-AIBP patients. L:R walking down the hall, moving in the room, utilizing bathroom privately.

Centers for Disease Control and Preventions. (2019). Heart failure fact sheet. Retrieved from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm

De Jong, M., Lorusso, R., Awami, F, Matteuci, F., Parise, O, Lozekoot, P.,...Gelsomino,S. (2018). Vascular complications following intra-aortic balloon pump implantation: an updated review. Perfusion, 33(2), 96-104.

Hoyer, E., Friedman, M., Lavezza, A., Wagner-Kosmakos,K., Lewis-Cherry, R., Skolnik, J. L., … Needham, D. M. (2016). Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project. Journal of Hospital Medicine, 11(5),341–347. https://doi.org/10.1002/jhm.2546

Macapagal, F., Green, L., McClellan, E., & Bridges, C. (2017). Mobilizing pre-heart transplant with a percutaneously placed axillary-subclavian intraortic balloon pump: A retrospective study. Journal of Nursing Education and Practice, 8(5). https://doi.org/10.5430/jnep.v8n5p1

Macapagal, F., McClellan, E., Macapagal, R., Green, L., & Bonuel, N. (2019). Nursing care and treatment of ambulatory patients with percutaneously placed axillary intra-aortic balloon pump before heart transplant. Critical Care Nurse, 39(2), 45-52.

Nwaejke, N., Son, A., Patel, C., Schroder, J., Milano, C., & Daneshmand, M. (2017). The axillary intra-aortic balloon pump as a bridge to recovery allows early ambulation in long-term use: Case series and literature review. Innovations, 12(6), 472-478.

Shumrock, K., Appel, J., & Toonstra, A. (2015). Axillary intra-aortic balloon pump placement as a means for safe mobility in a patient awaiting left ventricular assist device implantation: A case report. Cardiopulmonary Physical Therapy Journal, 26(3), 53-57.