Optimal IABP Settings During Cardiac Arrest

Technical Considerations

Invasive arterial pressure monitoring via an arterial line is essential for proper assessment of IABP effectiveness, and continuous ECG monitoring must be implemented alongside blood pressure monitoring, according to Praxis Medical Insights 1

For patients with refractory cardiac arrest despite IABP, early consideration of more advanced mechanical circulatory support is recommended, according to Praxis Medical Insights 1
After ROSC, maintaining mean arterial pressure above 90 mmHg or no more than 30 mmHg below baseline is recommended to ensure adequate coronary perfusion, according to Praxis Medical Insights 1

IABP may be reasonable to use as a rescue treatment when initial therapy is failing for cardiac arrest that occurs during PCI, with a Class IIb, LOE C-LD recommendation 2
Mechanical CPR devices may be used in conjunction with IABP to provide consistent chest compressions during cardiac arrest, with a Class IIb, LOE C-EO recommendation 2
Consider ECPR as an alternative or adjunct to IABP for cardiac arrest that occurs during PCI when initial therapy is failing 2

There is insufficient evidence to support or refute the routine use of extracorporeal cardiopulmonary resuscitation in cardiac arrest, as stated in Circulation 3
The pooled randomized data do not support IABP in patients with high-risk STEMI without cardiogenic shock, according to the European Heart Journal 4, 5
Meta-analyses of cohort studies in STEMI with cardiogenic shock show conflicting results based on reperfusion strategy, according to the European Heart Journal 4, 5

The IABP may be contraindicated in patients with aortic dissection, severe aortic regurgitation, or severe peripheral vascular disease, as recommended by the European Society of Cardiology 6

The American Heart Association recommends that after return of spontaneous circulation (ROSC), IABP should be continued in patients with post-cardiac arrest myocardial dysfunction to reduce afterload and improve coronary perfusion, with a strength of evidence based on studies published in Critical Care Medicine and Circulation 7, 8
Left ventricular unloading with IABP can prevent distension, ventricular stasis, and myocardial ischemia, potentially improving survival in patients with cardiac arrest, according to research published in Critical Care Medicine 7

Maximum augmentation increases diastolic pressure, which has been shown to improve coronary blood flow and potentially augment cardiac output, as recommended by the European Society of Cardiology 9

The primary goal during cardiac arrest is to maintain adequate coronary perfusion pressure (CPP), which is best achieved through high-quality chest compressions with minimal interruptions, as recommended by the American Heart Association 10
Maintaining a high CPR fraction (time spent performing compressions) of at least 60% is recommended to optimize outcomes, and IABP cycling may interfere with this goal, according to the American Heart Association 11

When cardiac arrest occurs in a patient with an IABP, focus on delivering high-quality CPR with proper depth (at least 5 cm), rate (100-120 compressions/min), and minimal interruptions, as recommended by the American Heart Association 10, 11
Minimize pre-shock and post-shock pauses in chest compressions as these significantly impact survival, with a recommendation from the American Heart Association to keep pauses as short as possible 11

When available, target a coronary perfusion pressure (CPP) >20 mmHg or arterial diastolic pressure >25 mmHg during CPR, as suggested by the American Heart Association 10
End-tidal CO2 monitoring should be used as a surrogate marker of CPR quality and cardiac output, with a recommendation from the American Heart Association to use this monitoring technique 10