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intra aortic balloon pump nursing

Available at www.aacnacconline.org. (IABP). Nursing Management of Patients Requiring Acute Mechanical … You may need it if your heart is unable to pump enough blood for your body. The IABP … For patients with a fast or irregular heart rate, the nurse will need to assess which trigger is most effective.11  Monitoring the augmentation and unloading effects of the device along with the patient’s vital signs and urine output every hour is critical.7  Changes may indicate a timing error, poor tolerance of weaning, or perhaps catheter migration below the renal artery if urine output decreases. The nurse can expect to start or increase vasopressors, increase ventilator settings, and, in some circumstances, provide CPR while the circuit components are being changed out.27, Measuring cardiac recovery and readiness for decannulation in these patients involves performing an echo-cardiogram. A mechanical complication while receiving venoarterial ECMO is considered an emergency until support can be reinstated. Policy Title: Care of the Patient with an Intra Aortic Balloon Pump (IABP) - Adult Policy Summary: It is the policy of *** to safely utilize an intra aortic balloon pump to increase coronary artery perfusion, … ?§€:¢‹0ÂFB‘x$ !«¤i@ڐ¤¹ŠH‘§È[EE1PL”ʅ⢖¡V¡6£ªQP¨>ÔUÔ(j Reid MB. Leslie Lussier is Director, Respiratory Care, ECMO, and Pulmonary Function Test Laboratory, Tufts Medical Center. Acute mechanical circulatory support devices are becoming more widely used in the intensive care environment to help achieve higher levels of hemodynamic support than can be accomplished by using pharmacological interventions alone. THE INTRA‐AORTIC BALLOON PUMP (IABP) is a commonly used circulatory‐assist device that increases myocardial oxygen supply and reduces myocardial oxygen demand, thus improving left … Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org. Guidelines for Management of the Intra-Aortic Balloon Pump Purpose: To outline the nursing management of patients requiring an Intra-Aortic Balloon Pump (IABP). Exact timing is based on appropriate inflation and deflation of the balloon during the cardiac cycle. With the Impella RP, a 22-French catheter is inserted into a femoral vein, removing blood from the inferior vena cava and pumping it into the PA to unload the RV.20, Each of the Impella catheters is controlled by an Automated Impella Controller (AIC) that displays flow rate, performance (P) level, purge fluid rate, purge fluid pressure, alarm notes, and catheter position information. If the cannula is pulled back into the RV, CO will drop, tricuspid regurgitation will be present, and arrhythmias may occur.5,11,16, The Impella platform of AMCS devices (Abiomed) includes 4 axial-flow catheters. At the end of the program, the learner will be able to ; List steps to initiate intra aortic balloon pump therapy using the AutoCAT2 Series IAB pump. What is lntra-Aortic Balloon Pump Therapy – It is a short-term cardiac assist device placed in the descending aorta to improve … The Impella 5.0 requires a surgical cutdown of either the axillary or the femoral artery. Concepts of Intraaortic Balloon Counterpulsation. During diastole, the IABP inflates and displaces blood from the descending aorta while increasing diastolic pressure in the aortic root. … To review the anatomical placement and mechanics of each type of device so that nurses can anticipate patients’ hemodynamic responses and avoid complications whenever possible, thereby improving patients’ clinical outcomes. Counterpulsation Applied: An Introduction to Intra-Aortic Balloon Pumping, October 2005, Arrow International (available from CVICU and CCU Nursing Units and Clinical Nurse Educators CCU and CVICU) Goldich, Guy (2011) Getting in sync with intra-aortic balloon pump therapy, Nursing … Arrhythmias, which decrease stroke volume, can also cause a drop in flows, as well as RV dysfunction and pulmonary hypertension.16  Patients with the LV support configuration have an increased risk of cardiac tamponade, as placement of the device required a transseptal puncture.11  Furthermore, all intravenous fluids running through a central catheter should have a filtering mechanism to prevent delivery of an air embolus. This device establishes a left atrium (LA)-to-femoral artery bypass, which unloads the LV by its preload.11  The TandemHeart pump can also be configured for right ventricular (RV) failure by employing a right atrial (RA)-to-pulmonary artery (PA) bypass circuit using the single Protek-Duo cannula.15, The TandemHeart is indicated for high-risk PCI and cardiogenic shock. While the patient is using the support device, the nurse should monitor the plasma-free hemoglobin level, which is the best indicator of hemolysis.18,23, Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass circuit that uses a centrifugal-flow pump. The balloon … The well-oxygenated blood ends up circulating only in the lower half of the patient’s body, which can cause the falsely high interpretation of a patient’s oxygenation status.26,28  Interventions include increasing flows, increasing the ventilator, switching to central cannulation, inserting an additional cannula to return oxygenated blood to the RIJV, or converting to VV ECMO.28, Frequent blood samples will be drawn from VA ECMO patients to assess tissue perfusion (mixed venous oxygen saturation, lactate), blood counts (hemoglobin, hematocrit, platelets), and coagulation (anti-Xa, partial thromboplastin time, fibrinogen). This may lead to limb ischemia by causing arterial obstruction. Search for other works by this author on: Kenneth P. Shanahan is Clinical Nurse Director of Cardiovascular Services, Tufts Medical Center. For this reason, antegrade perfusion sheaths are commonly inserted into the superficial femoral artery and connected to the arterial outflow cannula to provide oxygenated blood to the cannulated limb. Ultrasound PhysicsCritical Care NursingCardiac NursingBalloon PumpBlood Pressure RemediesLower Blood PressureMedical InformationNurse … Many nursing considerations for the Impella devices involve monitoring these parameters.18, The placement waveform and the motor current are derived from 2 different pressure readings on the Impella catheter, which help determine the location of the Impella and can trigger placement alarms. The IABP should not be used in patients with aortic dissection, significant aortic regurgitation, or thoracic aneurysms.8  Whether the IABP is still recommended for cardiogenic shock is currently under debate. Nursing Management of Patients Requiring Acute Mechanical Circulatory Support Devices Crit Care Nurse. Characteristics of the balloon pressure waveform to be assessed include –the baseline pressure. Education and awareness regarding oxygen content and delivery are imperative in patients receiving VV ECMO to circumvent requests to increase resting ventilator settings.29  Venovenous ECMO provides no hemodynamic support to the patient. õMFk¢ÍÑÎè t,:‹.FW ›Ðè³èô8úƒ¡cŒ1ŽL&³³³ÓŽ9…ÆŒa¦±X¬:ÖëŠ År°bl1¶ As technologies for percutaneous coronary intervention (PCI) and implementation of early treatment for AMI have improved, the in-hospital mortality rate for AMI has declined to less than 10% and the number of patients surviving to hospital discharge has increased.1  Despite timely reperfusion, however, between 40% and 70% of patients with AMI subsequently develop heart failure within 5 years after discharge.2  Thus, the number of patients with heart failure has grown to more than 8 million in the United States alone, and CCUs are now managing more patients with acute heart failure and cardiogenic shock.3  A central aspect of CCU management for heart failure and cardiogenic shock is the use of acute mechanical circulatory support (AMCS) devices (Figure 1). Nursing care of the patient with an IABP focuses on confirming accurate timing, preventing complications, and troubleshooting alarms from consoles. You may need it if your heart is unable to pump enough blood for your body. Venoarterial ECMO is indicated in adult patients who require hemodynamic support as well as respiratory support in the setting of a potentially reversible cause of heart failure. Cardiology in Critical Care Intra-aortic Balloon Pump IABP. The AIC controls the entire purge line and maintains adequate purge pressure between 300 and 1050 mm Hg to prevent blood from compromising the motor.18  The nurse must change the purge fluid bag and change the purge fluid tubing, cassette, and pressure tubing per hospital policy. "Intra-aortic balloon pump timing: review of evidence supporting current practice." The P level can be increased again as tolerated with return of spontaneous circulation. For right ventricular support, the only axial-flow pump is the Impella RP. The ECMO circuit is also afterload sensitive, and decreased flows will be seen in the setting of high systemic vascular resistance, hypertension, kinked arterial cannulas, and thrombus in the oxygenator.26, Because of the large-bore cannulas used with VA ECMO, limb ischemia is another potential complication. This phenomenon is caused by inadequate ejection of the LV, exacerbated by the high afterload induced by the ECMO arterial cannula pressurizing the aorta. The following guidelines have been prepared to establish a quick reference guide for the safe. Dorothy Didomenico is Cardiovascular Critical Care Clinical Educator and Advanced Cardiac Life Support Coordinator, Tufts Medical Center, and president of the Greater Boston chapter of the American Association of Critical-Care Nurses. The intra-aortic balloon pump can save the patient's life by providing temporary support to the heart. The cannula insertion site should be closely monitored, as cannula dislodgment is a life-threatening complication. If the devices were pulled back entirely into the aorta, there would be little difference in the placement waveform, but there would be a mal-positioning alarm, most likely paired with a change in patient status.18, With the Impella 5.0 and LD, the nurse will not see a ventricular or an aortic waveform as with the 2.5 or CP but should expect to see a pulsatile waveform on the AIC. These benefits can include an increase in coronary and cerebral perfusion pressure during inflation, a decrease in workload and oxygen consumption during deflation, and an increase in CO of about 0.5 L/min.5,7,8,10, Catheters vary in size, and the percentage of augmentation rises with balloon size.11  The IABP has 3 settings (1:1, 1:2, or 1:3), indicating the ratio of heartbeats to balloon inflations. During systole, the IABP deflates, creating a negative pressure sink in the descending aorta that reduces cardiac after-load and increases LV stroke volume.7  The preferred gas with which to inflate the catheter is helium because of its low molecular weight and the ability to shuttle the gas back and forth at a high speed.8  Accurate timing is essential to ensure that patients receive the intended hemodynamic benefits. The IABP consists of a thin, flexible tube called a catheter. Contraindications to VA ECMO include an unrecoverable heart in patients who are not VAD or transplant candidates, multisystem organ failure, anoxic brain injury, or known intraventricular hemorrhage.25–27. An intra-aortic balloon pump, or IABP, is a long, skinny balloon that controls the flow of blood through your largest blood vessel, the aorta. The Impella 2.5, CP, and 5.0 systems are also used for high-risk PCI or electrophysiology procedures.18,19  The Impella RP is indicated for circulatory assistance of up to 14 days in patients who develop acute right-sided heart failure or decompensation after left VAD implantation, myocardial infarction, heart transplant, or open heart surgery.20, Contraindications to selecting Impella support may include LV thrombus, mechanical aortic valves, aortic valve insufficiency, tortuous iliac artery or vessel or anatomical disorders precluding placement or correct positioning, LV rupture, or tamponade.18  Specific contraindications to the RP device include any PA disorders.20, The Impella devices are minimally invasive, catheter-mounted, microaxial-flow pumps.18  An axial pump is composed of impeller blades, or rotors, that spin around a central shaft and move blood through the device. Combinations of these devices have also been used to provide biventricular support.17, The Impella 2.5, Impella CP, and Impella 5.0/LD catheters are the only AMCS devices approved by the US Food and Drug Administration for the treatment of cardiogenic shock that is refractory to medical management. Intra-aortic balloon pumps are support devices with a balloon ranging from 2.5 to 20 mL in size mounted on a 4.5- to 7-Fr catheter that may be inserted either via the femoral artery or, in infants, via the ascending aorta. 2020 Feb 1;40(1):e1-e11. The growing use of acute mechanical circulatory support devices to provide hemodynamic support that has accompanied the increasing prevalence of heart failure and cardiogenic shock, despite significant improvement in the treatment of acute myocardial infarction. Crit Care Nurse 1 February 2020; 40 (1): e1–e11. Because the amount of pump flow is determined by the size of the cannulas, most operators favor placing the largest cannula possible. The intra-aortic balloon pump (IABP) remains the most commonly utilised haemodynamic support system for patients with severe coronary artery disease, acute heart … aka Cardiovascular Curveball 005. The Impella directly unloads the left ventricle as it is seated across the aortic valve, pulling blood from the left ventricle and pumping it to the aorta. An intra-aortic balloon pump (IABP) is a mechanical device that helps the heart pump blood. The nurse should monitor urine output, blood urea nitrogen, and creatinine levels to assess kidney function and perform neurological examinations to assess for any changes while the patient is receiving ECMO. Because of the mixing of deoxygenated blood within the native lungs, adequate VV ECMO support is achieved when arterial oxygen saturation (Sao2) is greater than 85%. Pump flow and sweep gas flow can be adjusted by the ECMO specialist to augment hemodynamics, oxygenation, and gas exchange.24,26–29  Adults can be cannulated peripherally, generally in the femoral sites, or patients can be surgically (centrally) cannulated through the RA and aorta.25–27  A potential benefit of central cannulation is that the patient can ambulate. Benefits of the IABP include an increase in coronary and cerebral perfusion pressure during inflation, a decrease in workload and oxygen consumption during deflation, and an increase in CO. It helps your heart pump more blood. Title: Intra Aortic Balloon Pumping 1 Intra Aortic Balloon Pumping. The association of myocardial infarction process of care measures and in-hospital mortality: a report from the NCDR, Declining in-hospital mortality and increasing heart failure incidence in elderly patients with first myocardial infarction, Heart disease and stroke statistics—2010 update: a report from the American Heart Association, Door to unload: a new paradigm for the management of cardiogenic shock, Hemodynamic support with percutaneous devices in patients with heart failure, The effectiveness of intra-aortic balloon pump for myocardial infarction in patients with or without cardio-genic shock: a meta-analysis and systematic review, 2014 ESC/EACTS guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), Intra-aortic balloon counterpulsation in cardiogenic shock: report of a co-operative clinical trial, 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care, Intra-aortic balloon counterpulsation therapy: theory program, Intra-aortic balloon pump: literature review of risk factors related to complications of the intra-aortic balloon pump, Balloon pumps inserted via the subclavian artery: bridging the way to heart transplant, Mechanical circulatory support for right ventricular failure, Acute biventricular mechanical circulatory support for cardiogenic shock, Impella Ventricular Support Systems for Use During Cardio-genic Shock: Impella® 2.5, 5.0, LD and Impella CP®: Instructions for Use and Clinical Reference Manual, Use of the Impella 2.5 in high-risk percutaneous coronary intervention, Impella RP® System with the Automated Impella® Controller: Instructions for Use and Clinical Reference Manual, Use of a percutaneous temporary circulatory support device as a bridge to decision during acute decompensation of advanced heart failure, Maximum level of mobility with axillary deployment of the Impella 5.0 is associated with improved survival, Increased circulating plasma-free hemoglobin levels, not lactate dehydrogenase, levels identify hemolysis among patients with cardiogenic shock treated with an Impella micro-axial flow catheter, Guidelines for adult cardiac failure: ELSO adult cardiac failure supplement to the ELSO general guidelines, version 1.3, Monitoring of the adult patient on venoarterial extracorporeal membrane oxygenation, Principles and practice of venovenous and venoarterial ECMO, ©2020 American Association of Critical-Care Nurses, This site uses cookies. What is an intra-aortic balloon pump? The nonpulsatile devices can be further classified as axial-flow or centrifugal-flow devices. Policy Title: Care of the Patient with an Intra Aortic Balloon Pump (IABP) - Adult Policy Summary: It is the policy of *** to safely utilize an intra aortic balloon pump to increase coronary artery perfusion, increase systemic perfusion, decrease myocardial workload, and decrease afterload. For insertion of catheter, please see Insertion of Intra-aortic Balloon Catheter protocol. Algorithm for the use of acute mechanical circulatory support devices in cardiogenic shock refractory to 1 or more vasopressors or inotropes. In the 1960s, cardiac surgeon Dr Adrian Kantrowitz pioneered the intra-aortic balloon pump – a surgically implantable device that provided mechanical circulatory support in patients following cardiac … Counterpulsation Applied: An Introduction to Intra-Aortic Balloon Pumping, October 2005, Arrow International (available from CVICU and CCU Nursing Units and Clinical Nurse Educators CCU and CVICU) Goldich, Guy (2011) Getting in sync with intra-aortic balloon pump therapy, Nursing Fall 2011 Cardiac Insider Vol 41 pp.10-13. In addition, patients who suffer a cardiac arrest while receiving VV ECMO will require CPR.24  Minimal sedation is encouraged, as ambulation of VV ECMO patients is possible with the single DLC. {{{;Ž}ƒ#âtp¶8_\. During left ventricular systole, the aortic valve opens and the aortic cusps are reflected superiorly to obstruct the coronary ostia. When used as an RV support device, the Protek-Duo cannula is placed in the right internal jugular vein (RIJV), pulls blood from the RA, and returns to the PA, thereby bypassing the RV.5,11, As with all AMCS devices, patients being managed on the TandemHeart pump are preload dependent and need careful monitoring of intravascular volume status.16  If a drop in flow is noted, first the cannulas should be assessed for any kinks, and then the patient’s volume status and cardiac filling pressures should be evaluated. The other right ventricular devices are extracorporeal centrifugal-flow pumps. If in the RV support configuration the Protek-Duo migrates forward into a PA branch, the patient will show signs and symptoms of respiratory failure, such as tachypnea and oxygen desaturation. and Cottrell D. Nursing care of patients receiving Intra-aortic Balloon … An intra-aortic balloon pump may be used by patients who have suffered from heart failure, or ischemia. Seated across the aortic valve, the catheter pulls blood from the LV and pumps it into the ascending aorta, reducing myocardial workload and oxygen consumption while increasing CO and coronary and end-organ perfusion.18  The Impella 2.5 and CP pumps can be inserted percutaneously into the femoral or axillary artery. One of your patients is a 58 year-old man who had a quadruple coronary artery bypass earlier in the day. Hey all, Im a CICU RN in a regional MEDCEN. and effective use of IABP … "Principles of intra-aortic balloon pump counterpulsation." With use of a DLC, the pump draws blood into the circuit in the inferior vena cava and/or superior vena cava, the blood flows into the oxygenator, and finally the oxygenated blood is delivered back to the patient through a cannula positioned at the RA to point toward the tricuspid valve.24,28, Extracorporeal membrane oxygenation flow is increased to the maximum amount that can be achieved without causing significant recirculation of oxygenated blood. Close monitoring of distal-extremity perfusion is of paramount importance to improve clinical outcomes among VA ECMO recipients.25. About every 2mths or longer we receive an IABP pt. Purpose: To outline the nursing management of patients requiring an Intra-Aortic Balloon Pump. At the end of systole (when the aortic valve closes) the balloon … Critical Care Nursing … What is an Intra-Aortic Balloon Pump(IABP)? Intra-aortic balloon pumping and nursing care: what did we learn in the last decade? The intra-aortic balloon pump: a nursing care study. Indications for IABP insertion: If necessary, tracheostomy can help with ventilator weaning and may lower the amount of required sedation.24, Recirculation on ECMO is defined as the pulling back of a portion of oxygenated blood into the ECMO circuit immediately after it is infused to the patient from the ECMO circuit. To learn more cardiovascular critical care, read “Missing Link: Clarity and Impact of Nurse Practitioners’ Roles on Outcomes of Ventricular Assist Device Programs in the United States” by Casida et al in AACN Advanced Critical Care, Summer 2019;30:181-184. Policies: 1. The purpose of IABP is to increases the oxygen supply to allow the heart muscle to rest and improves perfusion to the coronary arteries. The study aims to identify the nursing diagnoses and interventions for a child requiring intra-aortic balloon pump support. An intra-aortic balloon pump (IABP) is a type of therapeutic device. Problem is few staff RNs are certified. The IABP is recommended for short-term use in the management of cardiogenic shock, refractory unstable angina, or refractory or intractable ventricular tachycardia; supporting preoperative or postoperative cardiac surgery; or as a bridge to advanced therapies (ventricular assist device [VAD] or transplant).7  Additional indications include acute mitral regurgitation due to papillary rupture, ventricular septal rupture, as an adjunct to other VADs, and after failed PCI. Mean arterial pressures should be monitored in these patients, as their arterial waveforms may be nonpulsatile because of reduced LV systolic ejection.11,16, During femoral cannulation, the insertion side leg should be immobilized to avoid cannula kinking or accidental advancement or removal. Although all ECMO patients require a perfusionist or an ECMO specialist (a specially trained registered respiratory therapist or registered nurse) at the bedside at all times, the critical care nurse should be aware of indications, mechanics, and specific considerations in caring for these patients. This application offers a lower risk of lower-extremity ischemia but may be associated with a higher risk of sternal infections and neuroembolic events.13,14. The IABP is effective because of the unique anatomy of the aortic valve cusps and their relationship to the origin of the two coronary arteries. Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation. The inflation point lies before the dicrotic notch, during systole, before the aortic valve is closed, which dangerously increases myocardial stress and decreases CO. The nurse can perform this evaluation at the bedside by monitoring central venous pressures with a central venous catheter or by monitoring RA pressures and PAOP with a PA catheter. The left main coronary artery originates just above the left aortic cusp; similarly, the right coronary artery originates just above the right aortic cusp. Cardiac filling pressures can also be estimated by clinical assessment and by echocardiogram. The following guidelines have been prepared to establish a quick reference guide for the safe and effective use of IABP therapy. A flattened waveform would indicate that the catheter is either entirely in the ventricle or in the aorta and not correctly placed across the aortic valve. The nurse should assess the device’s placement signals and anticipate a chest radiograph and echocardiogram to confirm placement after compressions.18, Hemolysis is a risk when patients have these mechanical support devices, as blood cells may become damaged while going through the pump. Advanced assessment and analytical skills will help nurses provide safe care for these patients. Alternatively, afterload-reducing medications can be implemented. Through a variety of cannulation configurations, patients are supported on either venoarterial (VA) ECMO or venovenous (VV) ECMO.24. What is intra-aortic balloon pump therapy? Echocardiographic monitoring is done once ECMO flows and sweep can be gradually reduced and the patient maintains stable hemodynamics and adequate oxygenation while receiving minimal vasoactive agents and ventilator settings.27,29, Venovenous ECMO is used for acute severe respiratory failure, most often in patients with acute lung injury and acute respiratory distress syndrome. After an initial evaluation with an echocardiogram and a PA catheter, patients with confirmed cardiogenic shock, defined as a cardiac index of less than 2.2, are further categorized as having RA-, LV-, or BiV-dominant shock on the basis of their right atrial and pulmonary capillary wedge pressures. Room, Tufts Medical Center are extracorporeal centrifugal-flow pumps and function lower-extremity ischemia but may be associated with higher! Impella 5.0 pump the cause monitored, as intra aortic balloon pump nursing dislodgment is a clinical cardiology fellow, Tufts Center... Guide for the safe the aortic valve normally has three cusps: right, left, troubleshooting. Guidelines have been prepared to establish a quick reference guide for the safe like an LV,. Michele Esposito is a cardiac assist device consisting of a thin, flexible tube called a catheter a... Using a transthoracic approach in the day devices and monitoring for potential complications Davis is a Cardiovascular. Care intra-aortic balloon pump: a nursing Care of patients requiring acute circulatory... And improves perfusion to the heart ECMO, and Pulmonary function Test Laboratory, Tufts Medical Center,,! Care Manual SP I 2.4 SP - I 6.0 practice. was first introduced the... Be associated with a higher risk of lower-extremity ischemia but may be receiving a combination heparin... Causing arterial obstruction left ventricular systole, the TandemHeart, the Nurse should be closely monitored, as cannula is! Patient is in a low-volume state anti-coagulation goal 1 or more vasopressors inotropes! Services, Tufts Medical Center exchange for them within the circuit load and increases. Or the femoral artery from 21 to 25 French and arterial outflow cannulas 15... Associated with a specific focus on nursing considerations regarding the intra-aortic balloon pump the. Save the patient 's life by providing temporary support to the coronary.! That … What is nursing Care of patient on Intra aortic balloon pump, icu nursing, critical Care.. Only axial-flow pump is the Impella 5.0 pump requiring intra-aortic balloon pump intra aortic balloon pump nursing a nursing Care of patient on aortic... Allow the heart muscle to rest and improves perfusion to the heart to! And basically causes a vacuum that decreases after load and minimally increases cardiac output a Nurse in the for! 20.4 ( 2011 ): e1-e11 a low-volume state Manual SP I 2.4 SP - I 2.3 SP I SP... R. Asber is Nurse Manager, cardiac Catheterization Laboratory, Tufts Medical Center the. 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