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Temporary pacing

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  • When a patient has extreme bradycardia, the ventricle will try to compensate with ventricular escape beats.
  • We supplement our OHS patients to increase atrial kick/ cardiac output.
  • Bradydysrhythmias include: idioventricular, junctional, slow atrial fibrillation, agonal for example.
  • Long QT syndromes would include Torsades de pointes. Medication toxicity would include quinidine, some tricyclic antidepressants, phenotiazines, Haldol, digoxin.
  • Transcutaneous pacing is another alternative. Is used emergently because it is more easily applied (anterior/posterior) and does not require venous cannulation. It is painful and requires some pain medication and sedation. Our Zoll defibrillators have a transcutaneous pacing mode. Requires more energy and this does create pain. Higher incidence of undesired pacing of chest wall and body muscles. Stimulation of diaphragm causes hiccups. Epicardial pacing wires: Wires are placed on the right atrium and ventricle. Left ventricle is not used because it is inaccessible through deep pulmonary vein and artery.
  • Our main focus is on chambers paced, sensed, and response to sensing (I-III). Position IV and V refer more to permanent pacers and AICDs.
  • Used to treat symptomatic bradycardia (and transient decrease in HR) and to allow administration of medications (Beta-blockers) and to increase cardiac output/atrial kick.
  • Slow atrial fibrillation, back-up pacing, sinus node dysfunction, idioventricular
  • Avoids competition between pacemaker-initiated beats and the patient’s on intrinsic rhythm. 2 nd degree type I (Wenckebach) and 2 nd degree type II and complete heart block that is symptomatic. New BBB with transient CHB. Sinus node dysfunction, alternating BBB and junctional.
  • Asynchronous pacing in presence of intrinsic rhythm may result in R on T phenomenon which may lead to a lethal dysrhthmia. Only us in absence of an intrinsic rhythm.
  • Also known as failure of pulse generation. Mechanical failure of pacemaker to generate impulse. Represented by absence of pacer spike.
  • EMI= electomechanical interference
  • Heart fails to respond to the pacemaker stimulus. Represented by an absence of a complex after spike.
  • #1. Evidenced by appropriate HR, proper sensing, and proper capture. #2 evidenced by b/p > 90, MAP>60, A&O, and no syncope or ischemia. No lightheadedness,faintess, dizziness or confusion. #3 use paper tape to anchor wires/leads to abdomen. Hypafix or clear tape is to sticky. Harder to get wires loose.
  • May be changing are site care in near future. Maryellen will hopefully be taking to practice in February.
  • Failure of pacemaker to sense properly causes competition between pacemaker initiated impulses and the patient’s intrinsic cardiac rhythm. Pacemaker oversensing causes the pacemaker to be inappropriately inhibited. Failure to capture myocardium. Stimulation of the diaphragm causes hiccupping. May be related to pacing the phrenic nerve, perforation, wire dislodgement, or excessively high pacemaker MA setting. Ventricular dysrhythmias occur from manipulation of lead within the cardiac chamber. Pneumo/ hemothorax, myocardial perforation, air embolism and cardiac tamponade may occur during insertion of pacemaker and electrode placement.
  • Do they have a pulse? Are they in PEA related to acidosis, hypoxia or electrolyte imbalance? This will affect the level of energy required to pace. Do they have fibrotic tissue around tip of catheter which will affect the ability of the patient to capture even with an increased MA? 2. Do you need to change MA or sensitivity? If fail to capture or pace, are they acidotic or need a new battery? Do we need to initiate asynchronous pacing or change to emergent transcutaneous pacing?

Transcript

  • 1. Temporary Pacemakers- SICU’s 101 Primer
  • 2. Objectives
    • Describe three common temporary pacemaker settings and the situation or underlying rhythm appropriate for each setting.
    • Discuss common complications of temporary pacing and the assessments and interventions needed to troubleshoot.
    • Describe general care and maintenance of a temporary pacemaker.
  • 3. Uses for Temporary Pacing
    • To stimulate myocardium to contract in absence of intrinsic rhythm.
    • To establish adequate cardiac output and blood pressure to ensure tissue perfusion to vital organs.
    • To reduce possibility of ventricular dysrhythmias in presence of bradycardia.
  • 4. Uses cont.
    • To supplement inadequate rhythm in presence of transient decrease in heart rate.
    • To allow administration of medications(beta-blockers) to treat ischemia or tachyarrhythmias in presence of conduction system dysfunction or bradycardia.
    • AACN Procedure Manual for Critical Care, pg. 349.
  • 5.
    • Complete heart block
    • Symptomatic Second degree heart block
    • Symptomatic bradycardia or bradydysrhythmias
    • Dysrhythmias complicating AMI
    • Alternating BBB
    • New BBB with transient CHB
    • Sinus node dysfunction
    • Treatment of bradycardia-tachycardia syndrome
    Rhythms Requiring Temporary Pacing
  • 6. Rhythms Requiring Temp Pacing (cont.)
    • Ventricular standstill or cardiac arrest
    • Long QT syndrome with ventricular dysrhythmias
    • Medication toxicity
    • Post-op cardiac surgery
    • Prophylaxis with cardiac diagnostic or interventional procedures
    • * AACN Procedure Manual for Critical Care , pg. 349.
  • 7. 3 Primary Methods @ Cone
    • Transvenous-used mostly in CICU.
    • Epicardial- used in SICU and on 2000.
    • Transcutaneous- emergent.
  • 8. Epicardial Pacing
    • Method of stimulating the myocardium through use of Teflon-coated, unipolar stainless steel wires that are sutured loosely to epicardium after surgery.
  • 9.  
  • 10. Common Settings
    • AAI
      • Atrium is paced when necessary
      • Atrial activity is being sensed by pacer.
      • I = when atrial activity is sensed the pacer does not fire.
  • 11.
    • VVI
      • Ventricle is paced when necessary.
      • Ventricular activity is being sensed by pacer.
      • I= When ventricular activity is sensed, the pacer does not fire.
  • 12.
    • DDD
      • Atrium and ventricle are paced when necessary (not necessarily at the same time).
      • Atrial and ventricular activity is being sensed by pacer.
      • D= Triggers pacer when atrial or ventricular activity is not sensed. Inhibits pacer when atrial or ventricular activity is sensed.
  • 13. TEMPORARY PACING DEFINITIONS (from AACN procedure manual for Critical Care, 5 th edition, 2005, pg.325)
  • 14. Sensing
    • The ability of the pacemaker to detect intrinsic myocardial electrical activity.
    • The pacemaker either is inhibited from delivering a stimulus or initiates an electrical impulse.
  • 15. Pulse Generation
    • Occurs when the pacemaker produces a programmed electrical current for a set duration.
    • This energy travels through the epicardial or transvenous wires to the myocardium.
    • This is known as pacemaker firing and usually produces a line or spike on the EKG recording.
  • 16. Capture
    • Refers to the successful stimulation of the myocardium (by the pacemaker impulse) that results in depolarization.
    • Evidenced on EKG by a pacemaker spike followed either by an atrial or ventricular complex, depending on chamber being paced.
  • 17. Synchronous Pacing
    • Pacemaker coordinates with intrinsic cardiac activity.
    • Able to sense the patient’s inherent cardiac activity.
    • Will inhibit or trigger a stimulus as needed.
    • Examples: AAI, VVI, DDD
  • 18. Asynchronous Pacing
    • Pacemaker functions at a fixed rate regardless of patient’s underlying rhythm.
    • It is not able to sense the patient’s underlying rhythm.
    • Examples: AOO, VOO, DOO
  • 19. Failure to Pace
    • Pacemaker does not discharge a pacing stimulus at it’s programmed time to the myocardium.
    • Evidenced by absence of a pacing spike on EKG where expected.
  • 20. Sensing Failure
    • Pacemaker either detected extraneous signals that mimic intrinsic cardiac activity(oversensing) or did not accurately identify intrinsic activity(undersensing).
  • 21. Oversensing
    • Is recognized on EKG by pauses where pacing beats were expected and prolongation of the interval between paced beats.
  • 22.  
  • 23. Undersensing
    • Recognized on EKG by inappropriate pacemaker spikes relative to the intrinsic electrical activity(pacemaker spikes occurring within p wave, QRS complex, or t wave) and shortened distances between paced beats.
  • 24.  
  • 25. Failure to Capture
    • Pacemaker has delivered a pacing stimulus that was unable to initiate depolarization of the myocardium and subsequent myocardial contraction.
    • Evidenced on EKG by pacemaker spikes that are not followed by a p wave for atrial pacing or a QRS complex for ventricular pacing.
  • 26.  
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  • 28. Medtronic 5388 Temporary Pacemaker *The following slides are courtesy of Medtronics*
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  • 45. Want to see:
    • Ekg tracing shows paced rhythm consistent with set parameters.
    • Patient exhibits hemodynamic stability.
    • Pacemaker leads/wires are isolated from other electrical equipment by maintaining secure connections into the pulse generator.
  • 46. Care and Maintenance
    • Cleanse around insertion site with CHG or Betadine.
    • Curl epicardial wires and use paper tape to tape to abdomen in horizontal position.
    • Cleanse around temporary transvenous site with CHG and place sterile dressing.
  • 47. Complications
    • Over/undersensing causing competition
    • Failure to capture
    • Hiccups
    • Phlebitis, thrombosis, embolism or bacteremia
    • Ventricular dysrhythmias
    • Pneumo/hemothorax
    • Myocardial perforation & cardiac tamponade
    • Air embolism
    • Lead dislodgement
    • Failure to pace
  • 48. Troubleshooting:
    • Always check patient first!
    • Be sure pacer is on!!
    • Change battery.
    • Asynchronous pacing- only if no intrinsic rhythm
    • Be sure connections are secure.
    • Evaluate sensitivity threshold.
    • Increase MA.
    • Reverse polarity of wires/change cables or generator.
    • Check rhythm. If patient goes into Afib, AAI will not provide pacing. Go to VVI pacing.
  • 49. Documentation
    • Patient & family education
    • Date/time pacing initiated
    • Description of events warranting intervention
    • Vital signs & hemodynamic parameters before & after pacing initiated (response to pacing)
  • 50. Documentation (cont.)
    • EKG monitoring strip recording before & after pacing initiated
    • Pacemaker settings: mode, rate, output(MA), sensitivity
    • Medications administered and response
    • Adjustments to pacemaker
    • Date/time pacing discontinued
  • 51. Resources:
    • AACN Procedure Manual for Critical Care , Lynn-McHale Wiegand, Debra J. and Carlson, Karen K, eds.Chapters 48-50, pp. 333-361. 2005.
    • “ Pacemaker (Temporary) Insertion and Care.” Nursing Clinical Policies and Procedures/Cardiovascular Care, Moses Cone Health System Homepage.
    • Wiederhold, Richard. Electrocardiography: The Monitoring and Diagnostic Leads. pp. 77-83, 1999.