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A D V A N C E D P A C I N G

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Pacemakers

Pacemakers


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    • 1. ADVANCED PACING Understanding and Troubleshooting Pacemakers Sherry L. Knowles, RN, CCRN, CRNI
    • 2. Objectives
      • Understand the different pacemaker modes according to the NASPE/BPEG (NGB) universal code.
      • Recognize common pacemaker complications in a cardiac tracing.
      • Differentiate between failure to pace, loss of capture, under sensing and over sensing.
      • List appropriate nursing actions for common pacemaker complications.
      • Understand routine pacemaker settings and thresholds.
      • Identify the different types of pacemakers.
      • Understand and recognize pacemaker syndrome.
      • Be familiar with the proper use of a pacemaker magnet.
      • Understand routine nursing management of a patient with a pacemaker.
      • Recognize battery failure in temporary and permanent pacemaker devices.
      At the end of this presentation, the view will be able to:
    • 3. Pacemaker
    • 4. Nursing Action
    • 5. Indications for Pacing
    • 6. Indications for Pacing
      • Symptomatic Bradycardia
      • Heart Blocks
        • Second Degree AV Block – symptomatic
        • Complete AV Block
      • Sick Sinus Syndrome
      • Overdrive Pacing
      • Malfunctioning Pacemaker
      • Support During Electrolyte or Acid-Base Disturbances
      • To Improve Hemodynamics
      • Support During Procedures
      • Backup Support With Drug Therapy
    • 7. Types of Pacing
      • Temporary Pacing
        • Transvenous
        • Transcutaneous
        • Epicardial
      • Permanent Pacing
        • High/Low Rate Setting
        • PR and AV Intervals
        • Rate Response Pacing
        • Mode Switching
      • Fixed Rate
        • Controlled
        • Asynchronous
      • Demand
        • Backup
        • Synchronous
      • AV Sequential
        • Dual Chamber Pacing
        • Atrial & Ventricular wires
    • 8. Pacemaker Types
    • 9. Epicardial Pacing
    • 10. Transcutaneous Pacing
    • 11. Insertion Complications
      • Dysrhythmias
      • Perforation
      • Pneumothorax
      • Hematoma
      • Hemorrhage
      • Tamponade
      • Pericardial Friction Rub
      • Vein Thrombosis
      • Infection
      • Inadvertent Arterial Puncture
      • Diaphragmatic Stimulation
    • 12. Modes of Pacing R D D D Chamber Paced O = None A = Atrium V = Ventricle D = Dual ( A + V) Chamber Sensed O = None A = Atrium V = Ventricle D = Dual ( A + V) Response to Sensing O = None T = Triggered I = Inhibited D = Dual ( T + I) Programmability O = None P = Simple Programmable M= Multiple Programmable R = Rate Modulation
    • 13. Pacemaker Modes
      • AOO: Atrial pacing, no sensing, atrial fixed rate
      • VOO: Ventricular pacing, no sensing, ventricular fixed rate.
      • DOO: AV pacing, no sensing, AV fixed rate.
      • AAI: Atrial Pacing, atrial sensing, inhibited response to sensing. Atrial demand pacing.
      • VVI: Ventricular pacing, ventricular sensing, inhibited response to sensing. Ventricular demand pacing.
      • DDI: A pacemaker that senses and stimulates both atrium and ventricle. The stimulation rate is fixed.
      AOO VOO DOO AAI VVI DDI
    • 14. Pacemaker Modes
      • SSI: Single chamber pacing (atrial or ventricular), same chamber sensing, inhibited response to sensing. A pacemaker that senses and stimulates one chamber at one rate.
      • AAT: Atrial pacing, atrial sensing, triggered response to sensing. Atrial demand pacing.
      • VVT: Ventricular pacing, ventricular pacing, triggered response to sensing. Ventricular demand pacing.
      • VAT: Ventricular pacing, atrial sensing, triggered response to sensing. The ventricular stimulus will fire at a set interval after sensing a spontaneous atrial depolarization. AV synchronous pacing.
      • VDD: A pacemaker that senses the atrium and ventricle and paces the ventricle (atrial synchronous, ventricular inhibited).
      • DDD: A pacemaker that senses and stimulates both atrium and ventricle. The stimulation rate, tracking rate and minimum rate are determined.
      SSI AAT VVT VAT VDD DDD
    • 15. Pacemaker Modes
      • SSIR: A pacemaker that senses and stimulates one chamber at a rate determined by a sensor.
      • AAIR: A pacemaker that senses and stimulates the atrium at a rate determined by a sensor.
      • VVIR: A pacemaker that senses and stimulates the ventricle at a rate determined by a sensor.
      • DDIR: A pacemaker that senses and stimulates both atrium and ventricle. The stimulation rate is governed by a maximum rate, the rate determined by a sensor and the minimum rate.
      • DDDR: A pacemaker that senses and stimulates both atrium and ventricle. The stimulation rate is governed by a maximum rate, the rate determined by a sensor and the minimum rate.
      SSIR AAIR VVIR DDIR DDDR
    • 16. Single Chamber Pacing
      • AAI
        • Paces and senses only the atria
        • Must have proper AV conduction
      • VVI
        • Looses AV synchronicity
        • Used for temporary backup or with loss of AV conduction (AFib)
    • 17. Atrial Pacing
    • 18. Ventricular Pacing
    • 19. Loss of AV Synchrony
      • Loss of atrial contribution
      • Decrease in LV preload
      • Decrease in stroke volume
      • Decrease in cardiac output
      • Decrease in cerebral perfusion
      • Decrease in coronary perfusion
      • Increase risk of pacemaker syndrome
    • 20. Dual Chamber Pacing
      • Maintains / Restores AV Synchrony
      • Optimizes heart function
      • Reduces pacemaker syndrome
      • Useful in CHF
      • Capable of mode switching
    • 21. AV Pacing
    • 22. Rate Response Pacing
      • Uses sensor technology to provide rate modulation with exercise
      • AAIR
      • VVIR
      • DDDR
    • 23. Rate Response Sensors
      • Activity Sensors
        • sensors that detect body movement. The more the patient’s body is moving (so the reasoning goes) the faster the heart rate should be.
      • Breathing Sensors
        • measures the patient’s rate of breathing. The faster the breathing, the faster the heart rate should be.
    • 24. Rate Response Pacing
    • 25. Pacemaker Syndrome
      • Often due to loss of AV Synchrony and/or delayed conduction time
      • Shortness of Breath
      • Fatigue
      • Cough
      • Orthopnea
      • Headache
      • Syncope
      • Vertigo
      • Choking Sensation
      • CHF, Pulmonary Edema
      • Dizziness
      • Apprehension
      • Pulsations in the Neck
      • Palpitations
      • Chest Pain
      • Near Syncope
      • Jaw Pain
      • Confusion
      • Altered Mental Status
    • 26. Troubleshooting
      • Twelve Leads are Better than One.
      • Choose leads that show the P wave and QRS morphology best.
      • Look for the pacer spikes.
    • 27. Failure To Pace
    • 28. Causes of Output Failure
      • Lead Fracture
      • Lead Dislodgement
      • Lead Disconnect
      • Electromagnetic Interference
      • Battery Failure
      • Component Failure
      • Over sensing
    • 29. Nursing Actions
      • Assess and Treat Patient
      • Temporary Pacemaker
        • Make Sure Unit Is Turned On
        • Check Battery and Connections
        • Check Rate, Increase Rate As Needed
        • Check mA, Increase Output As Needed
        • Decrease Sensitivity (toward asynchronous or 20mV)
      • Prepare For Transcutaneous Pacing
      • Notify MD As Necessary
    • 30. Failure To Capture
    • 31. Failure To Capture
    • 32. Causes of Loss of Capture
      • Lead Dislodgement
      • Lead Insulation Defect
      • Battery Failure
      • Exit Block
      • Elevated Pacing Thresholds
      • Acute MI
      • Electrolyte Imbalance
      • Medications
      • Metabolic Disorders
      • Defibrillation
      • Long QT Syndrome
    • 33. Loss of Capture
      • Causes:
        • Catheter Dislodgement
        • Catheter Fracture
        • Unstable Connection
        • Local Myocardial Necrosis/Fibrosis
        • Local Myocardial Inflammation
    • 34. Loss of Capture
      • Causes:
        • Drug Effects
        • Metabolic Effects
        • Cautery (DC Cardioversion, Ablation)
        • Lead Conductor or Insulation Failure
        • Generator Malfunction
    • 35. Nursing Actions
      • Assess and Treat Patient
      • Temporary Pacemaker
        • Make Sure Unit Is Turned On
        • Check Battery and Connections
        • Check mA, Increase Output As Needed
        • Check Rate, Increase Rate As Needed
        • Decrease Sensitivity (toward asynchronous or 20mV)
      • Prepare For Transcutaneous Pacing
      • Notify MD As Necessary
    • 36. Pacemaker Sensitivity
      • Low Sensitivity
        • Towards Asynchronous
        • Toward Higher mV (20mV)
        • Decreases pacemaker sensing ability
      • High Sensitivity
        • Maximal Sensitivity
        • Toward Lower mV (1mV)
        • Increases pacemaker sensing ability
    • 37. Failure To Sense
    • 38. Failure To Sense
    • 39. Nursing Actions
      • Assess and Treat Patient
      • Temporary Pacemaker
        • Make Sure Unit Is Turned On
        • Check Battery and Connections
        • Increase Sensitivity (toward synchronous or 1mV)
        • Check mA, Increase Output As Needed
        • Check Rate, Increase Rate As Needed
      • Prepare For Transcutaneous Pacing
      • Notify MD As Necessary
    • 40. Pacemaker Interference
      • Electromagnetic Interference (EMI)
        • Electromagnetic fields
        • Defibrillation
        • Electrocautery
        • Ablation
        • Lithrotripsy
        • Magnetic Resonance imaging (MRI)
        • High dose radiotherapy
        • Cellular telephones
        • TENS
      • Twiddler’s Syndrome
    • 41. Fusion Beats
    • 42. Pacemaker Magnet
      • A pacemaker magnet placed over a pacemaker generator typically eliminates sensing and returns the pacemaker to an asynchronous pacing mode (AOO, VOO or DOO).
      • When using a pacemaker magnet, the rhythm changes to a controlled paced rhythm.
      • Use caution when removing a pacemaker magnet because it can cause a reentry tachycardia. The last asynchronous beat is conducted through the AV node to the atrium. In this case, treat this dysrhythmia by reapplying the magnet.
    • 43. Pacemaker Magnet Tracing
    • 44. Transvenous Pacing
      • Transvenous Pacing
        • Start with new battery
        • Secure leads and connections
        • Set mA to 5 and adjust for capture
        • Keep mA 2-3 times the threshold
    • 45. Transvenous Threshold
      • Transvenous Threshold
        • Gradually decrease mA from 5 (to 0) until 1:1 capture is lost. Then increase mA until 1:1 capture is reestablished.
        • Set the mA 2-3 times the threshold.
        • Check threshold qd and prn, unless directed otherwise by physician.
    • 46. Transcutaneous Pacing
      • Transcutaneous Pacing
        • Keep pads off pacemaker/ICD devices
        • Set mA to 40 and adjust for capture
        • Remove paste from chest wall
        • Avoid arching
        • Keep mA 2 X threshold
    • 47. Transcutaneous Threshold
      • Transcutaneous Threshold
        • Gradually decrease mA from to 40 until 1:1 capture is lost. Then increase mA until 1:1 capture is reestablished.
        • Set the mA 2 times the threshold.
        • Check threshold qd and prn, unless directed otherwise by physician.
    • 48. Epicardial Pacing
      • Epicardial Pacing
        • Start with new battery
        • Secure leads and connections
        • Set mA to 3-5 and adjust for capture
        • Keep mA 3 X threshold
    • 49. Epicardial Threshold
      • Epicardial Threshold
        • Gradually decrease mA from to 5 until 1:1 capture is lost. Then increase mA until 1:1 capture is reestablished.
        • Set the mA 3 times the threshold.
        • Check threshold qd and prn, unless directed otherwise by physician.
    • 50. Pacemaker Sensitivity
      • Low Sensitivity
        • Towards Asynchronous
        • Toward Higher mV (20mV)
        • Decreases pacemaker sensing ability
      • High Sensitivity
        • Maximal Sensitivity
        • Toward Lower mV (1mV)
        • Increases pacemaker sensing ability
    • 51. Sensitivity Threshold
      • Sensitivity Threshold
        • Set rate just below patient’s intrinsic rate, the pacemaker should stop pacing and the sensor light should start flashing.
        • Gradually decrease sensitivity until the pacemaker begins to fire. This is the sensitivity threshold.
        • Set sensitivity to 2-3 times the sensitivity threshold.
    • 52. Other Pacemaker Settings
      • High/Low Rate
        • Sets the highest and lowest rates that the pacemaker can pace.
      • AV Interval Control
        • Set between 150-250 msec to preserve AV synchrony.
      • Refractory Periods
        • Sets a period of msec in which the pacemaker will not respond after a sensed or paced beat.
    • 53. Special Considerations
      • Not necessary to disconnect temporary pacemaker during cardioversion or defibrillation
      • Changes in pacing threshold may occur with electrolyte imbalance, myocardial ischemia, anemia, CHF, hypoxia, or a change in drug therapy
      •   Pacing threshold increases over time
    • 54. Nursing Management
      • Continuous Cardiac Monitoring
            • Watch for pacemaker complications
            • Always evaluate cardiac tracings
      • Electrical Safety Measures
            • Use rubber gloves when handling external pacemaker components
            • Regularly inspect all connections
            • Replace batteries as needed ( have spares available)
            • Avoid EMI sources
      • Monitor Thresholds
      • Monitor All Imbalances
          • Temperature, Acid-Base, Electrolytes
      • Monitor Medication Effects
      • Watch For Pacemaker Syndrome
    • 55. Nursing Assessment
      • Assess the Patient
            • Vital Signs
            • Cardiac Rhythm (always run strips)
            • Patient Complaints
      • Assess the Pacemaker
            • Maintain Electrical Safety
            • Inspect and Secure Connections
            • Assess the Effectiveness of the Pacemaker
            • Check Thresholds
            • Change Battery As Needed (keep spares available)
    • 56. Pacemaker Evaluation
      • What is the rhythm?
      • Is the pacemaker functioning properly?
      • What is the immediate nursing action?
    • 57. Pacer Rhythm Evaluation
      • What is the pacing Mode?
      • What is the underlying rhythm?
      • Is the pacer firing appropriately?
      • Is the capture appropriate?
      • Is the sensing appropriate?
          • What is the low rate limit?
          • What is the high rate limit?
          • What is the AV delay?
    • 58. Nursing Management
      • Continuous Cardiac Monitoring
            • Watch for pacemaker complications
            • Always evaluate cardiac tracings
      • Electrical Safety Measures
            • Use rubber gloves when handling external pacemaker components
            • Regularly inspect all connections
            • Replace batteries as needed ( have spares available)
            • Avoid EMI sources
      • Monitor Thresholds
      • Monitor All Imbalances
          • Temperature, Acid-Base, Electrolytes
      • Monitor Medication Effects
      • Watch For Pacemaker Syndrome
    • 59. PRACTICE
    • 60. AAI AAI: A pacemaker that stimulates and senses the atrium at one rate
    • 61. VVI VVI: A pacemaker that stimulates and senses the ventricle at one rate
    • 62. DDI DDI: A pacemaker that senses and stimulates both atrium and ventricle. The stimulation rate is fixed.
    • 63. DDD
    • 64. DDD or VVI?
    • 65. DDDR
    • 66. DDI
    • 67. What’s the Mode?
    • 68. What’s the Mode?
    • 69. References
      • Guidelines for Pacemakers and Defibrillators Updated. Journal Watch General Medicine 1998: 2-2.
      • Wood, D.A., Fox, K.F., Gibbs, S.R. (2001). Rapid cardiology--for chest pain, breathlessness and palpitations. QJ Med 94: 177-178.  
      • HAMMILL, S. C., HUBMAYR, R. D. (2000). The Rapidly Changing Management of Cardiac Arrhythmias. Am J Respir Crit Care Med 161: 1070-1073.
      • Bauersfeld, U., Nowak, B., Molinari, L., Malm, T., Kampmann, C., Schonbeck, M. H., Schuller, H. (1999). Low-energy epicardial pacing in children: the benefit of autocapture. Ann. Thorac. Surg. 68: 1380-1383.
      • KURBAAN, A S, SUTTON, R (1999). Pacing for vasovagal syncope. Heart 82: 649-650
      • Braunwall, e. (1992) Heart Disease : a textbook of cardiovascular disease, 4 th edition, WB Saunders
      • American Radio Relay League, Inc., Technical Information Service, 225 Main St., Newington, CT 06111 (860) 594-0214.
      • Thelan, Lynne A., Davie, Joseph K., Urden, Linda D., Lough, Mary E. (1994) Critical Care Nursing: Diagnosis and Management. Second Edition. Pg 313-322.
      • Graver, K (1998) A Practical Guide to EKG Interpretation, 2 nd edition
      • On-line: http://www.emedicine.com/emerg/topic699.htm