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心臟植入性電子儀器(CIED)
護理照護指引-術中護理照護
中國醫藥大學附設醫院
心臟內科
護理師 洪佩琪
Pacemaker 術前準備
•核對病人 檢查同意書
•Check 前一天抽血 data
•術前一小時給予Cefazolin and
Gentamycin
•3 lead ECG monitor/recorder
•TCP
•Vital sig...
準備用物
生理系統監視儀
Subclavian Vein
vs.
Cephalic Vein
Approach
Access - Blood Vessels
Subclavian
Artery Subclavian
Vein
Cephalic
Vein
Aorta
Pulmonary
Artery
External Jugular
Internal Ju...
Cephalic Vein Approach
Ellenbogen KA et al. Clinical cardiac pacing, defibrillation, and resynchronization therapy 3th ed.
Cephalic Vein Approach
Cephalic Vein Approach
Subclavian Vein
Subclavian puncture
VVI upgrade to DDD
Access - Cardiac Chambers
Left Atrium
Mitral Valve
Aortic Valve
Left Ventricle
Right Ventricle
Tricuspid Valve
Right Atriu...
Transvenous Leads
Passive fixation
(tined)
The tines become lodged in the
trabeculae of the apex or the
pectinate of the a...
Tined lead and Screw lead
Single Chamber System
• One lead
– Atrium
– Ventricle (most common)
• May be used for patients in chronic AF (VVI
pacemake...
Dual Chamber System
• Two leads
– One lead implanted in the atrium
– One lead implanted in the ventricle
• Provides AV syn...
Dual Chamber Pacemaker
RV Lead at the Apex
RA Lead in Appendage
Triple Chamber System
• Three Leads:
– Right Atrium
– Right Ventricle
– Left Ventricle (via the Coronary Sinus vein)
• Mos...
Knowledge Checkpoint
術中注意事項
• 嚴謹遵守無菌原則
• 注意vital sign
Programmer
defibrillation threshold (DFT)
testing
• Diazepam or midazolam
• TCP 200J
• Check Vital sign
defibrillation threshold (DFT)
testing
pacemaker implantation test
Cont/.....
• Measurements
– 1.Sensing threshold
• Amplitude (Minimum : “P” - 2mV , “R” - 5mV)
• Slew rate
Pacemaker Implan...
• Measurements
– 2.Pacing threshold
• (Measured amplitude at various pulse widths)
• Paced rate > = 20 ppm above spontaneo...
Cont/.....
• Measurements
– 3.Lead stability
– 1V output, or 2X diastolic threshold (min. 1V)
– 10V output for diaphragm s...
Sensing
• Sensing is the ability of the pacemaker to
“see” when a natural (intrinsic)
depolarization is occurring
• Pacema...
Acceptable Sensing Values (mV)1
Acute Chronic
Atrium >1.5 >1.0
Ventricle >7.0 >5.0
Sensing
1Curtis, Anne B. (2010). Fundam...
Sensitivity
Amplitude(mV)
Time
5.0
2.5
1.25
1. Set RATE at least 20 ppm above patient’s intrinsic rate.
2. Decrease OUTPUT: Slowly turn OUTPUT dial counterclockwise u...
Strength Duration Curve
Example
Safety Margin = 2 x Amplitude Threshold
OR
3 x Pulse Width Threshold
Knowledge Checkpoint
What is the threshold?
1.25 V 0.05 V0.75 V1.00 V
A. 0.05 V
B. 0.75 V
C. 1.00 V
D. 1.25 V
Typical Lead Impedance Range
• Most important that ead impedance is
stable over the lifetime of the device.
Typical Impeda...
Programming Outputs
•Primary goal: Ensure patient safety and
appropriate device performance
•Secondary goal: Extend the se...
術後交班
• Pacemaker 設定
• Bed rest 12- 24 hours
•Cefazolin and Gentamycin
• Compression with 2kg sandbag over
chest wound for ...
Thanks For Your Attention!
心臟植入性電子儀器(CIED )護理照護指引- 術中護理照護_20130914中區
心臟植入性電子儀器(CIED )護理照護指引- 術中護理照護_20130914中區
心臟植入性電子儀器(CIED )護理照護指引- 術中護理照護_20130914中區
心臟植入性電子儀器(CIED )護理照護指引- 術中護理照護_20130914中區
心臟植入性電子儀器(CIED )護理照護指引- 術中護理照護_20130914中區
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心臟植入性電子儀器(CIED )護理照護指引- 術中護理照護_20130914中區

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Transcript of "心臟植入性電子儀器(CIED )護理照護指引- 術中護理照護_20130914中區"

  1. 1. 心臟植入性電子儀器(CIED) 護理照護指引-術中護理照護 中國醫藥大學附設醫院 心臟內科 護理師 洪佩琪
  2. 2. Pacemaker 術前準備 •核對病人 檢查同意書 •Check 前一天抽血 data •術前一小時給予Cefazolin and Gentamycin •3 lead ECG monitor/recorder •TCP •Vital sign •O2
  3. 3. 準備用物
  4. 4. 生理系統監視儀
  5. 5. Subclavian Vein vs. Cephalic Vein Approach
  6. 6. Access - Blood Vessels Subclavian Artery Subclavian Vein Cephalic Vein Aorta Pulmonary Artery External Jugular Internal Jugular Superior Vena Cava Inferior Vena Cava Diaphragm Lung
  7. 7. Cephalic Vein Approach
  8. 8. Ellenbogen KA et al. Clinical cardiac pacing, defibrillation, and resynchronization therapy 3th ed. Cephalic Vein Approach
  9. 9. Cephalic Vein Approach
  10. 10. Subclavian Vein
  11. 11. Subclavian puncture
  12. 12. VVI upgrade to DDD
  13. 13. Access - Cardiac Chambers Left Atrium Mitral Valve Aortic Valve Left Ventricle Right Ventricle Tricuspid Valve Right Atrium Pulmonary Valve
  14. 14. Transvenous Leads Passive fixation (tined) The tines become lodged in the trabeculae of the apex or the pectinate of the appendage which are fibrous meshworks of heart tissue Active fixation (screw-in) The helix, or screw, extends into the endocardial tissue – Allows for lead positioning anywhere in the heart’s chamber – The helix is extended using an included tool
  15. 15. Tined lead and Screw lead
  16. 16. Single Chamber System • One lead – Atrium – Ventricle (most common) • May be used for patients in chronic AF (VVI pacemaker) or patients with sinus node dysfunction and no history of AV block (AAI pacemaker) AAI PacemakerVVI Pacemaker
  17. 17. Dual Chamber System • Two leads – One lead implanted in the atrium – One lead implanted in the ventricle • Provides AV synchrony and pacing support in both atrium and ventricle if needed DDD Pacemaker
  18. 18. Dual Chamber Pacemaker RV Lead at the Apex RA Lead in Appendage
  19. 19. Triple Chamber System • Three Leads: – Right Atrium – Right Ventricle – Left Ventricle (via the Coronary Sinus vein) • Most commonly called a Bi-Ventricular Pacemaker but also called Cardiac Resynchronization Therapy (CRT–P) • Paces both ventricles together to “resynchronize” the beat DDD BiV Pacemaker
  20. 20. Knowledge Checkpoint
  21. 21. 術中注意事項 • 嚴謹遵守無菌原則 • 注意vital sign
  22. 22. Programmer
  23. 23. defibrillation threshold (DFT) testing • Diazepam or midazolam • TCP 200J • Check Vital sign
  24. 24. defibrillation threshold (DFT) testing
  25. 25. pacemaker implantation test
  26. 26. Cont/..... • Measurements – 1.Sensing threshold • Amplitude (Minimum : “P” - 2mV , “R” - 5mV) • Slew rate Pacemaker Implantation
  27. 27. • Measurements – 2.Pacing threshold • (Measured amplitude at various pulse widths) • Paced rate > = 20 ppm above spontaneous rate • Decrement variable output : Threshold < 1V @ 0.5ms • Impedance measurement : 300 - 1000 ohms tined: 500-2000 ohms Cont/..... Pacemaker Implantation
  28. 28. Cont/..... • Measurements – 3.Lead stability – 1V output, or 2X diastolic threshold (min. 1V) – 10V output for diaphragm stimulation test – Lead sutured in position – Re-measure sensing / pacing characteristics – Dual-chamber system - Measure Retrograde Conduction Time Pacemaker Implantation
  29. 29. Sensing • Sensing is the ability of the pacemaker to “see” when a natural (intrinsic) depolarization is occurring • Pacemakers sense cardiac depolarization by measuring changes in electrical potential of myocardial cells between the anode and cathode 0.5 mV signal 2.0 mV signal
  30. 30. Acceptable Sensing Values (mV)1 Acute Chronic Atrium >1.5 >1.0 Ventricle >7.0 >5.0 Sensing 1Curtis, Anne B. (2010). Fundamentals of Cardiac Pacing. Massachusetts: Jones and Bartlett Publishers. (pg. 98).
  31. 31. Sensitivity Amplitude(mV) Time 5.0 2.5 1.25
  32. 32. 1. Set RATE at least 20 ppm above patient’s intrinsic rate. 2. Decrease OUTPUT: Slowly turn OUTPUT dial counterclockwise until ECG shows loss of capture. 3. Increase OUTPUT: Slowly turn OUTPUT dial clockwise until ECG shows consistent capture. This value is the stimulation threshold. 4. Set OUTPUT to a value 2 to 3 times greater than the stimulation threshold value. This provides at least a 2:1 safety margin. 5. Restore RATE to previous value. Stimulation Threshold Procedure Medtronic, Inc., Minneapolis, MN December 2007
  33. 33. Strength Duration Curve Example Safety Margin = 2 x Amplitude Threshold OR 3 x Pulse Width Threshold
  34. 34. Knowledge Checkpoint What is the threshold? 1.25 V 0.05 V0.75 V1.00 V A. 0.05 V B. 0.75 V C. 1.00 V D. 1.25 V
  35. 35. Typical Lead Impedance Range • Most important that ead impedance is stable over the lifetime of the device. Typical Impedance range = 200 to 1,000 Ohms.* *Impedance is higher for specially designed high impedance leads. Hayes, David L., et. al. (2000). Cardiac pacing and defibrillation: a clinical approach. New York: Blackwell Publishing. (pg. 398).
  36. 36. Programming Outputs •Primary goal: Ensure patient safety and appropriate device performance •Secondary goal: Extend the service life of the battery –Typically program amplitude to < 2.5 V, but always maintain adequate safety margins –Amplitude values greater than the cell capacity of the pacemaker battery (usually about 2.8 V) require a voltage multiplier, resulting in markedly decreased battery longevity
  37. 37. 術後交班 • Pacemaker 設定 • Bed rest 12- 24 hours •Cefazolin and Gentamycin • Compression with 2kg sandbag over chest wound for 2-4 hours
  38. 38. Thanks For Your Attention!
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