心臟植入性電子儀器(CIED )護理照護指引- Cathroom Troubleshooting_20130907北區

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心臟植入性電子儀器(CIED )護理照護指引- Cathroom Troubleshooting_20130907北區

  1. 1. CIED implant trouble shoot in cath room 台北榮民總醫院 護理師 郭宜蘭
  2. 2. Venogram Subclavian vein cephalic vein
  3. 3. Acute Venous Stenosis Limiting Access
  4. 4. Implantation Techniques - Acute  Pneumothorax  Hemothorax  Pneumo- hemothorax  Brachial plexus injury  Arterial puncture  Chylothorax  Infection  Pocket Hematoma / Seroma
  5. 5. Pneumothorax In PASE Trial: 1.97%
  6. 6. Management for Pneumothorax  withdraw the needle, wait a moment or two to make certain that a rapid-onset, large, markedly symptomatic pneumothorax is not occurring, and then proceed  If a pneumothorax does develop, it may do so in this setting over a matter of hours and may not even be apparent radiographically at the end of the procedure.  If a lung puncture has occurred, obtaining another upright chest radiograph 6 hours after completion of the procedure is advisable. If a pneumothorax has developed, a chest tube or catheter evacuation procedure may be necessary, although frequently, a small to moderate pneumothorax that is not expanding can be managed conservatively without evacuation.
  7. 7. Avoid air embolism (esp. for large-bored sheaths) press proximal end of sheath and instruct patient to hold breath during pacing lead insertion use of introducer sheath with hemostatic valve
  8. 8. Myocardial Perforation  When recognized, lead MUST be pulled back  Be prepared for tamponade  May require open procedure to manage but heart usually seals itself.
  9. 9. Diaphragmatic Stimulation Lead in Cardiac Vein Lead inadvertently placed into Post.Cardiac V
  10. 10. Management of Pocket Hematoma  Observation and close follow- up – Soft – Minimal to no tenderness  Surgical evacuation – Tense pocket threatening suture line – Weeping suture line – Severe pain – Immunocompromised host
  11. 11. Causes of Open Circuit Due to Implant Technique  Loose set screw  Improperly seated lead terminal pin  Conductor fracture – Rib Clavicle Crush – Tight ligature  “Dry” pocket - air in pocket with unipolar configuration – Replacement
  12. 12. Pulse Generator Pocket Chronic  Pain - pocket neuralgia – Incorrect tissue plan – Incorrect location - too lateral – Smoldering infection  Erosion – Pressure necrosis – Smoldering infection  Migration  Twiddler’s Syndrome
  13. 13. Pressure Necrosis Thinning and discoloration at lateral margin Total breakdown and 2° Infection
  14. 14. Smoldering Pocket Infection with draining fistula  Presented 2 years post implant  Eschar and draining fistula at edge of incision, surrounding erythema  Waxed and waned on oral antibiotics  Local cultures were negative January 24, 2002
  15. 15. Improper Location of Pulse Generator If the pacemaker is placed too lateral, it will cause discomfort every time the patient rotates arm forward
  16. 16. Loose Anchoring Sleeve Twiddler’s Syndrome
  17. 17. Conductor Fractures  Occurs at stress points – Rib-Clavicle Crush – Tight Anchoring sleeve ligature – Angulation of lead – Traction on lead  If external conductor of bipolar lead, conversion to unipolar will allow for elective management
  18. 18. Tight Anchoring Sleeve Damage to Lead
  19. 19. Conductor Coil Fracture
  20. 20. Insulation Damage
  21. 21. Thanks for your listening:) See you next time. It’s time to wake up!!

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