心臟植入性電子儀器(CIED )護理照護指引- Cathroom Troubleshooting_20130914中區
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心臟植入性電子儀器(CIED )護理照護指引- Cathroom Troubleshooting_20130914中區

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心臟植入性電子儀器(CIED )護理照護指引- Cathroom Troubleshooting_20130914中區 心臟植入性電子儀器(CIED )護理照護指引- Cathroom Troubleshooting_20130914中區 Presentation Transcript

  • 心臟植入性電子儀器(CIED) 護理照護指引-Cathroom Troubleshooting 中國醫藥大學附設醫院 心臟內科 護理師 洪佩琪
  • Pacemaker Troubleshooting • Implant related Troubleshooting • Lead related Troubleshooting • Pacemaker malfunction
  • Early complications of pacemaker implantation – Pneumothorax/Hemothorax/vascular hemorrhage/AIR Emboli – SVT, VT/ Cardiac arrest – Lead dislodgement/Lead perforation
  • Pneumothorax • Absence of lung markings over the lung field ipsilateral to the pacemaker pocket assessed from the fluoroscopy or pre- discharge x-ray. • Non-puncture related, might occur at contralateral side
  • Pneumothorax Sign • Dyspnea(80~100%) • Chest pain(75~90%) • Dry cough(25~35%) • Hypotension、Tachycardia、SaO2 ↓
  • Pneumothorax • 0.66% (190/28,860 patients) in Danish Pacemaker Register – more often in women [OR 1.9], – age >80 years [OR 1.4], – prior history of chronic obstructive pulmonary disease [OR 3.9] – implantation of a dual-chamber PM [OR 1.5] – venous access with subclavian vein puncture [OR 7.8] – venous access with both subclavian vein puncture and cephalic vein cut-down [OR 5.7] – implantation in a non-university center [OR 2.1].
  • Old lady, kyphoscoliosis, chronic obstructive pulmonary disease
  • venous access with subclavian vein puncture
  • How to avoid pneumothorax • The cephalic vein cut-down technique should be applied whenever possible to avoid this complication.
  • Pneumothorax nursing care • Administer oxygen as prescribed. • Position the client in high fowler’s position. • Prepare for chest tube placement until the lung has expanded fully. • Monitor chest tube drainage system.
  • Air Emboli
  • Air Emboli
  • Air Emboli • More occurs in – Un-cooperated patients – Under respiratory distress – Old age – Snoring patients • Management – IV resuscitation – Raise patients’ legs – Increase FiO2
  • SVT / VT during implantation • Check Vital sign • Stable  Medication RV lead pacing • Unstable  Cardioversion
  • Lead perforation / cardiac tamponade • Rising stimulus threshold, RBBB morphology • Intercostal diaphragmatic pacing • Hypotension
  • Lead perforation / cardiac tamponade • Echo • Cardiocentesis
  • Rare but it happened sometimes
  • Hematoma formation at pulse generator / due to anticoagulants
  • Anticoagulation therapy • Warfarin was temporarily discontinued before device implantation when possible to achieve an INR value of < 1.7 • Administration of LMWH was stopped 24 h before the procedure • Antiplatelet therapy with ASA or clopidogrel was allowed to continue • Treatment with warfarin was resumed after 24 h and with LMWH after 12–24 h
  • Cardiac arrest • TPM pacing • TCP pacing • RV lead pacing
  • Lead related complications 1. Lead dislodgement Atrial > Ventricular 2. Lead fracture 3. Loss of integrity of insulation
  • Lead failure • Development of high pacing thresholds or sensing problems resulting in the need to program the device to a different pacing mode or the need for reoperation.
  • Lead dislocation
  • Atrial lead dislodge more frequently
  • Lead Dislodgement
  • Lead Dislodgement Diagnostic features – changes in the morphology of capture beats – changes in dipole of the pacing stimulus – changes in the lead position identified on a chest radiograph
  • Lead Dislodgment Treatment – surgical intervention to reposition the lead • an adequate heel on the intracardiac portion of the lead • look for a 2 to 3mV current of injury pattern • electrical and mechanical stability of the lead may be assessed – Twiddler’s syndrome • the portion of the lead within the pocket should be carefully inspected. • If damage to the conductor coil or insulation is noted, the lead should not be reused.
  • Order a Chest X-ray The chest x-ray revealed a dislodged lead
  • Pacemaker system malfunction- Troubleshooting
  • Pacing Stimuli Present with Failure to Capture - causes  Lead dislodgment • Early: unstable position • Late: Twiddler’s syndrome  Lead maturation • Early: inflammatory response • Late: progressive fibrosis  Late high thresholds • Progressive fibrosis • Myocardial infarction • Cardiomyopathy • Metabolic/drugs • Damaged lead or tissue interface  Insulation failure  Conductor failure • Lead fracture • Loose set-screw  Battery depletion  Functional non capture • Pseudomalfunction
  • Electrical stimuli delivered by the pacemaker do not initiate depolarization of the atria or ventricle Loss of Capture
  • Loss of Capture Possible Causes Corrective Measures •Threshold rise •Increase output (mA)/check thresholds •Fractured/dislodged lead •Replace/reposition lead •Battery depletion •Replace battery •QRS not visible •Adjust ECG •Tissue is refractory •Assess mode selection •Faulty cable connections •Check connections •Switch polarity (epicardial system)
  • Capture Loss of Ventricular Capture Atrial/Ventricular Stimulation Thresholds
  • Pacemaker fails to emit stimuli at the programmed intervals No Output
  • No Output Possible Causes Corrective Measures •Battery depletion •Replace battery •Pacemaker OFF •Verify pacemaker settings •Faulty cable connections •Check cable connections •Fractured/dislodged lead •Replace/reposition lead •Oversensing •Verify/adjust sensitivity
  • Failure of the pacemaker to sense intrinsic R-waves or intrinsic P-waves Undersensing
  • Undersensing Possible Causes Corrective Measures •Decreased QRS voltage •Increase sensitivity •Fractured/dislodged lead •Replace/reposition Lead •Battery depletion •Replace battery •Inappropriate sensitivity setting •Sensing test/increase sensitivity •Fusion beat
  • Sensing Atrial Undersensing Atrial/Ventricular Sensing Thresholds
  • Undersensing . . .Overpacing • Pacemaker does not “see” the intrinsic beat, and therefore does not respond appropriately Intrinsic beat not sensed Scheduled pace delivered VVI / 60
  • Inhibition of the pacemaker by events pacemaker should ignore, e.g. EMI, T-waves and myopotentials Oversensing
  • Oversensing Possible Causes Corrective Measures •Fractured/dislodged lead •Replace/reposition lead •Environmental interference •Eliminate interference •T-wave oversensing •Sensing test/decrease sensitivity •Faulty cable connections •Check connections
  • Oversensing …Underpacing • An electrical signal other than the intended P or R wave is detected Marker channel shows intrinsic activity... ...though no activity is present VVI / 60
  • Post implantation test
  • Correct
  • Thanks For Your Attention!