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

  1. 1. 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
  2. 2. Pacemaker Troubleshooting • Implant related Troubleshooting • Lead related Troubleshooting • Pacemaker malfunction
  3. 3. Early complications of pacemaker implantation – Pneumothorax/Hemothorax/vascular hemorrhage/AIR Emboli – SVT, VT/ Cardiac arrest – Lead dislodgement/Lead perforation
  4. 4. 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
  5. 5. Pneumothorax Sign • Dyspnea(80~100%) • Chest pain(75~90%) • Dry cough(25~35%) • Hypotension、Tachycardia、SaO2 ↓
  6. 6. 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].
  7. 7. Old lady, kyphoscoliosis, chronic obstructive pulmonary disease
  8. 8. venous access with subclavian vein puncture
  9. 9. How to avoid pneumothorax • The cephalic vein cut-down technique should be applied whenever possible to avoid this complication.
  10. 10. 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.
  11. 11. Air Emboli
  12. 12. Air Emboli
  13. 13. Air Emboli • More occurs in – Un-cooperated patients – Under respiratory distress – Old age – Snoring patients • Management – IV resuscitation – Raise patients’ legs – Increase FiO2
  14. 14. SVT / VT during implantation • Check Vital sign • Stable  Medication RV lead pacing • Unstable  Cardioversion
  15. 15. Lead perforation / cardiac tamponade • Rising stimulus threshold, RBBB morphology • Intercostal diaphragmatic pacing • Hypotension
  16. 16. Lead perforation / cardiac tamponade • Echo • Cardiocentesis
  17. 17. Rare but it happened sometimes
  18. 18. Hematoma formation at pulse generator / due to anticoagulants
  19. 19. 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
  20. 20. Cardiac arrest • TPM pacing • TCP pacing • RV lead pacing
  21. 21. Lead related complications 1. Lead dislodgement Atrial > Ventricular 2. Lead fracture 3. Loss of integrity of insulation
  22. 22. 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.
  23. 23. Lead dislocation
  24. 24. Atrial lead dislodge more frequently
  25. 25. Lead Dislodgement
  26. 26. 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
  27. 27. 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.
  28. 28. Order a Chest X-ray The chest x-ray revealed a dislodged lead
  29. 29. Pacemaker system malfunction- Troubleshooting
  30. 30. 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
  31. 31. Electrical stimuli delivered by the pacemaker do not initiate depolarization of the atria or ventricle Loss of Capture
  32. 32. 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)
  33. 33. Capture Loss of Ventricular Capture Atrial/Ventricular Stimulation Thresholds
  34. 34. Pacemaker fails to emit stimuli at the programmed intervals No Output
  35. 35. 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
  36. 36. Failure of the pacemaker to sense intrinsic R-waves or intrinsic P-waves Undersensing
  37. 37. 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
  38. 38. Sensing Atrial Undersensing Atrial/Ventricular Sensing Thresholds
  39. 39. Undersensing . . .Overpacing • Pacemaker does not “see” the intrinsic beat, and therefore does not respond appropriately Intrinsic beat not sensed Scheduled pace delivered VVI / 60
  40. 40. Inhibition of the pacemaker by events pacemaker should ignore, e.g. EMI, T-waves and myopotentials Oversensing
  41. 41. 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
  42. 42. 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
  43. 43. Post implantation test
  44. 44. Correct
  45. 45. Thanks For Your Attention!

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