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  • 16 Venous Access site The implanting physician must know the acute and chronic complications associated with the various access sites. The physician should also be capable of accessing any and all of these sites. If the physician only knows one technique, that physician should not be doing implants. The recommended access site is the cephalic vein and if this is absent or inadequate, next is the axillary vein. The axillary vein is also called the extrathoracic subclavian vein. It is a continuation of the subclavian vein once it has crossed over the first rib. While venipuncture of the subclavian vein remains the most commonly used approach, it carries with it the highest incidence of acute and chronic complications. The external and internal jugular veins are rarely used today. When there is Superior Vena Cava syndrome or no venous access from above and the implanting physician still wants to use endocardial leads, extra-long (100 cm) leads can be inserted via the femoral vein with the pocket located in the lower abdomen. These should be active fixation. Slide Series: X-Ray-99.ppt
  • EPS的術中護理經驗_20120916_南區

    1. 1. EPS 的術中護理經驗 沈 雅溫 高雄長庚醫院心導管室 2012.09.16
    2. 2. EP nurse 職責    1. 負責病患進入 EP room 後、手術中和離開 EP room 後, 生命徵象的監護 2. 檢 治療過程中協助醫師,記錄心臟電生理檢 數據等查 查 3. 準備 EP room ,準備和提供手術中應用的物品和器械 4. 熟悉 EP room 各種器械和設備的型號、存放位置、功能 5. 了解 EP Room 內各項相關儀器架設與設定   
    3. 3. Responsibility • Vital Signs • Heart Rhythm • Circulation • Patient Response
    4. 4. EP Lab • EP Studies • Device Implants • Catheter Ablation
    5. 5. Set Up the Equipment 1. EP Recording system 2. Stimulator 3. RFA generator ( IBI-1500T, XT 1000) 4. Electrodes 5. RFA catheter
    6. 6. Preparing the patient in the EP Room-I 1. Electrocardiogram: Several sticky electrode patches placed on chest, to monitor heartbeat throughout the procedure. 2. Blood pressure monitor: A blood pressure cuff will be placed on patient’s arm to automatically check blood pressure throughout the study. 3. Oximeter monitor: This small device will be attached to the finger to monitor the oxygen level of blood.
    7. 7. Preparing the patient in the EP Room-II 4. The groin or groins and the neck are cleaned with an antiseptic solution. 5. Venous Angio. (IC 20 or 22) 6. A Defibrillator on monitor and stand by for cardioversion in case unexpected VT / Vf occurs. (VT/ Vf 先貼 TCP 貼片 ) 7. A first aid kit should always in the workplace. 8. By order to administer sedation, such as Midazolam. 9. Antibiotics using for preventing infection before the implantation e.g. Cefamazine 1 gm
    8. 8. EPS • 一般會經右頸靜脈、右側股靜脈放置診斷性電擊 導管共 4 條分別放在 : – 高位右心房 HRA – 希氏束 HIS – 右心室尖 RV – 冠 靜脈竇狀 CS
    9. 9. Electrode catheter positionElectrode catheter position
    10. 10. Electrode catheterElectrode catheter • 1, 2 pacing • 3, 4 record Bipolar intracardiac recording (localized electrical activity- depolarization of tissue) 14 3 2 1 Dist. Prox.
    11. 11. EP Study • 電氣生理學檢 可以用來診斷出心臟電氣傳導的問題,醫師會從腹股查 溝旁的靜脈植入幾根 ( 三至四根 ) 導管,導管會沿著血管放至心臟內 去測量並記錄心臟電氣傳導訊號 • The electrodes detect the heart's electrical activity and are used to check the heart's electrical system. 電極導管可 以接收到心臟放電的訊號,分析訊號可了解心臟的電衝動 • Electrical signals may be used to make the heart skip beats or produce an abnormal heart rhythm. This can help the doctor understand more about what is causing the abnormal heart rhythm or where in the heart it is starting. • 電極導管可以傳送微小的電流刺激心臟,來改變心跳速率或節律。醫師可以 利用刺激來引發病患心臟不正常的節律的重現,藉以了解心律不整的原因及 機轉。 • Certain medicines may also be used for the same purpose.
    12. 12. 藥物使用 • 1. Atropine 1mg/1ml/Amp :抑制迷走神經,提高竇性心 律,加快房室傳導,產生心跳加速。通常用於病竇症候群 或是房室傳導阻斷的診斷。禁用於青光眼的病患身上。 • 2.Isuprel 0.2mg/1ml/Amp : 興奮交感神經,增加心肌收縮 及心跳速率,促進房室傳導和心律不整的誘發。 IV pump control: 1Amp in 0.9% NS 100 ml= 1ug= 30gtt  
    13. 13. During the procedure • 在病患被安置在心導管室檢 床上時,將被接上各種監測查 的儀器,同時在病患的身上,會覆蓋一層無菌巾。這時請 勿亂動或亂觸摸無菌巾, 因為整個侵入性的檢 過程必須查 是無菌以避免感染,再來醫師會在導管要插入的地方(鼠 蹊部、頸部或鎖骨下)消毒的十分乾淨。同時使用非常小 的針頭來做局部麻醉,使導管插入處失去感覺。首先以針 來扎血管(動脈或靜脈)再將皮膚切一小個切口便放入導 管護套,接著才將電極導管置入。電極導管是個含有電極 ,及軟且可彎曲的導線,它可以傳送電流訊號。
    14. 14. EPS procedureEPS procedure • A simple EPS lasts from 20 to 30 minutes. ItA simple EPS lasts from 20 to 30 minutes. It may take longer if other procedures aremay take longer if other procedures are involved.involved. • How the test will feel:How the test will feel: During the test, patientsDuring the test, patients will be awake and able to follow instructions. Tellwill be awake and able to follow instructions. Tell patients may feel your heart skipping beats orpatients may feel your heart skipping beats or racing at times.racing at times.
    15. 15. Nomenclature & Measurement ofNomenclature & Measurement of baseline cond. intervalsbaseline cond. intervals Cycle length = 60.000/ HR length of time bet. Heart beats V A V SCL P His electrogram (3 components) low RA- His-upper RV-no AVN
    16. 16. 排除 Electrical signals 不清楚的原因
    17. 17. 皮膚太乾 ? EKG 線壞了 ? Cable 接好了嗎 ? Electrode ?
    18. 18. 什麼情況要裝心律調節器? 1. 病人有昏倒、血壓下降或心跳每分鐘少於 40 次等臨床症狀。 2. 二十四小時心電圖檢視,發現心跳停頓大於 3 秒。   3. 電生理學檢 為心房、心室傳導阻斷。查 4. 因其他病情需要,如:心肌缺 、心臟移植後、擴張性心肌病變、快氧 速心律不整等,使用藥物後,或其他原因造成心跳過慢而導致心臟功 能喪失或不穩定,而此藥物因治療需要不可或缺,或造成原因無法以 其他醫療方式矯正時。 5. 嚴重鬱血性心臟衰竭併有完全性左側束枝傳導阻斷,藥物控制效果不 佳。
    19. 19. During Pacemaker implantation • To prevent infection and to keep the pacemaker insertion site sterile: • An antibiotic will be given through the IV at the beginning of the procedure. • A special soap will be used to cleanse the area : • (1.75% Alcohol 術前消毒,大塊燙傷紗布 cover , 2. 術前再以 含有 Alcohol- BI 洗手液作三次消毒, 3. 術前撲無菌面時,再以 75% Alcohol 和 Alcohol- BI 消毒 3 次 ) • Sterile drapes are used to cover you from your neck to your feet • A soft strap will be placed across your waist and arms to prevent your hands from coming in contact with the sterile area
    20. 20. Angio
    21. 21. Subclavian vein Cephalic Axillary vein
    22. 22. Implant Procedure-Venous access and Lead placement • Cephalic vein - via cut down (Cephalic approach – cutdown ,reduces risk of pneumothorax) • Subclavian vein - via puncture • Axillary vein - via cutdown or puncture Commonest
    23. 23. During the Device Implant-I • 1.The doctor will inject anesthetic drugs to "numb" or "freeze" the skin where the pacemaker will be implanted. • • 2.Once the skin area is numb, the doctor will make a 1-2 inch incision in the skin and make a pocket under the skin for the generator. The doctor will also use a needle to find the vein under the collarbone. • 3. One or more pacemaker leads will be inserted down the vein and guided by X-rays into the right places in the heart. These leads will be hooked or screwed into the muscle to minimize the chances they will fall out of place.
    24. 24. During the Device Implant-II • 4.The nursing or technologist staff will then take measurements from the leads to make sure the pacing leads will work well when needed. • 5.The doctor will then tie the lead down and plug the other end into the generator. The generator is placed in the pocket and the incision sewn up. The sutures used will dissolve on their own and will not need to be removed.
    25. 25. • 天然縫線 (Suture) 中屬於可吸收的有 : 羊腸線 (plain catgut) 與 腸線鉻 (chromic gut) • 不可吸收的則有絲線 (silk) 與棉線 (cotton) • 合成縫線中屬於可吸收的有聚乙醇酸 (polyglycolic acid) , Dexon 屬於此類之縫線
    26. 26. 可吸收縫線的吸收速率 文獻參考 : 縫線的比較與應用 ( 陳軒弘 、林怡君、賴玉玲 )
    27. 27. Suggested Acute Thresholds PacingPacing SensingSensing AtriumAtrium < 1.5 Volts< 1.5 Volts > 2.0 mV> 2.0 mV VentricularVentricular < 1.0 Volts< 1.0 Volts > 5.0 mV> 5.0 mV
    28. 28. Pacemaker Programmer
    29. 29. 美容膠
    30. 30. During the Device Implant- III • 密切觀察 patient's vital signs ,O2 saturation • 病患意識變化 況狀 : 嗜睡、突然愛 話、打哈欠等說 • 記 失血量錄 : 少於 20 ml • 記 手術記 單錄 錄 : 包括各家廠商使用的 Generator,Lead 型號等 ( 老人家忘了裝 一家哪 , 片 掉了,卡 丟 方便日後 F/U)
    31. 31. 3939 Radiofrequency Catheter Ablation 1980 年不整脈經導管燒灼術 (Trans catheter Radiofrequency Ablation for Arrhythmia) 開始發展,心律不整的治療 有相當 大的改變,此治療方式不同於一般的抗心律不整藥物治療、心 律調節器及心臟電擊術。除了外科手術外,不整脈經導管燒灼 術 (RFA) 是所有治療心律不整的方法中,唯一可以根治心律不 整的方法。 所謂的不整脈經導管燒灼術,乃是用電氣生理檢 出問題的所查 在,再以電流導引入放在心臟內的電極導管,用導管末端的金 屬端點產生熱能,來灼燒去除異常的傳導路徑。其中又以射頻 波 (Radiofrequency) 為最常使用的能量來源。
    32. 32. During the RFA • 在進行不整脈經導管燒灼時,醫師會如前述方式將四至五 根電極導管置於 的心臟,且確定導管位於心臟異常放電您 處。此時,讓電能源經由電極導管來灼燒心臟異常放電處 。 • 電極導管的前端具有加熱及破壞組織的功能,它可以直接 接觸於心臟不正常放電的組織,使心律不整消失。在整個 檢 治療過程中,視病患狀況給藥物,幫助放鬆。但是病查 患的意識仍是清醒的。同時,醫護人員會在整個過程中, 利用儀器來密切觀察病患的情況。
    33. 33. • 在整個治療過程中,通常不會有痛感,只有一開始植入導 管時使用局部麻醉時,會有局部的疼痛,以及在燒灼時, 胸部會有輕微不舒服。同時,病患可能會因需平 過久而躺 不舒服或疲倦。 • 在執行此項治療時,醫師會利用「微小電波刺激」來引導 出病患心臟心律不整的情況出現。但不會有被電到的感覺 ,病患可能會有心悸或像以前心律不整發作的症狀出來。 如果此時,有頭昏、眼花、心悸、胸痛、呼吸急促,記得 告訴醫護人員。而這樣心律不整的情形,如果沒有自動恢 復,醫師則會採用電刺激或電擊方式,來幫助恢復到正常 的心跳節律。 • 這樣一個不整脈經導管燒灼治療,通常需耗費 2 ~ 6 個小 時,情況通常是依病人的心律不整的情形而定,因此在台 上一定要和醫護人員合作不可隨意亂動或深呼吸以免造成
    34. 34. RFA Catheter • Cordis ( B,C,D,E,F curve 越大 ) • St. Jude : Daig ( Livewire M & L) • EPT • Tip: 4mm & 8 mm
    35. 35.
    36. 36. • Patient might feel “ 燒燒的” 。 • 停下來讓病人休息一下,再繼續。 • 注意 Vital signs
    37. 37. • Amount of electrode making contact to tissue ContactContact RF Lesion Formation
    38. 38. Swartz sheath ContactContact RF Lesion Formation
    39. 39. Tool
    40. 40. Set Up the Equipment -the ENSITE Photo source: http://www.sjmprofessional.com/Products/US/Mapping-and-Visualization/EnSite- System.aspx
    41. 41. • ENSITE: • 心臟電氣生理立體標測導引系統, 3D 立體心臟電氣生理定位 儀 用於 : 1. 廣泛用於 Af 電燒治療 2. 複雜性心律不整之電燒治療 ,VT
    42. 42. • The EnSite NavX system (St. Jude Medical) consists of a set of three pairs of 7 skin patches, a data module, a system reference patch, ten ECG electrodes, and a display workstation.
    43. 43. Cool Path™ Irrigated Ablation System – Therapy ™Cool Path ™ Irrigated Ablation Catheter – IBI 1500T RF Ablation Generator – Cool Point™ Irrigation Pump
    44. 44. With the irrigated ablation system there can be: • Deeper lesion formation • Less surface tissue damage with constant cooling allowing more conductive heating • Prevention of sudden impedance rise • Less chances of coagulum formation at tip.
    45. 45. Complications of Ablation: • 併發症 • 整體而言電氣生理學檢 及不整脈經導管燒灼術是屬於侵查 入性治療,因此當然也會有危險,但它的危險性相當低。 其併發症如下 : • 1. 心導管插入處會有瘀青、腫脹的情形 : 極少出現 • 2. 心導管插入處會有動靜脈瘤 : 極少出現 • 3. 死亡機率低於千分之一 • 4. 心臟破裂及心包膜填塞症機率:千分之一 • 5. 完全房室傳導阻斷機率:百分之二點六 • 6. 其他如冠狀動脈阻塞、血管受損、氣胸或血胸、感染 辦膜破裂 、及中風等併發症極微罕見
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