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TPI TEMPORARY PACING INDICATIONS TECHNIQUE.pptx
- 1.
- 2. Objectives Describe three commontemporary pacemaker settings and the situation or underlying rhythm appropriate for each setting. Discuss common complications of temporary pacing and the assessments and interventions needed to troubleshoot. Describe general care and maintenance of a temporary pacemaker.
- 3. Uses for TemporaryPacing To stimulate myocardium to contract in absence of intrinsic rhythm. To establish adequate cardiac output and blood pressure to ensure tissue perfusion to vital organs. To reduce possibility of ventricular dysrhythmias in presence of bradycardia.
- 4. Uses cont. Tosupplement inadequate rhythm in presence of transient decrease in heart rate. To allow administration of medications(beta-blockers) to treat ischemia or tachyarrhythmias in presence of conduction system dysfunction or bradycardia. AACN Procedure Manual for Critical Care, pg. 349.
- 5. Complete heart block SymptomaticSecond degree heart block Symptomatic bradycardia or bradydysrhythmias Dysrhythmias complicating AMI Alternating BBB New BBB with transient CHB Sinus node dysfunction Treatment of bradycardia- tachycardia syndrome Rhythms Requiring Temporary Pacing
- 6. Rhythms Requiring TempPacing (cont.) Ventricular standstill or cardiac arrest Long QT syndrome with ventricular dysrhythmias Medication toxicity Post-op cardiac surgery Prophylaxis with cardiac diagnostic or interventional procedures *AACN Procedure Manual for Critical Care, pg. 349.
- 7. 3 Primary Methods@ Cone Transvenous-used mostly in CICU. Epicardial- used in SICU and on 2000. Transcutaneous- emergent.
- 8. Epicardial Pacing Methodof stimulating the myocardium through use of Teflon-coated, unipolar stainless steel wires that are sutured loosely to epicardium after surgery.
- 9. The NASPE/BPEG Generic(NBG) Code Chamber(s) Sensed Response to Sensing Programmability Rate Modulation Antitachyarrhythmia Function(s) Position I Category Chamber(s) Paced II III IV V O = None A = Atrium V = Ventricle D = Dual (A+V) O = None A = Atrium V = Ventricle D = Dual (A+V) O = None T = Triggered I = Inhibited D = Dual (T+I) O = None P = Simple Programmable M = Multiprogrammable C = Communicating R = Rate Modulation O = None P = Pacing S = Shock D = Dual (P+S) Manufacturer’sS = Single Designation (A or V) Only S = Single (A or V) Note: Positions I through III are used exclusively for antibradyarrhythmia function
- 10. Common Settings AAI Atriumis paced when necessary Atrial activity is being sensed by pacer. I = when atrial activity is sensed the pacer does not fire.
- 11. VVI Ventricle ispaced when necessary. Ventricular activity is being sensed by pacer. I= When ventricular activity is sensed, the pacer does not fire.
- 12. DDD Atriumand ventricle are paced when necessary (not necessarily at the same time). Atrial and ventricular activity is being sensed by pacer. D= Triggers pacer when atrial or ventricular activity is not sensed. Inhibits pacer when atrial or ventricular activity is sensed.
- 13. TEMPORARY PACING DEFINITIONS (from AACNprocedure manual for Critical Care, 5th edition, 2005, pg.325)
- 14. Sensing The abilityof the pacemaker to detect intrinsic myocardial electrical activity. The pacemaker either is inhibited from delivering a stimulus or initiates an electrical impulse.
- 15. Pulse Generation Occurswhen the pacemaker produces a programmed electrical current for a set duration. This energy travels through the epicardial or transvenous wires to the myocardium. This is known as pacemaker firing and usually produces a line or spike on the EKG recording.
- 16. Capture Refers tothe successful stimulation of the myocardium (by the pacemaker impulse) that results in depolarization. Evidenced on EKG by a pacemaker spike followed either by an atrial or ventricular complex, depending on chamber being paced.
- 17. Synchronous Pacing Pacemakercoordinates with intrinsic cardiac activity. Able to sense the patient’s inherent cardiac activity. Will inhibit or trigger a stimulus as needed. Examples: AAI, VVI, DDD
- 18. Asynchronous Pacing Pacemaker functionsat a fixed rate regardless of patient’s underlying rhythm. It is not able to sense the patient’s underlying rhythm. Examples: AOO, VOO, DOO
- 19. Failure to Pace Pacemaker does not discharge a pacing stimulus at it’s programmed time to the myocardium. Evidenced by absence of a pacing spike on EKG where expected.
- 20. Sensing Failure Pacemakereither detected extraneous signals that mimic intrinsic cardiac activity(oversensing) or did not accurately identify intrinsic activity(undersensing).
- 21. Oversensing Is recognizedon EKG by pauses where pacing beats were expected and prolongation of the interval between paced beats.
- 22. Oversensing Myopotential inhibition EMI T-waves outside of refractory period Dislodged/fractured lead Inappropriate sensitivity setting
- 23. Undersensing Recognized onEKG by inappropriate pacemaker spikes relative to the intrinsic electrical activity(pacemaker spikes occurring within p wave, QRS complex, or t wave) and shortened distances between paced beats.
- 24. Undersensing Battery depletion Decreased QRS voltage Fusion beat Dislodged/fractured lead Inappropriate sensitivity setting
- 25. Failure to Capture Pacemakerhas delivered a pacing stimulus that was unable to initiate depolarization of the myocardium and subsequent myocardial contraction. Evidenced on EKG by pacemaker spikes that are not followed by a p wave for atrial pacing or a QRS complex for ventricular pacing.
- 26.
- 27. Feature of theTemporary DDD Pacemaker 2.5 1.25 0.5 Sensitivity
- 28. Medtronic 5388 Temporary Pacemaker *Thefollowing slides are courtesy of Medtronics*
- 29. Model 5388 DualChamber Temporary Pacemaker 1. Pace/Sense LEDs 2. Lock/Unlock Key 3. Lock Indicators 4. Rate Dial 5. Atrial Output Dial 6. Ventricular Output Dial 7. Menu Parameter Dial 8. Parameter Selection Key 9. Menu Selection Key 10. Pause Key 11. Power On Key 12. Power Off Key 13. Emergency/Asynchronous Pacing Key 14. Lower Screen 15. Ventricular Output Graphics 16. Atrial Output Graphics 17. Upper Screen 18. Rate Graphics 19. Setup Indicators 20. DDI Indicator 21. Low Battery Indicator 22. Setup Labels
- 30. Cable to DeviceConnections
- 31.
- 32. Low Battery IndicatorBattery Replacement
- 33. Off / OnKeys Values at Power-On • RATE • A OUTPUT • V OUTPUT • A SENSITIVITY 80 ppm 10 mA 10 mA 0.5 mV • V SENSITIVITY • UPPER RATE • AV INTERVAL 2.0 mV 110 ppm 170 ms • PVARP 300 ms
- 34. Indicators Pace/Sense Indicators Low Battery IndicatorDDI Mode Indicator Setup Indicators Padlock Indicator
- 35. Lock / Unlock Padlock Icon FlashingKey Icon Lock/Unlock Key Lock Indicator
- 36. Emergency Key EmergencyPacing Values RATE Current setting • A OUTPUT (or 80 ppm if device was off) 20 mA • V OUTPUT • A SENSITIVITY • V SENSITIVITY 25 mA ASYNC ASYNC • AV INTERVAL Current setting (or 170 ms if device was off)
- 37.
- 38. Rate and OutputAdjustments Ventricular Output Dial Atrial Output Dial Rate Dial
- 39. Lower Screen Menus Menu1: Pacing Parameters Menu 2: Rate-Based Pacing Parameters Menu 3: Rapid Atrial Pacing Menu M: Dial-A-Mode
- 40.
- 41.
- 42. Rate Dependent ParameterAdjustments PVARP Auto/Manual Setting Upper Rate AV Interval
- 43.
- 44.
- 45. Want to see: Ekg tracing shows paced rhythm consistent with set parameters. Patient exhibits hemodynamic stability. Pacemaker leads/wires are isolated from other electrical equipment by maintaining secure connections into the pulse generator.
- 46. Care and Maintenance Cleanse around insertion site with CHG or Betadine. Curl epicardial wires and use paper tape to tape to abdomen in horizontal position. Cleanse around temporary transvenous site with CHG and place sterile dressing.
- 47. Complications Over/undersensing causing competition Failureto capture Hiccups Phlebitis, thrombosis, embolism or bacteremia Ventricular dysrhythmias Pneumo/hemothorax Myocardial perforation & cardiac tamponade Air embolism Lead dislodgement Failure to pace
- 48. Troubleshooting: Always check patientfirst! Be sure pacer is on!! Change battery. Asynchronous pacing-only if no intrinsic rhythm Be sure connections are secure. Evaluate sensitivity threshold. Increase MA. Reverse polarity of wires/change cables or generator. Check rhythm. If patient goes into Afib, AAI will not provide pacing. Go to VVI pacing.
- 49. Documentation Patient & familyeducation Date/time pacing initiated Description of events warranting intervention Vital signs & hemodynamic parameters before & after pacing initiated (response to pacing)
- 50. Documentation (cont.) EKGmonitoring strip recording before & after pacing initiated Pacemaker settings: mode, rate, output(MA), sensitivity Medications administered and response Adjustments to pacemaker Date/time pacing discontinued
- 51. Resources: • • • AACN Procedure Manualfor Critical Care, Lynn-McHale Wiegand, Debra J. and Carlson, Karen K, eds.Chapters 48-50, pp. 333-361. 2005. “Pacemaker (Temporary) Insertion and Care.” Nursing Clinical Policies and Procedures/Cardiovascular Care, Moses Cone Health System Homepage. Wiederhold, Richard. Electrocardiography: The Monitoring and Diagnostic Leads. pp. 77-83, 1999.