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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 ...
Pneumothorax
• Absence of lung markings over the lung
field ipsilateral to the pacemaker pocket
assessed from the fluorosc...
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 [O...
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 complic...
Pneumothorax nursing care
• Administer oxygen as prescribed.
• Position the client in high fowler’s position.
• Prepare fo...
Air Emboli
Air Emboli
Air Emboli
• More occurs in
– Un-cooperated patients
– Under respiratory distress
– Old age
– Snoring patients
• Managemen...
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
• Hyp...
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...
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
...
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 stimu...
Lead Dislodgment
Treatment
– surgical intervention to reposition the lead
• an adequate heel on the intracardiac portion o...
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 s...
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/disl...
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 setting...
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 •R...
Sensing
Atrial Undersensing
Atrial/Ventricular Sensing Thresholds
Undersensing . . .Overpacing
• Pacemaker does not “see” the intrinsic
beat, and therefore does not respond
appropriately
I...
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 interfer...
Oversensing …Underpacing
• An electrical signal other than the
intended P or R wave is detected
Marker channel
shows intri...
Post implantation test
Correct
Thanks For Your Attention!
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

  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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