心臟植入性電子儀器(CIED )護理照護指引- 病房及CCU Troubleshooting_20130907北區

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心臟植入性電子儀器(CIED )護理照護指引- 病房及CCU Troubleshooting_20130907北區

  1. 1. 心臟植入性電子儀器(CIED )護理照護指引 病房及CCU Troubleshooting 台北榮民總醫院冠狀動脈加護中心 古玉貞 副護理長 2013 心臟電生理相關專業人員教育課程 2013 Taiwan Heart Rhythm Society~ Allied Professional Education Program Cardiovascular Implantable Electronic Device (CIED)
  2. 2. Troubleshooting Pacemakers General Concepts
  3. 3. 故障排除(Troubleshooting) 急性(Acute) 慢性(Chronic) 接頭的連接問題  螺絲鬆動(Loose setscrew)  導線與接頭未完全鎖緊 (Lead not set all the way into the header) 感應(Sensing)問題:  導線成熟度(Lead maturation)  不適當的程式設計 (Inappropriate programming)  導線脫落 (Lead dislodgement) 激搏(Pacing)問題:  導線絕緣破裂(Lead insulation break)  導體線圈斷裂 (Conductor coil fracture)  用藥變化(Medication changes)  病人的疾病或狀態(電解質) (Patient illness or status) (electrolytes)
  4. 4. 四個潛在的問題 捕捉失靈(Failure to capture) 輸出量喪失(Loss of output) 過度感應 (Oversensing) 感應不足(Undersensing)
  5. 5. 激搏技術“秘訣” (Pacing Technology “Secret”) 心律調節器做的只有兩件事情: Pace Sense
  6. 6. 激搏(Pacing) 定義 心臟去極化及心房或心室的收縮 (Cardiac depolarization and resultant contraction (atrial or ventricular)) 因心律調節器刺激所致 (Caused by pacemaker stimulus)
  7. 7. 心房激搏(Atrial Pacing) 激搏(Pacing)
  8. 8. 心室激搏(Ventricular Pacing) 激搏(Pacing)
  9. 9. 激搏“閾值” (Pacing “Threshold”) 定義 當節律器刺激心臟有100%收縮時所需的 最低輸出量 如何測試呢? 為什麼它很重要?
  10. 10. 捕捉失靈(Failure to Capture) 定義 一個電刺激後並不會引起去極化及心臟收縮 心律調節器所設定的輸出量小於激博閾值
  11. 11. Ventricular Failure to Capture Programmed Rate Programmed Rate VVI 75 ppm spike
  12. 12. 捕捉失靈的原因 (Failure to Capture Causes) 導線脫落 (Dislodged Lead) 傳導障礙(Exit Block) 絕緣破裂(Insulation Break) 穿孔(Perforation) 閾值提高(Threshold Increase)
  13. 13. 可能的解決方法 電壓增高(Program Voltage higher) 脈衝寬度增加(Program Pulse Width higher) 極性再編輯(Reprogram polarity) 激搏電極重新定位 (Reposition pacing electrode) 激搏電極更換(Replace pacing electrode)
  14. 14. 輸出量喪失(Loss of Output) 定義 心律調節器未發出刺激
  15. 15. Ventricular loss of output Pacemaker should have paced VVI 75 ppm
  16. 16. 輸出量喪失的原因 (Loss of Output Causes) 螺絲鬆脫(Loose Set Screw) 導線斷裂(Lead Fracture) 電池耗盡(Battery Exhaustion)
  17. 17. 激搏技術“秘訣” (Pacing Technology “Secret”) 心律調節器做的只有兩件事情: Pace Sense
  18. 18. 感應(Sensing) 定義 心律調節器有感應內在電子訊號的的能力 (Ability of the pacemaker to sense an intrinsic electrical signal) 取決於振幅、電刺激次數、訊號的頻率 (Depends upon the amplitude, slew rate, and the frequency of the signal)
  19. 19. 本體內的事件(Intrinsic Events) 定義 心臟事件來自於病人 (Cardiac events which come from the patient) 本體內的事件對評估心律調節器的感應是必要的!! (Intrinsic Events are essential to evaluate pacemaker sensing !!)
  20. 20. 敏感度設定 用最小電極所能感應部位而產生去極化波 Intrinsic P and R waves
  21. 21. 過度感應(Oversensing) 定義  持續過度感應自發性心跳,誤把等電位上的 波動當成電刺激 過度感應導致激搏不足( Underpacing)
  22. 22. Pacing interval Ventricular Oversensing Pacing interval Pacing interval Pacing interval Pacing interval VVI 75 ppm
  23. 23. 過度感應原因(Oversensing Causes) 絕緣破裂(Insulation Break) 間歇導線斷裂(Intermittent Lead Fracture) 肌肉電位(Myopotentials) 電磁干擾(EMI)
  24. 24. 可能的解決方法 敏感度數值調高 (Program sensitivity to a higher number) 不反應期調長 (Program the refractory period longer) 降低電磁干擾 (Reduce EMI)
  25. 25. 感應不足(Undersensing) 定義  無法感應自發性心跳,只依其節律不斷放電 易造成心室快速心律不整 感應不足導致過度激搏(Overpacing)
  26. 26. non-sensed R-waves Ventricular Undersensing VVI 75 ppm
  27. 27. 感應不足原因(Undersensing Causes) 心臟訊號不足 (Inadequate Cardiac Signal) 導線脫落 (Dislodged Lead) 絕緣破裂 (Insulation Break)
  28. 28. 可能的解決方法 敏感度調低 (Program the sensitivity to a lower number) 極性再編輯 (Reprogram polarity) 重新置放導線 (Reposition the lead)
  29. 29. 結論 心律調節器做的兩件事情要做好。 Pace Sense
  30. 30. Thank you for your attention!

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