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 arrest

– Lead dislodgement/Lead perforation

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

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 [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].

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 complication.

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.

Air Emboli

Air Emboli

Air Emboli

• More occurs in

– Un-cooperated patients

– Under respiratory distress

– Old age

– Snoring patients

• Management

– IV resuscitation

– Raise patients’ legs

– Increase FiO2

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

• Hypotension

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 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

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

different pacing mode or the need for

reoperation.

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 stimulus

– changes in the lead position identified on a chest radiograph

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.

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 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

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/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)

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 settings

•Faulty cable connections •Check cable connections

•Fractured/dislodged lead •Replace/reposition lead

•Oversensing •Verify/adjust sensitivity

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 •Replace/reposition Lead

•Battery depletion •Replace battery

•Inappropriate sensitivity setting •Sensing test/increase sensitivity

•Fusion beat

Sensing

Atrial Undersensing

Atrial/Ventricular Sensing Thresholds

Undersensing . . .Overpacing • Pacemaker does not “see” the intrinsic

beat, and therefore does not respond

appropriately

Intrinsic beat

not sensed

Scheduled pace

delivered

VVI / 60

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 interference •Eliminate interference

•T-wave oversensing •Sensing test/decrease sensitivity

•Faulty cable connections •Check connections

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

Post implantation test

Correct

Thanks For Your Attention!