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Critical Care Nursing Theory Temporary Pacemaker

Temporary Pacemaker

Artificial Pacemaker

An electronic device delivers stimuli to cardiac muscle when the native pacemaker of the heart is unable to do so.

Purposes

- To maintain heart rate.- To maintain cardiac output.

Pacemaker System

A - Pulse generator.

It contains the pacemaker’s power source/electrical supply source to provide the stimulus. It consists of batteries an electrical circuit and circuitry.A temporary pacemaker ,which isn’t implanted ,is about the size of a small radio or a telemetry box and is powered by alkaline batteries

B - Bridging cable.

An extension wire can be used between the pulse generator and the electrode catheter,

C – Pacing leads

It have either one electrode (unipolar) or two electrode(bipolar).

Indications

1- Bradydysrhythmias.2- Tachydysrhythmias.3- Permanent pacemaker failure.4- After cardiac surgery.

Pacing Routes

Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 1


1- Noninvasive / Transcutaneous (external).2- Invasive

a- Transthoracic. b- Transvenous (endocardial). c- Epicardial.

1- Noninvasive /Transcutaneous Pacing

- Nurse can perform it emergently.- Two large gelled electrodes are applied to chest wall and connected to an external pacemaker generator.

• Anterior electrode is applied on cardiac apex.• Posterior electrode is applied on back beneath the left scapula.

- It produce ventricular pacing.- It is used in high –risk situations as a systole or extreme bradycardia.- It is used in patients receiving anticoagulant or requiring thrombolytics.- it is for short-term therapy (1-18 hours ) till situation resolve or another route established.

Complications of transcutaneous (external) Pacing

1- Discomfort & burning sensation. 2- Skin burns.3- Electrical micro-shock. 4- Muscle twitching. 5- Coughing6- Psychological reactions

2-Invasive pacing

a- Transthoracic Pacing

- Needle is inserted via chest wall directed to the right ventricle.- Pacing wire threaded via needle to achieve direct endocardialcontact.

b- Transvenous (endocardial) Pacing



- It is accomplished by advancing a pacing electrode wire into the Rt. atrium or Rt. ventricle via a vein.

Complications of transvenous (endocardial)

1- Thrombophlebitis. 2- Infection at insertion site.3- Sepsis.4- Hiccups.5- Abdominal twitching6- Myocardial irritability. 7- Pacer induced dysrhythmias8- Perforation of chamber

c- Epicardial Pacing

- Wires attached to Rt. atrium & ventricle during surgery & broughtout via chest.- Atrial wires exit to Rt. of sternum.- Ventricular wires exit in same region Lt. of sternum.- Wires removed several days after the surgery.- Open- heart surgery.- Ventricular pacing, and possible atrial pacing.

Complications of epicardial

1- Cardiac tamponade. 2- Microshock 3- Infection. 4- Lead dislodgement. 5- Psychological reactions.

Principles of Cardiac Pacing

A- Sensing:-



- Ability of pacemaker detect intrinsic myocardial electrical activity. B- Pacing:-

- Specified level of energy travels from external pulse generator to myocardium.

C- Capture:-

- Successful stimulation of myocardium by pacemaker .Impulse lead to depolarization.

Types of Pacing:-

1- Single-chamber pacing -----→ Atria or ventricles paced).

2- Dual-chamber pacing -----→ Both atria & ventricles paced).

Pacing ModesMode of pacemaker indicates its functions

.

1- Fixed (Asynchronous)

Pacing at preset rate regardless of patient’s own rhythm.

2- Demand (Synchronous)

Pacing when patient’s intrinsic heart rate drops below preset rate.

Pacemaker Setting

A- Rate control

- Regulates number of impulses delivered to heart between 60 - 80 B/m

B- Output control

- Regulates amount of electrical current (mA) delivered to heart to initiate depolarization.



C- Sensitivity

- Regulates ability of pacemaker to detect heart’s intrinsic electrical activity (mV).

Pacing artifacts

- Spike seen on ECG tracing as pacing stimulus delivered to heart .

Pacemaker Malfunction

1-Pacing Malfunction 2-Sensing Malfunction

1-Pacing Malfunction

1- Failure to pace- Failure of pacemaker to deliver pacing stimulus result in disappearance of pacing artifact.

2- Failure to capture

- Inability of stimulus to depolarize heart spikes are not followed by wave form.



2-Sensing Malfunction

1- Undersensing

Pacemaker does not identify patient’s intrinsic rhythm.

2- Oversensing

Pacemaker pacing at a rate slower than the set rate.

Role of Nurse during insertion of pacemaker

1-Transcutaneous pacing

- Avoid use of flammable liquids. - Avoid shaving chest hair. - Avoid placement over bone, breast tissue & devices.- Evaluate hemodynamic status.- Use lowest energy level to pace.

2-Transvenous pacing

- Connect patient to 12- lead ECG.- Ensure personnel are shielded from radiation.

Role of nurse after insertion of pacemaker

1- Assessment & Monitoring:-



A- For patient:-

- ECG recording /4 hours.- Continuous ECG monitoring.- Vital signs & Mental status.- Skin color, warmth & integrity.- Urine output.- Level of comfort.

B-Pacemaker:-

- Setting, connections & function /shift.

2- Pain management:-- Administer analgesic or sedative.- Adjust level of energy.- Evaluate patient response.- Position patient comfortably. - Avoid accidental tension on wires & generator.

3- Providing site care:-- Change electrodes /24 hours.- Change dressing /48 hours

4- Maintaining Electrical Safety:-

a-Pacemaker

- Insert new battery before each use.- Wear rubber gloves when handling wire.- Cover exposed parts of pacing wire with glove.- Use a battery – operated ECG machine.- Do not allow contact of both extensions of pacing wire.- Do not simultaneously touch electrical equipment & pacing wire.

b- Environment

- Minimize use of additional line- powered equipment.- Disconnect electric beds.- Turn line-operated equipment off before disconnecting from an outlet. - Disconnect the patient cable from monitor before turning it on or off.



- Know source of emergency power.- Keep the patient and area dry.- Minimize use of patient-owned equipment.- Report sockets that do not hold plugs securely.- Do not permit temporary or makeshift equipment repairs.- Do not touch electrical equipment with wet hands.- Do not use cheaters or extension cords.

c- Equipment

- Test all new equipment before use.- Check inspection tags on equipment in use.- Use only properly grounded equipment.- Inspect strain relief on equipment power cords.- Unplug equipment giving off warning signs.- Do not unplug equipment by pulling the cord from the outlet.- Do not tolerate any deviations from the expected screen).- Do not use damaged equipment. - Do not step on plugs or line cords.- Report complaints of shocks or tingling sensations.- Report equipment that has been dropped.

d- Patient

- Remove excess gel.- Keep bed linens dry.- Monitor tracing on –screen for quality.

5- Eliminating electromagnetic field (EMF)

- Be aware of all sources of EMF that could interfere with pacemaker function. - Radiation therapy. - MRI. - Electrocautery. - Defibrillation. 6- Preventing pacemaker malfunction

- Secure temporary pacing lead & bridging cable to body with tape.- Secure external pulse generator to patient's waist with strap.- Ensure all connections are secure daily.- Replace battery in generator as necessary.



7- Patient and family Education - Potential sensations.- Possible intervention.- Insertion procedure.- Precautions and restrictions.- When to notify the nurse.

8- Documentation:-

- Date, time of insertion, type of wire inserted & location of insertion. - Date and time of initiation of pacing.- Pacemaker settings.- ECG monitoring strip recordings before & after pacing /pacemaker insertion.- Vital signs & hemodynamic parameters before, during & after procedure.- Patient tolerance, comfort level and related interventions.- Status of skin integrity. - Medications administered.- Complications and interventions.

Permanent Pacemaker

- A pulse generator contains both the battery and the intelligent circuits this device connected to a lead which makes contact with either the atrium or the ventricular muscle.

- A pacemaker uses batteries to send electrical impulses to the heart to help it pump properly.

- An electrode is placed next to the heart wall and small electrical charges travel through the wire to the heart.

- Most pacemakers are demand pacemakers .They have a sensing device.

- It turns the signal off when the heart rate is above a certain level. - It turns the signal back on when the heart beat is too slow.



Indications:-

When a chronic, recurrent conduction or impulse formation disturbance exists in the cardiac conduction system such as.-:

- Sick sinus syndrome.- Symptomatic sinus bradycardia.- Atrial fibrillation with a slow ventricular response.- Complete atrioventricular block (third- degree block).- Chronotropic incompetence (inability to increase the heart rate to match a level of exercise).

Complications:-

Pacemaker malfunction - Failure to output (no pacing spike) - Failure to capture. - Oversensing. - Undersensing.- Lead dislodgment. - Interference.- Diaphragmatic stimulation.

Operative failures

- Pneumothorax. - Hematoma.- Venous thrombosis. - Pericarditis.- Cardiac perforation. - Skin erosion.



- Infection. - Wound dehiscence. - Airembolism. - Subcutenous emphysema.- Nerve injury. - Thoracic duct injury.- Pain.- Subclavian aterial puncture with hemothorax.

Late Complications

- High thresholds. - Lead failure.- Diaphragmatic stimulation. - Infection.- Skin erosion. - Battery depletion.- Loose setscrew. - Pacemaker syndrome.- Venous thrombosis. - Pain.

Complications of lead placement and pocket formation

- Lead displacement can produce loss of pacing and sensing.

- Myocardial perforation is more common with stiff temporary leads.

- Perforation may produce no symptoms or may cause complete failure to pace /or diphragmatic pacing.

Nurse Role ( Pre-procedure care):-1- Preoperative Assessment:-- Patient history

- Past medical history. - Medication history. - Specific medical condition. - Assessing symptoms. - Life style.

- Baseline vital signs. - Physical assessment.- Basic laboratory investigation.- ECG.



- Chest x-ray.

2- Preoperative Preparation:-

- Fasting (NPO) for six to eight hours.- Heparin infusions discontinued 4- 6 hours.- Scrub and shave the right or lift subclavicular area. - Patient s dominant arm is identified. - Informed consent.- Mild sedative. - Instruct patient to continue taking routine medications.- Reduce or hold doses of insulin or oral hypoglycemic agents. temporarily.

3- Education:-

- Why the patient needs a pacemaker.- What a pacemaker generator and pacemaker leads look like.- Where the pacemaker generator will be implanted. - Use of general anesthesia or conscious sedation during procedure. - Details of the usual preoperative preparation.

Nurse Role ( Post-procedure care):-

1- Immediate post-procedure care 2- Caution and precaution.3- Monitoring pacemaker function. 4- Activity restrictions.5- Pain management. 6- Discharge Instruction.

1- Immediate post-procedure care:-

The goals of care in the immediate 24 to 48 hours postoperative period are to:-

- Monitor signs of post operative complications. - Manage the patients post procedure pain. - Monitor the patient and pacemaker for proper functioning and efficacy of pacemaker therapy in reliving pre-implantation symptoms.- Begin patient education and address patient/family concerns.



2- Caution and Precaution:-

- During hospital stay ,a dressing should be maintained as ordered by physician ,if the dressing become saturated with blood during this initial period, it may changed using sterile aseptic technique.- Avoid getting the incision site wet to lessen the risk of infection.- Inspect the site routinely for signs of infection as redness ,warmth, or drainage and the pacemaker pocket and lead dislodgment.- Caution the patient to avoid extending the arm above the level of the shoulder.- Use of a sling on the affected arm can serve to promote comfort and to remind the patient to limit use of that arm.

3- Monitoring pacemaker function:- A- Assessment of pacemaker performance

I- Monitoring heart rate

- Assessing the patients heart rate (If a permanent pacemaker is functioning correctly, the patient s heart rate should never drop significantly below the low rate setting on pacemaker).

- A drop of 1-2 beats per minute is not considered (significantly,) and may occur normally following pacemaker implantation, however, a rate that drops significantly may indicate a pacemaker malfunction.

II- Assessing upper rate limit

- Count a pulse rate and analyze the patients ECG strip.

- General guidelines to follow when evaluating a heart rate for proper upper rate limit functioning :

- The patient heart rate should never drop more than 1-2 beats below the low rate setting of the pacemaker.

- When the patient s rhythm is 100% paced, the paced rate should not exceed the upper limit setting.- When the patient s rhythm is a combination of paced beats and intrinsic rhythm ,the patients heart rate may exceed the upper rate limit setting.



III- Assessing rhythm strips

(provide a clue of pacemaker functionand malfunctions)

- Assess spike when and where expected.- Assess for presence or absence of random pacemaker spikes.- Calculate the heart rate.- Evaluate rhythm strip data.

B- Assessment of patient response to pacemaker therapy :

- Recurrence of pre-implantation symptoms.

- The development of new symptoms including, hypotension, dyspnea increased fatigue ,decreased activity tolerance, palpitations, or other symptoms.

- The development of other symptoms may indicate pacemaker Syndrome that occurs when the patient loses AV synchrony during pacing. New or worsening symptoms may indicate that the programmed settings may to be adjusted.

- Observing the patient s activity tolerance and ability to perform activities of daily living without symptoms.

- Clinical manifestations that are directly slow heart rate

- Transient dizziness.- Lightheadedness.- Near syncope or frank syncope as manifestations of transient cerebral ischemia.- More generalized manifestations such as marked exercise intolerance or frank heart failure.

6- Discharge Instruction:-

- Avoid get the incision wet until the sutures have been removed (1 week ) you may shower if you cover the incision with plastic wrap.



- Allow steri-strips to peel off on their own. If they haven’t peeled off on their own within 2 weeks, peel them off carefully (beginning at one side and peeling toward the center of the incision ).

- Visit the doctor to remove suture if any suture sticking out of incision, and avoid removing it by himself.

- Observe for signs of rednes , swelling ,or drainage from incision & report this immediately to doctor.

- Take temperature in the evening every day for 1 week. Call doctor if there is elevation in body temperature.

- Avoid heavy lifting or strenuous arm exercise for about 2 –3 weeks. Any exercise is fine after 3 weeks.

- Avoid taking aspirin until dr. tells to do so. If there is soreness from new pacemaker, take Tylenol (acetaminophen )as dr order.

- Carry ID card at all time including .The dr . responsible for pacemaker name & phone, Pacemaker nurse name & phone,

- Have a full pacemaker check in approximately I month in the doctor”s office then every 6 months or every year depending on the type of pacemaker generator.

- Regular pacemaker magnet checks (every 3 months to start). Magnet check up will be done either in the doctor”s office or over the telephone.

- Avoid being within 10 feet of strong magnetic currents (MRI scanners), or high out put electrical currents .

- Airport security systems will not affect pacemaker, pacemaker set off the alarm. If this happens, tell the guard of presence of a pacemaker.

- Operate any home electrical appliances, including microwave ovens.

- Drive when feel well , unless the dr. has inform him not to do so .



- Regular x-rays or CT scans will not affect the pacemaker.

- Notify dr. or dentist if any surgery that will involve general anesthesia or electrocautery will be needed.

- Return to a full and active life style when he is able. If there is any question talk with dr., nurse or rehabilitation team.

Follow up care after permanent pacemaker implantations:-

1- Initial follow up care :-

- Wound assessment. - Pacemaker assessment.- Clinical documentation. - Schedule for future evaluation.

2- Long- term follow up:-

- Transtelephone Monitoring. - Direct evaluation.


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