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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 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!