心臟植入性電子儀器照護指引- 手術前及手術後

• 主講人:孫佩勤護理長

How many people implantation pacemaker every year in Taiwan ?

Statistics 2010 Taiwan Device Implantation Units

4700

Pacemaker 4215

ICD 286

CRTD 64

CRTP 135

What Is a Pacemaker? A pacemaker is a small device that's placed in the chest or

abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate.

三部份所組成

由節律器（pulse generator ）

電極（electrode）電極的前端安置在心臟裡面

導線（lead）導線連接節律器與電極間，節律器以一定的速度將電刺激傳到心臟，使心臟維持規律的跳動。

Permanent Pacemakers組成 Pulse generator – 電池5-10years,

Lead wire –

Electrode(s) –

Unipolar – Spike 大

Bipolar –Spike 小

Pacemaker function

Most pacemakers perform four functions

• Stimulate cardiac depolarisation.

• Sense intrinsic cardiac function.

• Respond to increased metabolic demand by providing rate-responsive pacing.

• Provide diagnostic information stored by the pacemaker.

Indications for permanent cardiac pacing

• Sinus node dysfunction

• Atrioventricular (AV) block

• Ventricular tachycardia

• Carotid sinus hypersensitivity with recurrent syncope or ventricular asystole >3 seconds.

• Neurocardiogenic syncope with

• associated documented bradycardia.

• Atrial fibrillation Symptomatic,drug-refractory atrial fibrillation

with co-existing sinus node disease (tachy-brady syndrome).

• Heart failure

• Hypertrophic cardiomyopathy There is some evidence it reduces

intra-left ventricular systolic pressure (Ritter 2005).

Single or dual-chamber pacing

Toff et al (2005)

found that dual-chamber

pacemakers tended to

prevent more subsequent

heart problems than

single-chamber ventricular

pacemakers.

NASPE/BPEG generic code for antibradycardia pacing

Chamber paced

(電線刺激處,pacing處)

Chamber sensed (感知處)

Response to sensing

(感知有無跳動會做的反應)

Program-ability

(功能設定)

Antitachyarrhymia function

A= atrium

V=ventricle

D=dual

O=none

A= atrium

V=ventricle

D=dual

O=none

T=trigger I=inhibited

D=dual

O=none

P=simple

M=multiple

C=communicative or telemetry ability

R=rate responsive

capabilities

A= atrium

V=ventricle

D=dual

O=none

Pre-implant preparation Depression and anxiety are reported to be more common in patients with permanent pacemakers than in the general population (Duru et al 2001, Tagney 2010). • Important sufficient information pre-operatively to

prevent any misconceptions

• suggested that pre-operative information should include an explanation of why the pacemaker is required, the different components of the pacemaker (generator and lead), and the pre-operative routine.

• family should ideally be included in any discussions.

Pre-implant preparation

• Surgical Consent 手術/醫療處置之適應症

手術效益手術風險

替代方案

醫師補充說明/病人提出之疑問及解釋：

說明醫師

手術同意書

心律調節器去顫器心臟再同步治療說明暨同意書-20100208.doc

Pre-implant preparation

• local skin preparation

需例行剃除毛髮(shaving)，除非毛髮會影響手術部位。若需去 除毛髮應使用電動剪，並在手術前2小時內進行。

至少術前一日晚上或手術當天早上使用抗菌溶液，如 HIBISCRUB(2-4% chlorhexidine)淋浴或沐浴，特別是手術部位。

Pre-implant preparation • Expense

Pre-implant preparation

• 12-lead electrocardiogram.

• Chest X-ray.

• CBC BCS and electrolytes.

• Vital sign

• Methicillin-resistant Staphylococcus aureus screen,ideally at pre-

operative assessment.

• NPO for 4-6 hours depending on sedation or anaesthesia.

• Anticoagulants to be reviewed pre-procedure to minimise risk of

bleeding.

• Temporary alteration of diabetic medication.

• Antibiotic prophylaxis.於手術劃刀前30~60分鐘內給予，以維持組織有效濃度。預防性抗生素使用原則上不超過24小時；手術時間若超過3小時，應依據術式及抗微生物製劑之藥物動力學性質追加給藥。

• Mild pre-procedural sedation.

Post-procedure considerations • Analysing pacemaker rhythms

Ventricular Pacing-VVI 容易固定，atrial功能喪失導致

pacemaker syndrome:病人常會出現疲倦、頭昏、甚至昏厥，而在心室彈性差且舒張期灌注壓較高的病人則可能出現低血壓及肺鬱血的症狀。此併發症可以用DDD型節律器重建正常的心房心室收縮次序來改善。

雙腔型心臟節律調節器 (Dual chamber pacemaker)

• 二條導線分別置於心房與心室

• 可感應及去極化

Troubleshooting

• Failure to sensing：spike pace 在不正確的位置

Undersensing : Pacemaker does not "see" the intrinsic beat, and therefore does not respond appropriately

From http://www.pacemakerproject.com/treatments/tr_pacemaker_how.htm 2008/10/31

Oversensing : An electrical signal other than the intended P- or R-wave is detected

From http://www.pacemakerproject.com/treatments/tr_pacemaker_how.htm 2008/10/31

Troubleshooting

Failure to pacing: 該pacing, 卻沒有pacing

Post-procedure complications

Post-procedure complications

PPM 術後護理 1. 密切監測心電圖波形、生命徵象變化。 2. 維持靜脈給藥路徑管路通暢。 3. 檢視導管插入處啟動器放置傷口的情況，滿48小時後或

必要時予以換藥。 4. 在裝置PPM後可不須絕對臥床，只須限制 24-48小時內

勿過度伸展患側手臂

5. 勿過度活動或使患側手臂過度外展，用三角巾固定患側三天？

6. 依醫囑給予止痛劑止痛。 7. 依醫囑使用抗生素預防感染。 8. 記錄心搏啟動器的型式，植入日期及設定情形。 9. 裝置滿一週後拆線。

Post-operative education Wound care advice

• NICE (2008) recommends covering the wound

transparent dressing post-operatively for 48 hours

• Patients should be advised to look for wound complications such as haematoma or infection sign

• Wearing sterile gloves dressing

• Do not touch wound and pacemaker

Post-operative education

Driving

• The Driver and Vehicle Licensing Agency (2010)states that a car or motorbike cannot be driven for at least one week post-pacemaker insertion.

• ICD patient Recommendation 3-6 months driving

Post-operative education

• Work

• when patients return to work as long as they feel well enough to do so.

• activity in the first few weeks to prevent lead dislodgement.

Post-operative education

• Electronic Article Surveillance System/EAS

• 進出大賣場、書店 – 正常走 (10~15秒)

– 賴著不走 (15公分，2分鐘)

病人衛教事項-1

1. 教導測量脈搏的技巧，並告知每日自我測量的重要性。

2. 告知若脈搏高於或低於預定速率時，需告知醫師。

3. 注意失效或功能異常可能出現的徵象。

4. 心勿重擊，避免穿緊身衣，以免壓迫心搏啟動器。

5. 心臟節律器植入後預防冰凍肩，一星期內手可平行活動，一個星後手可以慢慢舉高，一個月後可以可恢復日常活動。

病人衛教事項-2

7. 活動無限制但在一個月內，避免急速或劇烈肩關節活動例如游泳及高爾夫，或提重物超過5公斤（患側）。

8. 避免及防止電干擾，如遠離高電量（大型發電機或馬達）、強磁場（工業用磁鐵、手機基地台），勿靠近高壓電（Kusumoto＆Goldschlager,1998）。

9. 定期返院追蹤檢查。

10.隨時攜帶識別卡。

醫療檢查及治療-1

1. 拔牙：不影響，但應評估是否給予預防性抗生素。

2. 核磁共振：依機型而定，請call廠商來協助。

3. 放射線檢查：若腫瘤生於心搏啟動器置放處，需考慮更換部位。若PPM直接暴露於離子放射線，應先使用防護罩，並監測累積輻射量。

4. 體外去顫整流器：應先關閉其速率

調整功能，必要時調整為VOO。

最好離15公分以上的位置，並備有TCP

醫療檢查及治療-2

5. 體外震波碎石術：最好離15公分以上的位置。DDD調為VVI。

6. 經皮神經電流刺激術：此項程序會將電流傳入人體，因此可能影響體內的植入裝置。考慮進行這項程序者最好先諮詢其心臟科醫師。

Permanent pacemaker remove when body care

• 因容易發生嚴重影響焚化爐產生高電熔且有引爆焚化爐之顧慮

• 告知家屬須於屍體護理時取出

• 醫令碼:62009C00-肌肉或深部組織異物取出

• 皮下剪斷lead ‚取出電池即可

Thanks for your attention

歡迎指教 台大心臟內科護理長孫佩勤

suen@ntuh.gov.tw