Академический Документы
Профессиональный Документы
Культура Документы
Pacemaker
University Hospitals Case Medical Center
Andrew Plante MD
Objectives
Abnormalities that benefit from temporary pacing
Temporary pacing modalities
Unipolar vs. bipolar temporary pacing leads
Epicardial wire failure
Microshock and how to avoid it
Temporary generator overview
Monitoring temporary pacemaker settings
Sensitivity, stimulation threshold and advanced settings
Antitachycardia pacing
Troubleshooting pacemaker malfunction
Transition to permanent pacemaker
Temporary epicardial lead removal
MRI and temporary pacemaker leads
Conclusions/Review
Overview1
Evolution of temporary epicardial
pacing from simple single
chamber systems to complex
dual chamber systems
Pacing often best method of
treating temporary rhythm
disturbances postoperatively
Knowledge required for
postoperative management of
cardiac surgery patients
Tachycardia
Other
V = IR
V:
I:
Voltage
Difference in potential energy between two points
Causes electrons to move through a circuit
Measured millivolts (mV)
Current
R:
Resistance
Opposition to the flow of electricity
Measured in ohms
http://www.Scienceblogs.com
Transvenous
Epicardial
Pacing Wires1,3
Unipolar
Bipolar
Atrial Lead
Blue
Exits on right of sternum
Usually higher than V lead
Ventricular Lead
Brown
Exits on left of sternum
Usually lower than A lead
Microshock10
Skin resistance is bypassed
20 mA can produce fatal dysrhythmias
Epicardial wire:
Temporary Generator11
Generator Indicators11
Sensitivity/AV
interval/Tracking
Upper Rate/PVARP
Rapid Atrial Pacing
Dial-A-Mode
Daily Checklist
1.
2.
3.
Underlying Rhythm1
Best done by turning down pacing rate and
allowing endogenous rhythm to appear
Turning down pacing energy output until loss of
capture or disconnecting the pacing wires can
result in an inability to re-establish capture
Rate1
Cardiac output is the product of stroke
volume and heart rate
After a point, as heart rate increases,
stroke volume falls and oxygen demands
increase
With temporary pacemakers, optimal heart
rate is rarely titrated to cardiac output and
is usually left at 80 to 90 bpm
Sensitivity1,11
Sensitivity
value
Checking Sensitivity1,11,12
1. Set pacemaker rate below endogenous rate
2. Place pacemaker in VVI, AAI or DDD mode
3. Slowly increase sensitivity number (pacemaker becomes less
sensitive)
4. Stop when sense indicator stops flashing
5. Pacing should now be asynchronous in chamber being tested
(Danger: R-on-T)
6. Turn the sensitivity number down (pacemaker becomes more
sensitive) until sense indicator flashes with each endogenous
depolarization (in time with P or R on surface ECG)
7. The number this first occurs at is the pacing threshold
8. UH protocol: generator set at half the pacing threshold (twice as
sensitive as necessary to sense activity)
9. If no endogenous rhythm, sensitivity typically set at 2 mV
Capture/Stimulation Threshold1,12
Minimum pacemaker output required to
stimulate an action potential in the
myocardium
Should not be checked if there is no
underlying rhythm (may lose capture)
If no underlying rhythm, watch for
occasional missed beats which may
indicate a rise in the capture threshold
AV Delay14,15
Interval following atrial depolorization
before a ventricular spike is delivered
Allows the pacemaker to perform the
function of the AV node
In a review of 13 patients undergoing
cardiac surgery, the optimal AV delay
varied between 0.100 and 0.225 s
In most patients, the default setting is
sufficient
Blanking Periods11
Atrial or ventricular blanking periods begin
immediately after an impulse is delivered
in the other cardiac chamber
No sensing occurs so no timing intervals
can be reset
This prevents cross-talk between leads
and is usually preset and not adjustable
Antitachycardia Pacing15
Overdrive pacing can effectively treat
tachyarrhythmias in some instances
Exceptions: V-Fib, A-Fib and sinus tach
When attempting overdrive pacing, V-tach
or V-fib may result
Be prepared for DC cardioversion
AV Junctional Tachycardia15,16
Rates usually 100-120 bpm
Common following cardiac surgery
Can be managed with AOO, AAI, DOO, or
DDD
Pacing rate is increased to ~120% of
endogenous rate
Once 1:1 capture occurs, rate is reduced
Often establishes a stable, slower sinus
rhythm
Atrial Flutter16,17
Overdrive pacing effective in type I atrial flutter
with < 320-340 atrial bpm, but not in type II
(higher bpm)
Set the pacemaker to just above the flutter rate
and then gradually increase until the atrial
complexes on the surface ECG change
morphology
Typically occurs at 10-20 bpm faster than the
flutter rate
Pacemaker is then slowed to an acceptable rate
Troubleshooting15,18
In a study of 1675 patients undergoing
cardiac surgery over 18 months, the
incidence of temporary epicardial
pacemakers requiring troubleshooting was
0.4%
No other data is available specific to the
incidence of troubleshooting with
temporary pacemakers
Troubleshooting11
Failure to pace
Failure to capture
Failure to sense
Failure to Pace15
No electrical output at the pacing wire tip when
the set pacing mode requires an output
Absence of pacing spikes on the surface ECG
(differentiates between failure to pace and
failure to capture)
May be related to:
Failure to Pace11
Failure to Pace12,15
Make sure all connections between the
patient and the pacing generator are intact
Try changing generator battery or a new
generator unit
If cross-talking is suspected, try adjusting
sensitivities
Eliminate sources of external interference
Failure to Capture15,19
Electrical output occurs at the lead tip but fails to
generate a cardiac contraction
Must be checked by comparison with the A-line or pulse
oximeter waveform
Caused by an increase in the resistance at the
lead/myocardium interface (fibrosis)
Increased threshold may also be secondary to:
Acute or ongoing MI
Electrolyte imbalances (Hyperkalemia or acid/base disorders)
Medications (specifically the antiarrhythmics)
Following cardiac defibrillation
Failure to Capture20
Failure to Capture12,15
View rhythm in different leads, verify with
A-line or pulse oximeter
Increase pacing output (mA)
Check connections
Change battery, cables, generator
Consider reversing polarity of leads
Failure to Sense15
Occurs for many of the same reasons as
failure to capture
Must be distinguished from a normal
pacemaker with inappropriate settings
(overly long intervals or refractory periods)
Failure to Sense20
Failure to Sense20
Failure to Sense12,15
Check all pacemaker settings, consider
resetting to factory defaults
Increase pacemakers sensitivity
(decrease mV)
Check electrolytes
Check pH/ABG
Consider conversion to unipolar pacing
Pacemaker-mediated tachycardia
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Conclusions
Although the temporary pacemaker used in
postoperative cardiac patients can be managed with
limited knowledge, suboptimal patient care often results
After this review you should understand:
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
MC Reade. Temporary epicardial pacing after cardiac surgery: a practical review. Part 1:
General considerations in the management of epicardial pacing. Anaesthesia 2007; 62: pages
264271.
Timothy PR, Rodeman BJ. Temporary pacemakers in critically ill patients: assessment and
management strategies. American Association of Critical-Care Nurses Clinical Issues 2004;15:
30525.
Spotnitz, H. Optimizing temporary perioperative cardiac pacing. Journal of Thoracic and
Cardiovascular Surgery 2005; 129: 5-7.
Bernstein AD, Daubert JC, Fletcher RD, et al. The revised NASPE BPEG generic code for
antibradycardia, adaptiverate, and multisite pacing. North American Society of Pacing and
Electrophysiology British Pacing and Electrophysiology Group. Pacing and Clinical
Electrophysiology 2002; 25: 2604.
Elmi F, Tullo NG, Khalighi K. Natural history and predictors of temporary epicardial pacemaker
wire function in patients after open heart surgery. Cardiology 2002; 98: 17580.
Daoud EG, Dabir R, Archambeau M, Morady F, Strickberger SA. Randomized, double-blind
trial of simultaneous right and left atrial epicardial pacing for prevention of postopen heart
surgery atrial fibrillation. Circulation 2000; 102: 7615.
Farhad E, Tullo NG, Khalighi K. Natural history and predictors of temporary epicardial
pacemaker wire function in patients after open heart surgery. Cardiology 2002; 98: 175-80.
Del Nido P, Goldman BS. Temporary pacing after open heart surgery: complications and
prevention. Journal of Cardiac Surgery 1989; 4: 99-103.
Ohms Law. Wikipedia: http://en.wikipedia.org/wiki/Ohm's_law.
Barash, Paul G. Chapter: Electrical and Fire Safety, Passage: Microshock. Clinical
Anesthesia. 2009 6th edition. Lippincott Williams & Wilkins.
Scales G. Medtronic Model 5388 Dual Chamber Temporary Pacemaker Technical Manual.
Minneapolis: Medtronic, 2006.
References
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Preuss T, Wiegand DL. Chapter 50: Temporary Transvenous and Epicardial Pacing. AACN
Procedure Manual for Critical Care: American Association Critical Care Nurses. 2005 5th
edition. Saunders, W. B.
Rastogi, S et al. Anaesthetic Management of Patients with Cardiac Pacemakers and
Defibrillators for Noncardiac Surgery. Annals of Cardiac Anaesthesia 2005; 8: 21-32.
Durbin CG Jr, Kopel RF. Optimal atrioventricular (AV) pacing interval during temporary AV
sequential pacing after cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia
1993; 7: 31620.
MC Reade. Temporary epicardial pacing after cardiac surgery: a practical review. Part 2:
Selection of epicardial pacing modes and troubleshooting. Anaesthesia 2007; 62: pages 364
373.
Rozner MA, Trankina M. Cardiac pacing and defibrillation. In: Kaplan JA, Reich DL, Lake CL,
Konstadt SN, eds. Kaplans Cardiac Anesthesia. Philadelphia: W. B. Saunders, 2006; 82743.
Donovan KD. Cardiac pacing in intensive care. Anaesthesia and Intensive Care 1985; 13: 41
62.
Wasiak J. What Is the Incidence of Temporary Epicardial Pacemakers Requiring
Troubleshooting? Clayton, Victoria, Australia: Center for Clinical Effectiveness, Monash
University, 2000.
Atlee JL, Bernstein AD. Cardiac rhythm management devices (Part II): perioperative
management. Anesthesiology 2001; 95: 1492506.
Shepard S. Temporary Pacemakers. Childrens Hospital San Diego, CA. April 2007.
Bojar RM. Manual of Perioperative Care in Adult Cardiac Surgery, 4th edn. Malden, MA:
Blackwell Publishing, 2004.
Bethea BT. Determining the Utility of Temporary Pacing Wires After Coronary Artery Bypass
Surgery. Annals of Thoracic Surgery 2005; 79: 104-7.