心臟植入性電子儀器(CIED)護理照護指引-術中護理照護

中國醫藥大學附設醫院

心臟內科

護理師 洪佩琪

Pacemaker 術前準備 •核對病人 檢查同意書

•Check 前一天抽血 data

•術前一小時給予Cefazolin and Gentamycin

•3 lead ECG monitor/recorder

•TCP

•Vital sign

•O2

準備用物

生理系統監視儀

Subclavian Vein

vs.

Cephalic Vein

Approach

Access - Blood Vessels

Subclavian

Artery Subclavian

Vein

Cephalic

Vein

Aorta

Pulmonary

Artery

External Jugular

Internal Jugular

Superior

Vena Cava

Inferior

Vena Cava Diaphragm

Lung

Cephalic Vein Approach

Ellenbogen KA et al. Clinical cardiac pacing, defibrillation, and resynchronization therapy 3th ed.

Cephalic Vein Approach

Cephalic Vein Approach

Subclavian Vein

Subclavian puncture

VVI upgrade to DDD

Access - Cardiac Chambers

Left Atrium Mitral Valve Aortic Valve

Left Ventricle

Right Ventricle

Tricuspid Valve Right Atrium

Pulmonary Valve

Transvenous Leads

Passive fixation (tined)

The tines become lodged in the trabeculae of the apex or the pectinate of the appendage which are fibrous meshworks of heart tissue

Active fixation (screw-in)

The helix, or screw, extends

into the endocardial tissue

– Allows for lead positioning

anywhere in the heart’s

chamber

– The helix is extended using

an included tool

Tined lead and Screw lead

Single Chamber System

• One lead

– Atrium

– Ventricle (most common)

• May be used for patients in chronic AF (VVI pacemaker) or patients with sinus node dysfunction and no history of AV block (AAI pacemaker)

AAI Pacemaker VVI Pacemaker

Dual Chamber System

• Two leads – One lead implanted in the atrium

– One lead implanted in the ventricle

• Provides AV synchrony and pacing support in both atrium and ventricle if needed

DDD Pacemaker

Dual Chamber Pacemaker

RV Lead at the Apex

RA Lead in Appendage

Triple Chamber System

• Three Leads:

– Right Atrium

– Right Ventricle

– Left Ventricle (via the Coronary Sinus vein)

• Most commonly called a Bi-Ventricular Pacemaker but also called Cardiac Resynchronization Therapy (CRT–P)

• Paces both ventricles together to “resynchronize” the beat DDD BiV Pacemaker

Knowledge Checkpoint

術中注意事項

• 嚴謹遵守無菌原則

• 注意vital sign

Programmer

defibrillation threshold (DFT)

testing

• Diazepam or midazolam

• TCP 200J

• Check Vital sign

defibrillation threshold (DFT)

testing

pacemaker implantation test

Cont/.....

• Measurements

– 1.Sensing threshold

• Amplitude (Minimum : “P” - 2mV , “R” - 5mV)

• Slew rate

Pacemaker Implantation

• Measurements

– 2.Pacing threshold

• (Measured amplitude at various pulse widths)

• Paced rate > = 20 ppm above spontaneous rate

• Decrement variable output : Threshold < 1V @ 0.5ms

• Impedance measurement : 300 - 1000 ohms

tined: 500-2000 ohms

Cont/.....

Pacemaker Implantation

Cont/.....

• Measurements

– 3.Lead stability

– 1V output, or 2X diastolic threshold (min. 1V)

– 10V output for diaphragm stimulation test

– Lead sutured in position

– Re-measure sensing / pacing characteristics

– Dual-chamber system

- Measure Retrograde Conduction Time

Pacemaker Implantation

Sensing

• Sensing is the ability of the pacemaker to “see” when a natural (intrinsic) depolarization is occurring

• Pacemakers sense cardiac depolarization by measuring changes in electrical potential of myocardial cells between the anode and cathode

0.5 mV signal

2.0 mV signal

Acceptable Sensing Values (mV)1

Acute Chronic

Atrium >1.5 >1.0

Ventricle >7.0 >5.0

Sensing

1Curtis, Anne B. (2010). Fundamentals of Cardiac Pacing. Massachusetts: Jones and Bartlett

Publishers. (pg. 98).

Sensitivity

Am

plit

ude (

mV

)

Time

5.0

2.5

1.25

1. Set RATE at least 20 ppm above patient’s intrinsic rate.

2. Decrease OUTPUT: Slowly turn OUTPUT dial counterclockwise until ECG shows loss of capture.

3. Increase OUTPUT: Slowly turn OUTPUT dial clockwise until ECG shows consistent capture. This value is the stimulation threshold.

4. Set OUTPUT to a value 2 to 3 times greater than the stimulation threshold value. This provides at least a 2:1 safety margin.

5. Restore RATE to previous value.

Stimulation Threshold Procedure

Medtronic, Inc., Minneapolis, MN December 2007

Strength Duration Curve

Example

Safety Margin = 2 x Amplitude Threshold

OR

3 x Pulse Width Threshold

Knowledge Checkpoint

What is the threshold? 1.25 V 0.05 V 0.75 V 1.00 V

A. 0.05 V

B. 0.75 V

C. 1.00 V

D. 1.25 V

Typical Lead Impedance Range

• Most important that ead impedance is stable over the lifetime of the device.

Typical Impedance range = 200 to 1,000 Ohms.*

*Impedance is higher for specially designed high impedance leads.

Hayes, David L., et. al. (2000). Cardiac pacing and defibrillation: a clinical approach. New York: Blackwell

Publishing. (pg. 398).

Programming Outputs

• Primary goal: Ensure patient safety and appropriate device performance

• Secondary goal: Extend the service life of the battery

– Typically program amplitude to < 2.5 V, but always maintain adequate safety margins

– Amplitude values greater than the cell capacity of the pacemaker battery (usually about 2.8 V) require a voltage multiplier, resulting in markedly decreased battery longevity

術後交班

• Pacemaker 設定

• Bed rest 12- 24 hours

•Cefazolin and Gentamycin

• Compression with 2kg sandbag over chest wound for 2-4 hours

Thanks For Your Attention!