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Cardiac Implantable Devices Nursing Care: The Basics and Beyond.
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Transcript of Cardiac Implantable Devices Nursing Care: The Basics and Beyond.
Cardiac Implantable Devices
Nursing Care:
The Basics and Beyond
Welcome!
Terri Rhodes, RN, BSNClinical Level III, CEP Lab Nurse
Laura Hess, RN, BSNClinical Level II, CEP Lab Nurse
Please feel free to ask questions during the presentation!
Objectives:Examine device terminologyExamine the components, functions and
indications for a pacemakerInventory the components, indications and
functions of an internal cardiac defibrillator (ICD)Compare the pacing modes using NBG pacing
code system Assess patient needs preoperativelyManage patient postoperativelyAnalyze rhythm strips for appropriate pacemaker
and ICD functioning
Outline
1. Welcome and general information2. Pacemakers3. ICD’s4. NBG codes5. Biventricular Pacing6. Nursing Considerations7. Pacemaker Practice Strips
Normal Conduction System
A Brief History of Implantable Devices
1958 - First human implantDr. Senning in Stockholm, only lasted 3 hours
1960- First clinically successful human implant Dr’s Chardack and Gage in the USWilliam Greatbatch, engineer
1965- First VVI implanted1972- Partially programmable1977-Multiprogrammable1981- Dual chamber multi-programmable
Along Came ICD’s…1980 - First human implantThoracotomy
Epicardial patch & lead Large device placed in abdomen Not programmable; i.e. only one setting
Second generation ICD Transvenous electrode Bradycardia & anti-tachycardia pacing
Fifth generation Dual-chamber rate responsive pacing Improved recognition of SVT
The Next Generation Remote interrogation CHF Management S-ICD- subcutaneous ICD
General “Device” Terms to Understand
SenseFireCapture
Sense
Sense: the ability of the device to recognize the presence or absence of an innate “p” wave or “qrs” complex
Fire
Fire: the device has sensed a missed “p” wave or “qrs” complex, and has sent energy down the pacing wire to the tissue
Capture
Capture: the energy has contracted the myocardial tissue, and resulted in a “p” wave or “qrs” complex on skin leads
Device Terms Continued… Failure to Capture:
A spike is noted on strip, but is not followed by appropriate “p” or “qrs” wave form
Failure to Sense Spike (energy) is missing during absence of “p” or “qrs” Spike noted at inappropriate times
R on T Occurs when device fails to sense, and delivers energy during
vulnerable T wave - or – if programmed at VOO/AOO, the pacemaker delivers the energy in spite of intrinsic activity and paces on the t-wave.
Failure to Fire Device does not send energy (pacer spike) when indicated
***If you notice any of these, check your patient, check pulse and notify physician***
What Do You Need To Have a Paced Beat?
Atrial Paced Beat: “a” pacing spikeP wave immediately following pacer spike
Ventricular Paced Beat:“v” pacing spike QRS immediately follows pacing spike
Examples of Paced “a”,Paced “v”, and Both
Pacemakers
What is a pacemaker?
A internal device that regulates electrical impulses through the heart. Sense FireCapture
Single Chamber, Dual Chamber and Bi-Ventricular
Pacemaker Components
Pulse generator- battery which provides the energy. Controls the rate, output, and sensitivity. The “Can”
Leads- carries the impulse to the heart tissueAtrial Right VentricleLeft Ventricle
Coronary Sinus
Indications for pacemakersSymptomatic 2nd degree, Mobitz Type II heart
blockComplete heart block (3rd degree) AsystoleSymptomatic bradycardiaSinus node dysfunctionCarotid sinus syndrome and hypersensitivity
An exaggerated response to carotid sinus baroreceptor stimulation. Sometimes even mild stimulation in the neck region causes a marked decrease in heart rate, blood pressure, and causes syncope.
Other Indications
Hypertrophic Obstructive Cardiomyopathy (HOCM)S/P Alcohol Septal Ablation
Congestive heart failure (CHF) Biventricular pacing
Magnet Placement for a Pacemaker
Temporarily changes the mode of pacing to asynchronous (VOO, DOO) while magnet is in place.
Paces regardless of rhythmThis is programmable feature of the
device; NOT ONE SIZE FITS ALL
Break???
Intracardiac Cardioverter Defibrillatorsor
ICD’s
What is an ICD?
An internal device that can regulate electrical impulses through the heart, but its main function is to detect and terminate tachy arrhythmias. DefibrillationOverride pacingCardioversion Pacemaker Functions (Single/Dual/BiV)
Components of an ICD
Pulse generator- battery which provides the energy. Detects tachy arrhythmias and delivers defibrillation energy when indicated. Controls the rate, output, and sensitivity of the pacemaker function. The “Can”
Leads- carries the impulse to the heart tissueRight Ventricle
Endo Coil – High output leadAtrium
Pacemaker leadLeft Ventricle
Placed via the Coronary Sinus when placed in EP lab, and epicardial when placed in OR
Unipolar ICD
Indications for ICDs
Secondary prevention (already had event)Sudden Cardiac Death; NSVT, Sustained VT, V-
fib arrestInducible VT (EP testing)Primary prevention (trying to treat FIRST event)Cardiomyopathy (SCD-HeFT)At risk for sudden cardiac death
Unknown etiologyLong QTBrugada Syndrome (Na channel abnormality resulting in
RBBB with J point elevation and concave ST elevation)Cardiac Sarcoid
And the Latest…S-ICD
The S-ICD System is intended to provide defibrillation therapy for the treatment of life-threatening ventricular tachyarrhythmias in patients who do not have:
*symptomatic bradycardia
*incessant VT
*spontaneous, frequently recurring VT that is reliably terminated with anti-tachycardia pacing
Which one do you want?Traditional ICD S-ICD
*Provides effective defibrillation *Provides effective defib for for ventricular arrhythmias ventricular arrhythmias*Provides brady pacing *No risk of vascular injury*Provides ATP pacing *Low risk of systemic injury*Provides atrial diagnostics *Preserves venous access*Familiarity of implant technique *Avoids risk of endovascular lead extraction
Magnet Placement for an ICD Suspends tachycardia detection while
the magnet is in place
Pacing parameters remain unchanged This is a programmable feature of the
ICD, and may be different
Caution!Place magnet on device ONLY under
guidance or supervision from a physician or Electrophysiology Department nurse.
Examples of when placing magnet is appropriate: ICD “ shocking” at inappropriate timesDuring OR procedures requiring cautery. Stat
pads must be placed on patient.During a code situation when you want to take
‘control of the shocking’
Special Considerations for Pt’s with ICD’s If ICD discharges?
1. Check your pt: Think BLS/ACLS! ABC’s, is pt. responsive, what rhythm are they in?Take appropriate action if pt. is not stable
2. If pt. is stable notify EP departmentDuring a CODE?
DO NOT place STAT pads directly over device UCH policy: Place external defibrillator pads 4-6 inches away
from the device laterally if possible. Pt. is going for another OR procedure
Notify Anesthesia that pt. has device, tell them the company and they will notify the EP department
Break?
NBG CodesGeneric code created for NASPE and
BPEG. (NASPE is the North American Society of Pacing and Electrophysiology.BPEG is the British Pacing and Electrophysiology Group.)
Pacemaker programming codes that identifies how the pacemaker is programmed to function.
NBG Codes: Programming the pacemaker
I- What chamber do you want to pace?II- What chamber do you want to sense?III-What do you want to do with the
sensed information? Inhibit pacing or trigger pacing?Tracking the Atrial activity
IV-Do you want to increase the rate with the patient’s activity?
NBG Code ReviewNBG Code Review
IChamber
Paced
IIChamber
Sensed
IIIResponseto Sensing
IVProgrammableFunctions/Rate
Modulation
V: Ventricle V: Ventricle T: Triggered P: Simpleprogrammable
A: Atrium A: Atrium I: Inhibited M: Multi-programmable
D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating
O: None O: None O: None R: Rate modulating
S: Single (A or V)
S: Single (A or V)
O: None
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
O-None
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
IV
The NBG pacing code
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
O-None
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
IV
The NBG pacing code
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
O-None
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
IV
The NBG pacing code
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
O-None
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
IV
The NBG pacing code
Single Chamber Pacing
How Do We Use The NBG Language?
Ventricular lead
• Ventricular pacing
• Ventricular asynchronous pacing at lower programmed pacing rate
• Used for: surgical procedures with cautery
*
• No sensing
VOO
I*Ventricular
lead
• Sensed intrinsic QRS inhibits ventricular pacing
• Used if patient is in A-fib, do not want to tract the atrial rate
• Ventricular pacing
• Ventricular sensing
VVI
*Atrial lead• Atrial asynchronous pacing
at lower programmed pacing rate
• Atrial pacing
• No sensing
AOO
*Atrial lead
Indications: Sinus Node Dysfunction
• Atrial pacing
• Atrial sensing
• Intrinsic P wave inhibits atrial pacing
AAI
Dual Chamber Pacing
Tracking Mode:
Both triggers and inhibits pacing
Benefits of Dual Chamber PacingBenefits of Dual Chamber Pacing
Provides AV synchronyProvides AV synchrony
Lower incidence of atrial fibrillation Lower incidence of atrial fibrillation
Lower risk of systemic embolism and Lower risk of systemic embolism and strokestroke
Lower incidence of new congestive heart Lower incidence of new congestive heart failurefailure
Lower mortality and higher survival ratesLower mortality and higher survival rates
*
*Atrial lead
Ventricular Lead
• Pacing in both the atriumand ventricle
• Sensing in both the atrium and ventricle
• Intrinsic P wave and intrinsic QRS can inhibit pacing
• Intrinsic P Wave can “trigger” a paced QRS
• Maintain AV synchronization
I
DDD
DDD pacing
Dual-chamber pacing capable of pacing and sensing in both the atrial and ventricular chambers of the heart
4 distinct patterns can be observed with DDD pacing
DDD pacingSensing in both the atrium and the ventricle (inhibiting in both the atrium and the ventricle)
DDD pacingPacing in the atrium with sensing (inhibition of pacing) in the ventricle
DDD pacingSensing in the atrium (inhibition of atrial pacing) and pacing in the ventricle
Also known as “P wave tracking”
DDD pacingAtrial pacing and ventricular pacing (no inhibition of pacing)
DDD mode
May resemble other modes of pacing
Will strive to maintain AV synchrony with variable atrial rates and AV conduction
Dual Chamber Timing ParametersDual Chamber Timing Parameters
Lower rateLower rate
Upper rate intervalsUpper rate intervals
Lower Rate Interval
APVP
APVP
Lower Rate Lower Rate
The lowest rate the pacemaker will pace The lowest rate the pacemaker will pace the atrium in the absence of intrinsic atrial the atrium in the absence of intrinsic atrial eventsevents
DDD 60 / 120
New Slide
ASVP
ASVP
DDDR 60 / 100 (upper tracking rate) Sinus rate: 100 bpm
Lower Rate Interval {
Upper Tracking Rate Limit
Upper Tracking RateUpper Tracking Rate
The maximum rate the ventricle can be The maximum rate the ventricle can be paced in response to sensed atrial eventspaced in response to sensed atrial events
SAV SAVVA VA
New Slide
Rate responsiveness/ adaptive-rate pacing
The 4th Letter in the NBG Code
Rate responsiveness/adaptive-rate pacing
Rate response attempts to mimic the sinus node by increasing heart rate in response to increasing metabolic demand
Rate responsiveness/adaptive-rate pacing
Sensor(s) detect changes in physiologic needs and increase the
pacing rate accordingly
Rate responsiveness/adaptive-rate pacing
The sensor detects changes by:Sensing motion (crystal or
accelerometer)
Sensing changes in intrathoracic impedance, e.g., minute ventilation
DDDR pacing
Example of Dual-Chamber Rate-Responsive pacing
Biventricular PPM or ICD
A Brief Overview of What It Means To BiV Pace
Biventricular pacing
Three lead system:
Right atrial
Right ventricular
Left ventricular
Biventricular pacing
Cardiac Resynchronization Therapy (CRT)
Patient Indications
Bi-Ventricular ICD
Moderate to severe HF (NYHA Class III/IV) patients
Symptomatic despite optimal, medical therapy
QRS 130 msec
LVEF 35%
Biventricular pacing Also known as cardiac resynchronization
therapy, keeps the right and left ventricles pumping together by sending small electrical impulses to the heart muscle coordinating their contractions.
The heart is able to fill and pump blood more effectively. This along with medical therapy, helps to improve heart failure symptoms.
Improves quality of life in many.
Biventricular pacing
Achieved by: Inhibiting intrinsic ventricular rhythm
Ensure pacing in RV and LV
Short A-V delays to promote pacing in the ventricle
Break?
When Devices Go Bad!!!!
Complications of Device Implantation:
Pocket hematoma Pocket infectionPneumothoraxCardiac perforationCardiac tamponadeVascular damage
Lead dislodgementLead fractureLead infectionInappropriate shocks
Laser Lead Extraction Program
Implemented at UCH in 2008 by Chancey Weaver RN and Dr. Michelle Khoo M.D.
First laser lead extraction in January 2009~30 leads extracted/year
Reasons for a lead extraction: Fractured Leads Infected Lead(s)Non-functional leads/too many leadsRegaining venous access
Unexplained Dents!
Device Erosion
Lead Fracture
Intraprocedure
Extracted Lead
Extracted Generator and Lead
Nursing Considerations
Preoperative ICD Placement
and
Postoperative Care
Preoperative
Left/right arm IV Reinforce patient and family education
EP department performs education prior to and after procedure, any further questions, please call the EP lab
NPO Surgical site Pre-op medications
Antibiotics Blood work (WBC, Platelets, INR, Basic) Anesthesia in the procedure Restrictions after procedure
Postoperative Vital signs
Changes may indicate pericardial effusion or pneumothorax
Type of device and settings ECG interpretation and documentation, as per unit guidelines Activity HOB <30 degrees for the first 4 hours Antibiotics Incision site X-ray within 1 hour of arriving back in room and X-ray in AM as well
**Pt. placed in sling for 24 hours to allow leads to adhere to tissue**
Documentation According to hospital policy:
University of Colorado HospitalCall report to telemetry: Include device manufacturer and
model number, mode (VVI, DDD, etc.), and lower and upper programmed rates (should be given in report).
Place in computerized documentation: Device manufacturer, mode, rate, rate cut off, therapies, and date of implant.
If the device fires, document any therapies of the device including the precipitating dysrhythmia and outcome in your charting. Include ECG strips, if available, documenting the dysrhythmia, the delivery of the therapy via the ICD and the resultant rhythm and the patient response.
Strip Documentation
According to hospital policy, and individual unit guidelines.Minimal information includes “running” a strip
every 12 hours or with a change in rhythmDocumentation: date, time, patient's name,
medical record #, heart rate, PR, QRS, and QT intervals, and rhythm analysis
Wound care S/S of infectionNo submersion under water for 3 weeksNo direct water spray (shower spray) for 1 week
Coughing and deep breathing Activity
All information in Post Op packetNO lifting arm above shoulder for 6 weeks
Follow-up appointment Remote interrogations Electromagnetic interference Identification card
Patient and Family Education
Patients Admitted With a PPM or an ICD
Patients admitted with a PPM/ICD
Ask patient for device information, i.e. registration card
EP does not need to be consulted if a patient is admitted for a non-device related problem and the device appears to be working appropriately.
MRI not recommended (except new Medtronic PPM)
Pre-op/Post-op patients may require device programming changes ICD- tachy therapies off, or may fire during cautery PPM- reprogram to VOO, or may fail to pace
appropriately
Pacemaker Practice Strips
What You Need to Document
Underlying rhythm?Is it “a” paced, “v” paced or both
Is the device doing what it is programmed to do?
Troubleshooting
Failure to:SenseFireCapture
How to interpret a “paced” strip: One method of many…
1. Is intrinsic activity present?2. Are pacing spikes present: “A”, “V”, or both?3. Is 1:1 capture present?4. Is intrinsic activity sensed appropriately?
Over sensing- sensing of an inappropriate singleLeads to underpacing
Under sensing- failure to sense intrinsic cardiac signal
Results in overpacing5. What is the heart rate? 6. What is the programmed pacing rate?
Compliments of Northwestern Memorial Hospital, October 2002
Is This Normal Device Operation?Is This Normal Device Operation?
Is This Normal Device Operation? Is This Normal Device Operation?
What Device Operation is This?What Device Operation is This?
Is This Normal Device Operation?Is This Normal Device Operation?
Is This Normal Device Operation?Is This Normal Device Operation?
What is missing?
Thank YouCardiac Electrophysiology
Dena Keilman, RN Kari Jackson, RN Noelle Hernandez, RN Amanda Lange, RN Heidi Huber, RN Terri Rhodes, RN Dan Sullivan, RN Claire Rutherford, RN Matt Upton, RN Laura Hess, RN Diane Ridgway, RN Ann Czyz. RN
William H. Sauer, MDDuy Nguyen, MDPaul Varosy, MDRyan Aleong, MDJoe Schulller, MDWendy Tzou, MDChristine Tompkins, MDDavid Katz, MDCathy Kenny, ANP
References
Burke M, et al. Safety and Efficacy of a Subcutaneous Implantable-Defibrillator (S-ICD System US IDE Study). Late-Breaking Abstract Session. HRS 2012.