Presentation on theme: "ELECTROPHYSIOLOGY LAB"— Presentation transcript:
1ELECTROPHYSIOLOGY LAB EP: The Shocking Truth!Nursing Grand RoundsJune 15, 2011Kris Martin, RNJulie MacDonald, RN
2in between the OLD ICU and WHERE ARE WE?Wyman Groundin between the OLD ICU andRadiation Oncology
3What do we do? Pacemaker and ICD implants Electrophysiology Studies TEE’sCardioversions (Electrical and Chemical)Yearly Defibrillator testingAblations- Atrial flutter and SVT, AVNRTTilt-Table TestingPacemaker/ICD Clinic
4Why an EP study?Diagnoses abnormal heart rhythms and/or induces cardiac arrhythmia's in order to:Determine the source of arrhythmia symptomsevaluate the effectiveness of certain medications in controlling the heart rhythm disorderpredict the risk of a future cardiac event, such as Sudden Cardiac Deathassess the need for an implantable device (ICD or pacemaker) or treatment procedure (ablation)copyright Heart Rhythm Society 2004
5An Overview of the Procedure Pt receives conscious sedation and local anesthesia.Femoral VEIN is accessed-one or both sides.EP catheters are guided under fluoroscopy to the right atrium and ventricle via the IVC.Electrodes at catheter tip collect data from various points in the heart (electrical mapping).Various arrhythmia's can then be induced or ablated, or the decision to implant a pacemaker or ICD can be made.
6We Maintain a Sterile environment, same as the OR
7AblationsRadio frequency energy is delivered through EP catheters to burn a small section of the myocardium.This prevents the arrhythmia from continuing or returning.At Mount Auburn, we do SVT and Atrial flutter ablations (Afib and VT ablations are not done here).EP studies and ablations are typically done as outpatient procedures.
9TEE Transesophageal echocardiogram Ultrasound probe passed into esophagus-posterior view of heart.Diagnoses thrombus, valve disease, septal defects?source of embolus, bacteremia, or CVA/TIA.Pre-cardioversion to rule out existing thrombus.Patients get conscious sedation and generally need to remain NPO for 4 hours after.
11Cardioversion Synchronized shock to terminate Afib or flutter. Pts receive MAC (monitored anesthesia care-propofol) by anesthesiologistChemical Cardioversions are when medications are given like Ibutilide orFlecainide and EKG is monitored for conversion and arrhythmia.
12Defibrillator Testing DFTs: defibrillator threshold testing.Usually done on ICD implant and yearly, or if there is a potential device/lead issue.Frequently outpatient basis.Patient receives MAC (propofol).The ICD programer is used to induce VF and looks for the device to deliver a shock.
14Pre-op Pacemaker/ICD implant Pt must be NPO after midnightNo applesauce with meds orOJ for low blood sugar!AM meds are okay with a small sip of waterMeds to hold:heparin, multivitamins, oral hypoglycemics, insulinCheck blood sugar if diabetic**LEFT sided IV**
15Post-OP Care of Pacemaker/ ICD Watch site for S+S infectionpt will have prophylactic antibioticWatch site for hematoma or bleedingModerate amount of bleeding on DSD okayBedrest usually for 12 hours post opPain: Manual manipulation during implant Percocet or Tylenol
16this helps prevent dislodgment of leads! Post Op CareKeep arm in sling overnight, affected arm stays lower than shoulder height, no extended reachingthis helps prevent dislodgment of leads!Next day chest X-ray to confirm lead placement, and device interrogation.Pt will have a Green/purple folder in chart to take home. Please make sure to give them to patient on dischargeCall MD regarding procedure site, orders, functionof pacemaker.
17Leads... Thin wires with flexible silicone coating Connect the pacemaker generator to the myocardiumSensing of heart activity and discharge of electrical impulse.
18Leads are screwed into myocardium. 6-8 weeks for lead to mature: scar tissue forms around the lead and anchors it.Extended reaching or lifting during this time may dislodge the lead requiring re-do.
20Pacemaker leads as seen on Xray- (Dual chamber system) Atrial leadVentricular leads
21Pacemakers and defibrillators are a complicated business and that is why we have specialists.As a nurse you can not figure out what apacemaker or ICD is doing by just lookingat the monitor.There are a few things that you should know thatwill help you decide what to do.
22What is a pacemaker or Defibrillator? Pacemaker is sensing and monitoring patients own heart rate and delivers an impulse in either the atrium or ventricle in the absence of a sensed beat.Defibrillator is sensing and monitoring the patients own heart rate for a fast rate usually set 188bpm to deliver a shock to convert to NSR. Can also pace if heart rate is slow usually 40 bpm.
23What do you need to know? How many leads does the pacemaker have? 1 lead only sees what is happening in its chamber so a VVI pacemaker only knows what is happening in ventricle.2 leads sees what is happening in both chambers the atrium and ventricle. Mode DDD/ DDIWhat is the lower rate set at?If it is 60 it will not pace if heart rate isgreater than 60bpm.
24A Dual chamber pacemaker or DDD will pace in Atrium at lower rate and then that sets up a timingcycle for the Ventricle to either pace or inhibit.In a DDD pacemaker you can see all different types ofpacing on EGM strips:A sensed V sensed = NSR/ AFIB, pacemaker is inbititedA paced V sensed = Sinus bradycardiaA sensed V paced = Heart blocks / CHB/2:1 blockA paced V paced = Heart block/Sinus arrest/asystole
25Where will you find all this information? You will find it in Meditech under CardiologyReports tab.If there is no report then they have not been seenat Mount Auburn Hospital Pacemaker Clinic.Ask the patient/family if they have an ID card for theirpacemaker. Which will identify the manufacturer.Call pacemaker 5622 to evaluate the device.
26Pacemaker Report Pacemaker Report Clinic Tel: 617/499-5628 _____________________________________________________________________________Date of Pacemaker check: 03/14/11Pacemaker Type: Medtronic Sensia Implanted: 09/10/09Pacemaker programmed rate: 70bpm Mode: DDDRResponse with magnet: Asynchronous pacing 3 at 100bpm then 85bpmPresenting Rhythm: AV PacedUnderlying Rhythm: HB with PVC Pacemaker Dependent: NArrhythmia Recorded on Diagnostics: NoneBattery Life Stable: YImpedance: A= ohms RV= ohmsSensing: P-wave= mv R-wave= mvLOC: A= @ ms RV= @ msComments: In-house s/p fall. Appropriate sensing and capture testing. Noarrhythmia's recorded. Unable to promote intrinsic rhythm with AVDat max, no changes made. Reprogramming for testing only. Followup in six months.
27When would you apply a magnet to a pacemaker? During electrocautery use in OR or GI Unit.In a pacemaker a magnet causes the pacemaker toAsynchronously pace at a set rate usually 85bpm-100bpmWhat does this mean?It means that the pacemaker can no longer see what thepatients heart is doing and is going to pace at the magnet rate.If the patient is pacemaker dependent or has a HR belowthen you need to apply a magnet. If a magnet is notapplied it could result in long pauses or asystole.
28What if the patient has a Higher HR? If a patient has their own HR then you would not applya magnet since asynchronous pacing could cause apacing spike to come in on a T-wave resulting in VT!Remember when you place the magnet on a pacemakerit can no longer see what the patient’s own heart is doingA magnet should be available to place over device ifinhibition of pacing occurs resulting in pauses.
29When do you call pacemaker clinic? This device is over sensing and thinks itsees ventricular activity and inhibitspacing.
30What you might see on monitor Normal functionNon Sensing of R waveNon Capture
31What do you need to know about an ICD? You need to know if it is a single (VVI) or dual chamber(DDD) device and the lower rate.You need to know what the Zones are set at. VT zone or VF zone.The magnet response will always be: Inhibits therapies, no effect on pacemaker.If they are pacemaker dependent,they will need to be reprogrammed for surgery to an Asynchronousmode
32What do you need to know about a ICD? That it can overdrive pace a patient out of a fast HR if it falls into the VT zone.That it is not always able to distinguish between AFIB and VT especially if it is a single lead device. A VVI device doesn’t know what the atrium is doing.You can put a magnet over ICD to disable the therapies and prevent or stop inappropriate shocks.
34This is what a magnet looks like some are blue You can find them on all the code carts throughoutthe hospital, in the OR and GI units.When would you place a magnet over an ICD?If a patient is getting inappropriate shocks.During cautery in OR or GI unit.CMO status until device can be reprogrammed.A Doctors Order is need to apply a Magnet anddisable a device.
35ICD Patients that are Pacemaker Dependent If they are pacemaker dependent,they will need to bereprogrammed for surgery to an Asynchronous mode.Remember that a Magnet only Inhibits therapies, has no effect on Pacemaker in an ICD Patient.How do you know if they are pacemaker dependent?Look at the report in Meditech.you will need to call Pacemaker clinic 5622 to arrange for someone to come and evaluate device and reprogram if necessary.
36In OR, GI unit when cautery is being used the ICD should be disabled by a magnet.Electrocautery can cause noise on the lead,an ICD would interpret it as fast heart rate and deliveran inappropriate shock.The patient should always be on a monitor whenthe magnet is in place.The benefit of this is that if a VT/ VF episodeoccurs you can remove the magnet and the devicewill deliver a shock. If the device was programmedOFF then would need to externally shockthe patient..
37This is an example of noise on an ICD lead from Cautery.The device thinks this is VF and would deliver a shock ifa magnet was not applied.
38You can always call clinic, 5622 and we will help you figure it out!
39If a patient has been made CMO you may place a magnet over device until it can be reprogrammed.A note must be in the chart from attending physicianthat it has been discussed with patient and or family.An order must be written to turn off ICD, before it can be done. If you are applying a magnet an order should be written.This has no bearing on pacemaker portion of ICD and we do NOT turn off pacemakers in CMO patients.
40When would you apply a magnet to an ICD? If a patient was receiving shocks that you/MD determine to be inappropriate you may apply a magnet to stop the therapies/shocks.An example of this would be a patient who is in rapid AFIB with ventricular rate in 190bpm and has a single chamber device with a VT zone set for 188bpm. The ventricular lead only knows that the rate is above 188bpm and that it is programmed to give a shock.
41Another example of when to place a magnet is the patient is telling you they are getting Shockedand this is the rhythm on monitor/EKG.This is NSR and if the patient is getting shocksfrom ICD, then you need to disable it with a magnetThe lead is most likely broken and over sensingthe device will continue to give shocks until it isdisabled.
42What if the device is not giving a shock and you see VT on monitor?The device will only do what it has been programmed to doIf a VT Zone is set at 188bpm and a patient is in a180bpm the device is never going to give a shock.You would need to externally shock the patient.The pads should be placed to avoid damaging the ICD.
43What if your patient tells you his device is BEEPING or VIBRATING in their Chest?They are NOT crazy! The devices are set up to alert patientsof a problem.You should notify the pacemaker clinic or cardiologist on call. They can call in a company representative to interrogate and find the problem.The beeping and or vibrating will continue every 6-10hours until device is reprogrammed.8am pm pm
44Why is Pacemaker/ ICD follow-up important? We often find new onset AFIB. Device can date and timethe event, amount and duration of episodes and give atrialand ventricular rates.
45We evaluate Histograms to tell us if the heart rate has been fast or if it has been stuck at the lower rate. Medications areoften adjusted or Rate Response added.
46We find broken leads or batteries that need replacement. Non capture orintermittentcapturebroken lead onx-rayThrombus/emboli
47We find non-sustained episodes of VT in pacemaker patients that otherwise would go undetected. This couldbe causing them dizziness or syncope.New onset Afib is common to find also.
48In an ICD we can find episodes that received ATP or a shock In an ICD we can find episodes that received ATP or a shock. After reviewing with the cardiologist, their meds may be adjusted to prevent further therapies.
49In an ICD we can find episodes of AF getting inappropriate therapies. Medications would be evaluated and adjusted.Atrialventshock
50This is another example of inappropriate shock forSinus Tachycardiaand the patient shouldhave medications adjustedto prevent their sinus ratefrom going this high.