Presentation on theme: "Pacemaker follow up and troubleshooting. When the patient leaves the cath. lab with a permanent pacemaker what should I do?"— Presentation transcript:
Pacemaker follow up and troubleshooting
When the patient leaves the cath. lab with a permanent pacemaker what should I do?
Should I? A- Educate the patient. B- Document. C- Start follow up. D- Non of the above. E- All of the above.
Educate The patient Wound care activity Concerns Follow up The pacemaker site should be kept clean and dry. The patient may take a tub bath when you go home after getting a pacemaker, but keep the incision dry for at least two weeks. The dressing should be changed every day using sterile gauze. He must not use ointment on the incision site unless instructed to do so by the doctor. Carefully inspect the incision with each dressing change to note any redness, swelling or discharge. The arm on the same side as the pacemaker should not be lifted above shoulder level for four weeks. He should be careful not to hit or rub the insertion site. Instruct the patient not to "fiddle" or play with the pacemaker under your skin. avoid activities like heavy lifting, running, or contact sports. Do not lift more than 5 kilograms for two weeks. If you have any specific questions regarding activity, ask your doctor. It is best to take it easy for four weeks at home to avoid damaging the pacemaker. Cellular Phones: You may use a cellular phone; however, do not hold the cellular phone on the same side as your pacemaker or place it in your shirt pocket over the pacemaker. Strong Magnets: Avoid strong magnets. Examples are magnets used for an MRI and hand-held security wands. Strong Electrical Fields: Avoid strong electrical fields. Examples are radio transmitting towers, ham radios, and arc welders. Also, avoid leaning over the open hood of a running car because its electrical field can interfere with your pacemaker. Microwave Ovens: You may cook with a microwave oven. Microwave ovens in good working order are safe to use. Emphasize on the importance of follow up Give him the exact place and time Provide him with a phone number
Document Demographic information on patient Pacemaker operative record Manufacturer, model number and serial number of all implanted hardware Records of data from each follow-up visit Patient symptoms or complaints Evaluation of the pacemaker site Documentation of hardware advisory or recall, or any surgical complications Current medications
What is the aim of the follow up visits? 1- patient and family education. 2- Collect and maintain patient records and institutional databases. 3- Optimize pacing system function including maximizing power source utilization. 4- detect and correct pacemaker system abnormalities. 5- Act as a resource centre for cardiac pacing (RESERCH AND TRAINING)
Frequency Of Pacemaker Follow Up Postimplantation Two weeks 12 weeks Maintenance period Six months Intensified follow up period
Considerations in determining a pacemaker follow-up schedule Patient-related considerations Pacer system-related considerations Patient dependency on pacing. Stability of rhythm and cardiovascular symptoms. High or unstable thresholds or low and stable thresholds. Patient’s ability to report symptoms accurately. Patient distance from follow-up clinic. Known reliability of the implanted pacing system. How long the patient has had the pacemaker Programmed parameters (higher outputs = shorter time from elective replacement time to end of service) Complexity of pacing system. Collection duration for diagnostics. Concurrent use of implantable cardioverter- defibrillator. Application of cardioversion, electrocautery or defibrillation.
Patient related problems What troubles to shoot? 1- pocket related problems. 2- pacemaker syndrome. 3- accessory muscle stimulation.
Under passing or no pacing Patient related problems What troubles to shoot?
Battery depletion Generator failure: 1- temporary. 2- perminant. Over sensing: 1-myopotential. 2- interference. 3-cross-talke. 4- fare field sensing. Improper fixation. Lead problems: 1- twiddelers syndrome. 2- lead fructure. 3- insulation breake Electrode tissue interface: 1- lead imaturity. 2- electrolytes. 3- drugs. 4- MI.
Current is escaping Decreased Resistance Increased Current Drain Pacing and sensing problems
Current cannot reach heart Increased Resistance Decreased Current Drain Pacing and sensing problems
The ability of a device to sense intrinsic signals Think of sensitivity as a wall. Raise the wall and you can see less. Lower the wall and you see more.
1.0 mV 4.0 mV 2.0 mV
Myopotential Oversensing T - Wave Oversensing Pacing system senses signals other than P/R waves and inhibits pacing output.
1.0 mV 4.0 mV 2.0 mV
Under passing or no pacing Over passing Patient related problems What troubles to shoot?
Interference: MRI. Under sensing: 1-Lead problem 2- Electrode tissue interface. 1- Endless loop tachycardia. 2- Atrial arrhythmia or myopotential
To correct: Programming a lower number increases the sensitivity of the device, causing more signals to be sensed. 1.0 mV 4.0 mV 2.0 mV
Under passing or no pacing Over passing Patient related problems What troubles to shoot? Psudo-malfunction 1- hysteresis., 2- rate smoothing. 3- mood swithc. 4- fusion and psudo-fusion.
Escape Interval = Pacing interval
A B C Hysteresis Rate LRL Rate (ppm) A - Pacing inhibited by intrinsic rate > LRL B - Intrinsic rate falls below the Hysteresis Offset, pacing rate jumps to LRL C - DDD pacing at the LRL B Rate Hysteresis with Rate Smoothing
Fusion Beats: CHANGE in MORPHOLOGY An intrinsic cardiac depolarization occurs simultaneously with the pacemaker output pulse. Fusion
The pacemaker paces immediately after, or in an intrinsic depolarization. Pseudofusion