cardiac implantable devices nursing care: the basics and beyond
TRANSCRIPT
![Page 1: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/1.jpg)
Cardiac Implantable Devices
Nursing Care:
The Basics and Beyond
![Page 2: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/2.jpg)
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!
![Page 3: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/3.jpg)
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
![Page 4: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/4.jpg)
Outline
1. Welcome and general information2. Pacemakers3. ICD’s4. NBG codes5. Biventricular Pacing6. Nursing Considerations7. Pacemaker Practice Strips
![Page 5: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/5.jpg)
Normal Conduction System
![Page 6: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/6.jpg)
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
![Page 7: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/7.jpg)
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
![Page 8: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/8.jpg)
General “Device” Terms to Understand
SenseFireCapture
![Page 9: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/9.jpg)
Sense
Sense: the ability of the device to recognize the presence or absence of an innate “p” wave or “qrs” complex
![Page 10: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/10.jpg)
Fire
Fire: the device has sensed a missed “p” wave or “qrs” complex, and has sent energy down the pacing wire to the tissue
![Page 11: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/11.jpg)
Capture
Capture: the energy has contracted the myocardial tissue, and resulted in a “p” wave or “qrs” complex on skin leads
![Page 12: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/12.jpg)
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***
![Page 13: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/13.jpg)
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
![Page 14: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/14.jpg)
![Page 15: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/15.jpg)
Examples of Paced “a”,Paced “v”, and Both
![Page 16: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/16.jpg)
Pacemakers
![Page 17: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/17.jpg)
What is a pacemaker?
A internal device that regulates electrical impulses through the heart. Sense FireCapture
Single Chamber, Dual Chamber and Bi-Ventricular
![Page 18: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/18.jpg)
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
![Page 19: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/19.jpg)
![Page 20: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/20.jpg)
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.
![Page 21: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/21.jpg)
Other Indications
Hypertrophic Obstructive Cardiomyopathy (HOCM)S/P Alcohol Septal Ablation
Congestive heart failure (CHF) Biventricular pacing
![Page 22: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/22.jpg)
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
![Page 23: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/23.jpg)
Break???
![Page 24: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/24.jpg)
Intracardiac Cardioverter Defibrillatorsor
ICD’s
![Page 25: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/25.jpg)
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)
![Page 26: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/26.jpg)
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
![Page 27: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/27.jpg)
Unipolar ICD
![Page 28: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/28.jpg)
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
![Page 29: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/29.jpg)
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
![Page 30: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/30.jpg)
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
![Page 31: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/31.jpg)
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
![Page 32: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/32.jpg)
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’
![Page 33: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/33.jpg)
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
![Page 34: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/34.jpg)
Break?
![Page 35: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/35.jpg)
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.
![Page 36: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/36.jpg)
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?
![Page 37: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/37.jpg)
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
![Page 38: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/38.jpg)
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
![Page 39: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/39.jpg)
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
![Page 40: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/40.jpg)
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
![Page 41: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/41.jpg)
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
![Page 42: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/42.jpg)
Single Chamber Pacing
How Do We Use The NBG Language?
![Page 43: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/43.jpg)
Ventricular lead
• Ventricular pacing
• Ventricular asynchronous pacing at lower programmed pacing rate
• Used for: surgical procedures with cautery
*
• No sensing
VOO
![Page 44: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/44.jpg)
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
![Page 45: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/45.jpg)
*Atrial lead• Atrial asynchronous pacing
at lower programmed pacing rate
• Atrial pacing
• No sensing
AOO
![Page 46: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/46.jpg)
*Atrial lead
Indications: Sinus Node Dysfunction
• Atrial pacing
• Atrial sensing
• Intrinsic P wave inhibits atrial pacing
AAI
![Page 47: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/47.jpg)
Dual Chamber Pacing
Tracking Mode:
Both triggers and inhibits pacing
![Page 48: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/48.jpg)
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
![Page 49: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/49.jpg)
![Page 50: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/50.jpg)
*
*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
![Page 51: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/51.jpg)
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
![Page 52: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/52.jpg)
DDD pacingSensing in both the atrium and the ventricle (inhibiting in both the atrium and the ventricle)
![Page 53: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/53.jpg)
DDD pacingPacing in the atrium with sensing (inhibition of pacing) in the ventricle
![Page 54: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/54.jpg)
DDD pacingSensing in the atrium (inhibition of atrial pacing) and pacing in the ventricle
Also known as “P wave tracking”
![Page 55: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/55.jpg)
DDD pacingAtrial pacing and ventricular pacing (no inhibition of pacing)
![Page 56: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/56.jpg)
DDD mode
May resemble other modes of pacing
Will strive to maintain AV synchrony with variable atrial rates and AV conduction
![Page 57: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/57.jpg)
Dual Chamber Timing ParametersDual Chamber Timing Parameters
Lower rateLower rate
Upper rate intervalsUpper rate intervals
![Page 58: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/58.jpg)
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
![Page 59: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/59.jpg)
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
![Page 60: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/60.jpg)
Rate responsiveness/ adaptive-rate pacing
The 4th Letter in the NBG Code
![Page 61: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/61.jpg)
Rate responsiveness/adaptive-rate pacing
Rate response attempts to mimic the sinus node by increasing heart rate in response to increasing metabolic demand
![Page 62: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/62.jpg)
Rate responsiveness/adaptive-rate pacing
Sensor(s) detect changes in physiologic needs and increase the
pacing rate accordingly
![Page 63: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/63.jpg)
Rate responsiveness/adaptive-rate pacing
The sensor detects changes by:Sensing motion (crystal or
accelerometer)
Sensing changes in intrathoracic impedance, e.g., minute ventilation
![Page 64: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/64.jpg)
DDDR pacing
Example of Dual-Chamber Rate-Responsive pacing
![Page 65: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/65.jpg)
Biventricular PPM or ICD
A Brief Overview of What It Means To BiV Pace
![Page 66: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/66.jpg)
Biventricular pacing
Three lead system:
Right atrial
Right ventricular
Left ventricular
![Page 67: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/67.jpg)
Biventricular pacing
![Page 68: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/68.jpg)
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%
![Page 69: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/69.jpg)
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.
![Page 70: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/70.jpg)
Biventricular pacing
Achieved by: Inhibiting intrinsic ventricular rhythm
Ensure pacing in RV and LV
Short A-V delays to promote pacing in the ventricle
![Page 71: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/71.jpg)
Break?
![Page 72: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/72.jpg)
When Devices Go Bad!!!!
![Page 73: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/73.jpg)
Complications of Device Implantation:
Pocket hematoma Pocket infectionPneumothoraxCardiac perforationCardiac tamponadeVascular damage
Lead dislodgementLead fractureLead infectionInappropriate shocks
![Page 74: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/74.jpg)
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
![Page 75: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/75.jpg)
Unexplained Dents!
![Page 76: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/76.jpg)
Device Erosion
![Page 77: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/77.jpg)
Lead Fracture
![Page 78: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/78.jpg)
Intraprocedure
![Page 79: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/79.jpg)
Extracted Lead
![Page 80: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/80.jpg)
Extracted Generator and Lead
![Page 81: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/81.jpg)
Nursing Considerations
Preoperative ICD Placement
and
Postoperative Care
![Page 82: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/82.jpg)
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
![Page 83: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/83.jpg)
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**
![Page 84: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/84.jpg)
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.
![Page 85: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/85.jpg)
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
![Page 86: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/86.jpg)
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
![Page 87: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/87.jpg)
Patients Admitted With a PPM or an ICD
![Page 88: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/88.jpg)
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
![Page 89: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/89.jpg)
Pacemaker Practice Strips
![Page 90: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/90.jpg)
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?
![Page 91: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/91.jpg)
Troubleshooting
Failure to:SenseFireCapture
![Page 92: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/92.jpg)
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
![Page 93: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/93.jpg)
Is This Normal Device Operation?Is This Normal Device Operation?
![Page 94: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/94.jpg)
Is This Normal Device Operation? Is This Normal Device Operation?
![Page 95: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/95.jpg)
What Device Operation is This?What Device Operation is This?
![Page 96: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/96.jpg)
Is This Normal Device Operation?Is This Normal Device Operation?
![Page 97: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/97.jpg)
Is This Normal Device Operation?Is This Normal Device Operation?
![Page 98: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/98.jpg)
![Page 99: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/99.jpg)
What is missing?
![Page 100: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/100.jpg)
![Page 101: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/101.jpg)
![Page 102: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/102.jpg)
![Page 103: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/103.jpg)
![Page 104: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/104.jpg)
![Page 105: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/105.jpg)
![Page 106: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/106.jpg)
![Page 107: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/107.jpg)
![Page 108: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/108.jpg)
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
![Page 109: Cardiac Implantable Devices Nursing Care: The Basics and Beyond](https://reader035.vdocuments.mx/reader035/viewer/2022081603/56649dfe5503460f94ae6b6d/html5/thumbnails/109.jpg)
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.