SARASOTA MEMORIAL HOSPITAL

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1 SARASOTA MEMORIAL HOSPITAL TITLE: NURSING PROCEDURE PACEMAKERS AND DETERMINING PACEMAKER DATE: REVIEWED: PAGES: 10/99 11/18 1 of 7 PS1094 ISSUED FOR: Nursing RESPONSIBILITY: *Qualified RN PURPOSE: To establish a policy for the use of external pulse generators for patients. To determine the pacemaker threshold in patients with a temporary pacemaker, when ordered by physician. KNOWLEDGE BASE: 1. Qualified RNs may assume responsibility for independent use of external pulse generators. 2. Any patient with a femoral pacemaker must be placed in either Critical Care or Cardiac Acute Care. 3. Independent use of external pulse generators will occur under the following conditions: To prevent further clinical deterioration of patients who exhibit: 1) Symptomatic bradycardia 2) Sudden onset asystole 3) Symptomatic atrial fibrillation/flutter with a slow ventricular response 4. In the event that the use of an external pulse generator is required, the initial settings will be: MA 5, rate 70, ventricular demand mode. Increase MA as needed to elicit capture. May increase the rate to optimize the patient s hemodynamic status. 5. A Qualified RN may also change pacemaker settings as needed for a symptomatic patient. 6. Repositioning of pacing wires may only be done by a physician. EXCEPTIONS: As stated in the physician's orders. PROCEDURE: 1. HANDLING EQUIPMENT (WIRES, CABLES, GENERATORS): a. Wires

2 PAGE: 2 of 7 1) Gloves must be worn when handling exposed wires. 2) Avoid touching tips of wires together. Wrap A and V wires separately during dressing change. 3) See Nursing procedure (pac07) for care and dressing changes of the epicardial wires b. Generators 1) A fresh battery will be used with initiation of pacemaker therapy. 2) While in use, the pacemaker battery will be changed at least once a week, or PRN as needed. 2. TROUBLESHOOTING: NOTE: ECG strips documenting rhythm before and after pacemaker changes will be placed in the patient s chart. NOTE: Toxicity of antiarrhythmic agents and electrolyte imbalances such as hypokalemia, hyperkalemia, or hypomagnesemia may affect pacing. See Attachment Troubleshooting a Temporary Pacemaker PROCEDURE: DETERMINATION:

3 PAGE: 3 of 7 OBJECTIVE: CAUTION: DEFINITION: To determine threshold values so that appropriate settings can be made for output and sensitivity. Patients who are pacemaker dependent (with no underlying rhythm or inadequate underlying rhythms) should NOT have threshold testing done. Sensitivity Threshold: The level at which intrinsic myocardial activity is recognized by the sensing electrode. Stimulation Threshold: The amount of electric current (mas) that is necessary to stimulate the myocardium to depolarize. *Qualified Registered Nurses (RNs) are RNs assigned to special care or monitored areas (Critical care, Cardiovascular/Thoracic Unit (7CYT), Cardiac Acute, Cath Lab, ECC RNs, Intervention RNs, PACU) PROCEDURE: 1. Temporary pacemakers will be maintained as set in CVICU, or per order of the physician. 2. On the cardiac telemetry area, when checking the pacemaker threshold, two nurses will be present, one of whom must be a Registered Nurse. 3. To test the Stimulation Threshold: The pacemaker ma will be decreased to determine at what threshold pacing occurs. Increase the RATE to at least 10 bpm above the patient s intrinsic rate. This ensures pacing. 4. Gradually decrease the ma (output) until capture is lost. Gradually increase the ma (output) until consistent 1:1 capture is established. The pace light will be flashing. This is the stimulation threshold. 5. Once the threshold is determined, the MA will be set at 2-3 times the stimulation threshold and documented in the EMR as well as with a rhythm strip in the Physicians Progress Notes. 6. Note on Sensitivity Threshold Testing: Many physicians prefer to have the pacemaker sensitivity set all the way to demand mode (most sensitive), regardless of the sensitivity threshold. However, if inappropriate pacer inhibition occurs because the pacer is over-sensing by detecting and interpreting extra-myocardial activity (e.g., muscle movement, artifact), sensitivity threshold should be set as below.

4 PAGE: 4 of 7 7. To test the Sensitivity Threshold: Turn the rate control to at least 10 bpm below the patient s intrinsic rate to avoid competition between the pacemaker and the patient s intrinsic rhythm. Gradually turn the sensitivity to a higher numeric setting (less sensitive) and observe the sense indicator light for flashing. The sense indicator light stops flashing when the device is unable to sense the patient s intrinsic rhythm. Then slowly turn the sensitivity to a lower numeric setting (more sensitive) until the sense indicator flashes with each complex and the pace indicator stops. This value is the sensitivity threshold. 8. Set the sensitivity setting to the number that was half the sensitivity threshold to provide a 2:1 safety margin. For example: an appropriate setting for a patient with a 5.0 mv sensing threshold is 2.5 mvs or less. 9. Restore the Heart rate and output to desired values. DOCUMENTATION: Document the determined threshold and the setting in the Electronic Medical Record, and include a labeled rhythm strip in the progress notes. PROCEDURE: DISCONTINUING EPICARDIAL PACING WIRES- This procedure can only be done by an MD or specially trained RN. Refer to pac07-care of Patients requiring Temporary Epicardial Pacemakers, including Grounding, Dressing Change, and Discontinuation. DISCONTINUING TRANSVENOUS PACING WIRES: a. With a physician's order, CVICU RN s may remove transvenous pacing wires. Exception: Cardiovascular/Thoracic Step Down Unit (7CYT) and Cardiac Acute Care, A specially trained RN or MD must remove the transvenous pacing wire. b. Turn pulse generator off. c. While wearing clean gloves, disconnect the pacing wire from the pacing cable. d. Check to be sure the balloon is deflated if the patient has a Balloon Temporary Pacing Electrode. e. Pull the pacing wire out of the sheath introducer using a continuous motion. Observe the cardiac monitor for ventricular dysrhythmias while discontinuing the wire. If resistance is met when

5 PAGE: 5 of 7 attempting to remove the wire from the sheath, stop and notify the physician. REFERENCE: SMH Nursing Procedure. Care of Patients Requiring Temporary Epicardial Pacemakers Including Grounding, Dressing Change and Discontinuation (pac07). SMH: Author. Wiegand, D. (2017). AACN Procedure Manual for Critical Care, 7 th edition. Saunders. St. Louis: MO. REVIEWING AUTHOR (S): Nancy Olson, MSN, RN-BC, NPD Specialist, Cardiovascular Services Elizabeth Blaisdell Breault, BSN, RN, NPD, 7CYT ATTACHMENTS: Troubleshooting Temporary Pacemakers APPROVAL: Clinical Practice Council 11/1/18 Attachment Troubleshooting Temporary Pacemakers

6 PAGE: 6 of 7 Problem Cause Intervention Loose, broken or Check all disconnected connections wires Pacemaker too sensitive (see over-sensing) Failure to Pace: No evidence of pacing stimulus Failure to capture: Pacing stimulus is not followed by ECG evidence of depolarization Battery depletion Pulse generator failure Output setting (ma) is set too low Loose, broken or disconnected wires Lead not positioned well Perforation of the myocardium Decrease sensitivity by increasing the number on the sensitivity control. Replace battery Change pulse generator Increase the output (ma) Check all connections Reposition patient on their side Failure to Sense (Oversensing): The pacemaker is so sensitive that it inappropriately senses internal or external signals as QRS complexes and inhibits its Increasing in pacing threshold due to medication or metabolic changes External causes of over-sensing could be electromagnetic or radiofrequency signals or electronic equipment in use near the pacemaker. Check medication profile and labs. External: Identify any potential sources of electrical interference around the patient. Check electrical plugs and make sure they are grounded.

7 PAGE: 7 of 7 output. Internal causes can be large P waves, Large T waves voltage, or local myopotentials for example the ventricular chamber senses the atrial output and inhibits the ventricular pace. Internal: Decrease the sensitivity. (Turn to a higher mv setting) If the patient is AV paced and decreasing the sensitivity doesn t work, you can discontinue atrial pacing if the patient can tolerate it. Problem Cause Intervention Lead Check all disconnected connections from the pacemaker Async pacing Failure to sense (undersensing): the pacemaker fails to recognize intrinsic activity that is present Intrinsic QRS voltage too low to be sensed by the pacemaker Battery depletion Turn the sensitivity control to the Demand mode. Make the pacemaker more sensitive by decreasing the number on the sensitivity control Replace battery