Temporary pacemaker 삼성서울병원 심장혈관센터심장검사실 박정왜 RN, CCDS

Temporary pacemaker 삼성서울병원 심장혈관센터심장검사실 박정왜 RN, CCDS

NBG Codes 1st Letter 2nd Letter 3rd Letter A V D Chamber(s) Paced = atrium = ventricle = dual (both atrium and ventricle) Chamber(s) Sensed A = atrium V = ventricle D = dual O = none Response to Sensing I = inhibit (Demand mode) T = triggered D = dual O = none (Asynch) Chamber paced Chamber sensed Action or response to a sensed event V V I D D D

Temporary pacemaker is Acute management of medically refractory bradyarrhythmias Management of certain tachyarrhythmias

Kind of Temporary pacemaker Transcutaneous cardiac pacing Transvenous pacing Epicardial pacing Transesophageal pacing

Temporary pacemaker indication In Acute Myocardial Infarction Medically refractory symptomatic sinus node dysfunction Mobitz II second-degree AV block with acute anterior infarction Third-degree AV block with anterior infarction New bifascicular block Alternation bundle branch block Alternating Wenckebach block New bundle branch block with anterior infarction Bundle branch block of indeterminate age with anterior or indeterminate location infarct Medically refractory AV block with bradycardia and symptoms regardless of infarct location In Absense of Acute Myocardial Infarction Medically refractory symptomatic bradycardia -sinus node dysfunction -second or third degree AV block Third-degree AV block with wide QRS escape or ventricular rate <50bpm Prophylactic Swan-Ganz catheterization or endocardial biopsy in patient with left bundle branch block Cardioversion in setting of sick sinus syndrome New AV or bundle branch block with acute enddocarditis ( especially aortic valve endocarditis) Perioperatively in patient with bifascular block and history of syncope To allow pharmacilogic treatment with drugs that worsen bradycardias Treatment of Tachyarrhythmias Termination of recurrent ventricular or supraventricular tachycardia Suppression of bradycardia-dependant ventricular tachyarrhyhmia including torsades de pointes

Transcutaneous cardiac pacing :external pacemaker Transcutaneous cardiac pacing has emerged as the preeminent initial mode of cardiac pacing for brady-asystolic arrest situations and prophylactic pacing application Transcutaneous cardiac pacing produces depolarization of myocardial tissue by pulsed electrical current conducted through the chest between electrodes adherent to the skin Coughing and discomfort from cutaneous nerve and skelectal muscle stimulation are the most frequent problems.

External pacemaker Skin preparation Shave/clip hair at electrode sites, if necessary Clean and abrade the skin at the electrode sites Dry the skin Location 전부에두개전극판이위치한경우 : 오른쪽쇄골하방, 상부흉골의오른쪽에위치, 심첨부의약간바깥쪽 전부에한개, 후부에한개위치한경우 : 앞쪽은우심실위를감싸면서흉골의왼쪽에위치, 뒤쪽은척추의왼쪽

Transvenous cardiac pacing Transvenous pacing provides the consistent and reliable means of temporary cardiac pacing in clinical practice. Transvenous pacing uses intravenous catheter electrodes to stimulate atrial or ventriclar myocardial tissue directly with electrical current pulses provides by an external generator. Decisions regarding the site of venous access for pacing should take into consideration the urgency to initiate pacing, desired lead stability, need to avoid specific complication, and anticipated duration of pacing.

Insertion site Without fluoroscopy : external jugular vein, brachial vein With fluoroscopy : cephalic vein, internal jugular vein, subclavian vein Femoral vein : risk of thrombosis, phlebitis, and infection

Epicardial pacing Transthoracic pacing is possible using temporary pacing wires passively fixed to the atrial and ventricular epicardium at the time of cardiac surgery or thoracotomy. They are exposed through the skin in the subxiphoid region. Transesophageal pacing The anatomic proximity of the esophagus to the posterior left atrium makes transesophageal atrial pacing possible in nearly all patients. The technique is relatively noninvasive and virtually free of serious complication.

Temporary pacemaker Model 5388 operation

Model 5388 Dual Chamber Temporary Pacemaker 1. Pace/Sense LEDs 2. Lock/Unlock Key 3. Lock Indicators 4. Rate Dial 5. Atrial Output Dial 6. Ventricular Output Dial 7. Menu Parameter Dial 8. Parameter Selection Key 9. Menu Selection Key 10. Pause Key 11. Power On Key 12. Power Off Key 13. Emergency/Asynchronous Pacing Key 14. Lower Screen 15. Ventricular Output Graphics 16. Atrial Output Graphics 17. Upper Screen 18. Rate Graphics 19. Setup Indicators 20. DDI Indicator 21. Low Battery Indicator 22. Setup Labels

ON/OFF keys Values at Power-On RATE A OUTPUT V OUTPUT A SENSITIVITY V SENSITIVITY UPPER RATE AV INTERVAL PVARP 80 ppm 10 ma 10 ma 0.5 mv 2.0 mv 110 ppm 170 ms 300 ms

Demand Pacing Dual Chamber Demand Pacing (DDD) Demand Pacing in the Atrium (AAI) Demand Pacing in the Ventricle (VVI) Pace Sense Pace Sense Pace Sense A + V A + V A A V V

Rate and Output Adjustments Rate Dial Atrial Output Dial Ventricular Output Dial

1. Set RATE at least 10 ppm above patient s intrinsic rate. 2. Decrease OUTPUT: Slowly turn OUTPUT dial counterclockwise until ECG shows loss of capture. 3. Increase OUTPUT: Slowly turn OUTPUT dial clockwise until ECG shows consistent capture. This value is the stimulation threshold. 4. Set OUTPUT to a value 2 to 3 times greater than the stimulation threshold value. This provides at least a 2:1 safety margin. 5. Restore RATE and OUTPUT to previous values.

Sensitivity Adjustments

Sensitivity (mv) 5 (mv) 2.5 (mv) 1.25 (mv) Sensitivity settings : at least a 2:1 safety margin

1. Set rate at least 10 ppm below patient s intrinsic rate. 2. Adjust output: Set OUTPUT to 0.1 ma (A OUTPUT for atrial threshold; V OUTPUT for ventricular threshold). 3. Highlight SENSITIVITY (atrial or ventricular) (Menu 1). 4. Decrease SENSITIVITY: Slowly turn MENU PARAMETER dial counterclockwise until pace indicator flashes continuously. 5. Increase SENSITIVITY: Slowly turn MENU PARAMETER dial clockwise until sense indicator flashes and pace indicator stops flashing. This value is the sensing threshold. 6. Set SENSITIVITY to half (or less) the threshold value. This provides at least a 2:1 safety margin. 7. Restore RATE and OUTPUT to previous values.

Rate-Dependent Parameters

Rapid Atrial Pacing

Basic Device Operation Turning device off Battery Replacement Push Buttons at the same time Push both buttons at the same time to turn OFF

Locking Feature Slide plastic cover over dials to protect against changes in settings Emergency Pacing Rate Check Rate Output Turn to MAX Sensitivity Turn to ASYNC MAX output Use caution when setting the sensitivity to asynchronous Asynch.

Normal capture

Loss of Ventricular Capture

Threshold test

Atrial/Ventricular Sensing Sensing Atrial Undersensing

Ventricle undersensing oversensing

arrhythmia in Temporary pacemaker VT : myocardial ischemia, acute infarction, hypoxia, general anesthesia, vagal stimulation, drug toxicity and catechoramine administration and coronary artery catheterization) VF : inf. Infarction inner 24 hours

Nursiug care Paced QRS complex : LBBB (if RBBB complex is coronary pacing, lead perforation into Lt ventricule or pericardial space) -> f/u EKG Protective dressing, examined daily for infection After insertion, pacing or sensing malfunction : 14~34% 발생 -> reposioning or catheter replace 24HR-inflammatory response : thresthold 증가 thromboembolism 예방 : anticoagulationg After pass 3 day, 50% infection risk.

References Ellenbogen KA, Wood MA. Cardiac Pacing & ICDS. 4th ed. Malden : Blackwell Science, Inc; 2005. Hayes DL, Lloyd MA, Friedman PA. Cardiac Pacing and Defibrillation : A Clinical Approach. Armonk: Futura ; 2000. Moses HW, Moulton KP, Miller BD, et al. A Practical Guide to Cardiac Pacing. 5 th ed. Boston : Little, Brown; 2000. Medtronic. inc