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Cardiac Implantable Devices

Cardiac Implantable Devices. Nursing Care: The Basics and Beyond. Welcome!. Terri Rhodes, RN, BSN Clinical Level III, CEP Lab Nurse Laura Hess, RN, BSN Clinical Level II, CEP Lab Nurse Please feel free to ask questions during the presentation!. Objectives:. Examine device terminology

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Cardiac Implantable Devices

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  1. Cardiac Implantable Devices Nursing Care: The Basics and Beyond

  2. Welcome! Terri Rhodes, RN, BSN Clinical Level III, CEP Lab Nurse Laura Hess, RN, BSN Clinical Level II, CEP Lab Nurse Please feel free to ask questions during the presentation!

  3. Objectives: Examine device terminology Examine the components, functions and indications for a pacemaker Inventory the components, indications and functions of an internal cardiac defibrillator (ICD) Compare the pacing modes using NBG pacing code system Assess patient needs preoperatively Manage patient postoperatively Analyze rhythm strips for appropriate pacemaker and ICD functioning

  4. Outline 1. Welcome and general information 2. Pacemakers 3. ICD’s 4. NBG codes 5. Biventricular Pacing 6. Nursing Considerations 7. Pacemaker Practice Strips

  5. Normal Conduction System

  6. A Brief History of Implantable Devices 1958 - First human implant Dr. Senning in Stockholm, only lasted 3 hours 1960- First clinically successful human implant Dr’s Chardack and Gage in the US William Greatbatch, engineer 1965- First VVI implanted 1972- Partially programmable 1977-Multiprogrammable 1981- Dual chamber multi-programmable

  7. Along Came ICD’s… 1980 - First human implant Thoracotomy 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

  8. General “Device” Terms to Understand Sense Fire Capture

  9. Sense Sense: the ability of the device to recognize the presence or absence of an innate “p” wave or “qrs” complex

  10. Fire Fire: the device has sensed a missed “p” wave or “qrs” complex, and has sent energy down the pacing wire to the tissue

  11. Capture Capture: the energy has contracted the myocardial tissue, and resulted in a “p” wave or “qrs” complex on skin leads

  12. 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***

  13. What Do You Need To Have a Paced Beat? Atrial Paced Beat: “a” pacing spike P wave immediately following pacer spike Ventricular Paced Beat: “v” pacing spike QRS immediately follows pacing spike

  14. Examples of Paced “a”,Paced “v”, and Both

  15. Pacemakers

  16. What is a pacemaker? A internal device that regulates electrical impulses through the heart. Sense Fire Capture Single Chamber, Dual Chamber and Bi-Ventricular

  17. Pacemaker Components Pulse generator-battery which provides the energy. Controls the rate, output, and sensitivity. The “Can” Leads-carries the impulse to the heart tissue Atrial Right Ventricle Left Ventricle Coronary Sinus

  18. Indications for pacemakers Symptomatic 2nd degree, Mobitz Type II heart block Complete heart block (3rd degree) Asystole Symptomatic bradycardia Sinus node dysfunction Carotid 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.

  19. Other Indications Hypertrophic Obstructive Cardiomyopathy (HOCM) S/P Alcohol Septal Ablation Congestive heart failure (CHF) Biventricular pacing

  20. Magnet Placement for aPacemaker Temporarily changes the mode of pacing to asynchronous (VOO, DOO) while magnet is in place. Paces regardless of rhythm This is programmable feature of the device; NOT ONE SIZE FITS ALL

  21. Break???

  22. Intracardiac Cardioverter DefibrillatorsorICD’s

  23. 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. Defibrillation Override pacing Cardioversion Pacemaker Functions (Single/Dual/BiV)

  24. 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 tissue Right Ventricle Endo Coil – High output lead Atrium Pacemaker lead Left Ventricle Placed via the Coronary Sinus when placed in EP lab, and epicardial when placed in OR

  25. Unipolar ICD

  26. Indications for ICDs Secondary prevention (already had event) Sudden Cardiac Death; NSVT, Sustained VT, V-fib arrest Inducible VT (EP testing) Primary prevention (trying to treat FIRST event) Cardiomyopathy (SCD-HeFT) At risk for sudden cardiac death Unknown etiology Long QT Brugada Syndrome (Na channel abnormality resulting in RBBB with J point elevation and concave ST elevation) Cardiac Sarcoid

  27. 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

  28. 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

  29. 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

  30. 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 times During OR procedures requiring cautery. Stat pads must be placed on patient. During a code situation when you want to take ‘control of the shocking’

  31. 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 department During 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

  32. Break?

  33. NBG Codes Generic 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.

  34. 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?

  35. NBG Code Review I II III IV Programmable Chamber Chamber Response Paced Sensed to Sensing Functions/Rate Modulation P: Simple programmable V: Ventricle V: Ventricle T: Triggered M: Multi- programmable A: Atrium A: Atrium I: Inhibited D: Dual (A+V) D: Dual (T+I) D: Dual (A+V) C: Communicating O: None O: None O: None R: Rate modulating S: Single (A or V) S: Single (A or V) O: None

  36. The NBG pacing code Position I II III IV Category Chamber(s) Paced Response to Sensing Programmability, rate modulation Chamber(s) Sensed Letters Used O-None A-Atrium V-Ventricle D-Dual (A+V) O-None A-Atrium V-Ventricle D-Dual (A+V) O-None T-Triggered I-Inhibited D-Dual (T+I) O-None R-Rate modulation S- Single (A or V) Manufac- turer’s Designation Only S- Single (A or V)

  37. The NBG pacing code Position I II III IV Category Chamber(s) Paced Response to Sensing Programmability, rate modulation Chamber(s) Sensed Letters Used O-None A-Atrium V-Ventricle D-Dual (A+V) O-None A-Atrium V-Ventricle D-Dual (A+V) O-None T-Triggered I-Inhibited D-Dual (T+I) O-None R-Rate modulation S- Single (A or V) Manufac- turer’s Designation Only S- Single (A or V)

  38. The NBG pacing code Position I II III IV Category Chamber(s) Paced Response to Sensing Programmability, rate modulation Chamber(s) Sensed Letters Used O-None A-Atrium V-Ventricle D-Dual (A+V) O-None A-Atrium V-Ventricle D-Dual (A+V) O-None T-Triggered I-Inhibited D-Dual (T+I) O-None R-Rate modulation S- Single (A or V) Manufac- turer’s Designation Only S- Single (A or V)

  39. The NBG pacing code Position I II III IV Category Chamber(s) Paced Response to Sensing Programmability, rate modulation Chamber(s) Sensed Letters Used O-None A-Atrium V-Ventricle D-Dual (A+V) O-None A-Atrium V-Ventricle D-Dual (A+V) O-None T-Triggered I-Inhibited D-Dual (T+I) O-None R-Rate modulation S- Single (A or V) Manufac- turer’s Designation Only S- Single (A or V)

  40. Single Chamber Pacing How Do We Use The NBG Language?

  41. VOO • Ventricular pacing • No sensing • Ventricular asynchronous pacing at lower programmed pacing rate • Used for: surgical procedures with cautery * Ventricular lead

  42. VVI • Ventricular pacing • Ventricular sensing • Sensed intrinsic QRS inhibits ventricular pacing • Used if patient is in A-fib, do not want to tract the atrial rate I Ventricular lead *

  43. AOO • Atrial pacing • No sensing • Atrial asynchronous pacing at lower programmed pacing rate * Atrial lead

  44. AAI • Atrial pacing • Atrial sensing • Intrinsic P wave inhibits atrial pacing * Atrial lead Indications: Sinus Node Dysfunction

  45. Dual Chamber Pacing Tracking Mode: Both triggers and inhibits pacing

  46. Benefits of Dual Chamber Pacing Provides AV synchrony Lower incidence of atrial fibrillation Lower risk of systemic embolism and stroke Lower incidence of new congestive heart failure Lower mortality and higher survival rates

  47. DDD • Pacing in both the atriumand ventricle • Sensing in both the atrium and ventricle Atrial lead • Intrinsic P wave and intrinsic QRS can inhibit pacing * Ventricular Lead I * • Intrinsic P Wave can “trigger” a paced QRS • Maintain AV synchronization

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