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Pacemaker Battery Change: An Outpatient Procedure
AORN JOURNAL
GCTOBER 1988, VOL. 48, NO 4
Pacemaker Battery Change AN OUTPATIENT PROCEDURE Mariece Huffman, RN
T
he most common indication for a permanent pacemaker is complete heart block, which has causes including sick sinus syndrome, Stokes-Adams syndrome, trauma, surgery, and myocardial infarction. Another indication is certain rapid dysrhythmias, but pacemakers usually are inserted for people whose heart rates are too slow to maintain an adequate cardiac output. Slow cardiac output may be demonstrated by fainting, dizziness, or fluid accumulation (eg, swollen ankles).' A permanent pacemaker system consists of a power source called the pulse generator,which houses the battery, circuitry electrodes that deliver an electrical impulse to the myocardium, and a lead that connects to the generator and electrodes (Fig 1). Pacemaker activity (firing) is indicated on the electrocardiogram(ECG) by a pacemaker spike. Elective battery (ie, pulse generator) replacement is a relatively simple procedure and can be performed on an outpatient basis. Battery depletion is the most frequent indication for battery replacement, but lead problems and pacemaker erosion or infection also can lead to reoperation. This article describes the development of pacemakers, the technique for battery replacement, and perioperative nursing care of the patient.
including atrial and ventricular pacing, atrioventricular sequencing, hysteresis, rate smoothing, overdrive suppression, and defibrillation.3 When the first artificial pacemakers were developed in the early 1950s, the mercuric-oxide batteries that operated them had to be replaced every 18 to 36 months; the battery was not reliable and did not achieve the longevity that was expected. The need for frequent replacement increased the cost of pacemakers, added significantly to morbidity, and increased the psychological burden of frequent clinical visits and hospitalization! In the 197Os, lightweight lithium batteries were developed for use in pacemakers. The pulse generator battery is a hermetically sealed metal
History
Mariece Huffman, RN, CNOR, is a clinician III, cardiac unit, Fairfax Hospital, Falls Church, Va She received her nursing diploma from Barnes Hospital School of Nursing, St Louk. The author acknowledges Patricia C. Seifert, RN,MSN, CNOR; Pat Casey, RN,MSN CCRN; and Sharon Thiebautfor their assistance.
T
he first artificial pacemaker was implanted in Stockholm in 1958 by R Elmquist and A Senning.2 Since its clinical introduction in the early 1950s, the cardiac pacemaker has been updated with many complex functions,
733
_ 4 0 K h JOL _K h A L _
~~
~
~
~
~
OCTOBER 1988. VOL 48. NO 4
-
Fig 1. Typical pacemaker pulse generator with ventricular lead attached. (Phofograph courtesy of Medtronic, Inc, MinncJapolis)
container and weighs approximately 25 to SO grams. These batteries last eight to 12 years. substantially reducing the frequency of battery replacement. In 1987, approximatelq 275,000 pacemakers were implanted worldwide. an increase of 35 over 1 986.5There are now more than 1 million people with pacemakers. The worldwide sales of pacemakers is estimated at approximately $1 billion (Fig 2).h Approximately 85,000 new single-chamber (ventricular) pacemakers are implanted in the United States each year, or about one in every 3,000 people.; Dual-chamber (atrial/ventricular) pacemakers currently make up approximately 20% to 259; of sales in the United States.h Atrial and ventricular 7
.u
electrodes are capable of sensing and pacing in either or both chambers. The most important advantage of a dual-chamber system is its ability to maintain the normal atrioventricular sequence of the electrical depolarization in the heart.
Assessing the Need for Battery Change
W
hen the pulse generator is near depletion, the patient’s heart rate will decrease and his or her pulse width as seen on the ECG will increase. Each change occurs gradually and s i m u l t a n e ~ u s l y . The ~ increased pulse width offsets the reduced battery voltage, thus keeping total energy output relatively constant. When the voltage in a lithium battery
OCTOBFR I Y X 8 , VOI.. 48, NO 4
AORN J O U R N A L
-pack'g
Total $1.9 6dfion 1987
Fig 2. Chart of 1987 expenditures of cardiovascular devices. Slightly more than half of the $1.9 billion expenditure are for pacing systems. (Adapted from 1987 Medtronic Annual Report, with permission from Medtronic, Inc, Minneapolis) drops to a certain point, the pacemaker automatically decreases the rate of stimulation by five to 10 beats per minute.'" Computers also help monitor rate change. A printout is sent to each physician at regular intervals. Physicians and nurses should note that the height of the pacer spike is not a reliable indicator of battery power." Transmitters are routinely given to patients at the time their pacemakers are implanted. When the transmitter is used, the heart's electrical impulses are converted to electronic signals that can be transmitted over the telephone. A receiver records the patient's ECG. Many models incorporate a switch that is activated by placing a magnet on the skin over the pulse generator. The magnet puts the pacemaker in the fixed-rate mode, so that the pulse rate will reflect pacemaker function. Because the postimplantation period is unpredictable, frequent telephone transmissions are recorded, initially as often as every week and later about once every three months.
Preoperative Care
A
pacemaker can be viewed as an artificial organ, but unlike an artificial limb, the pacemaker controls function of the patient rather than the patient controlling it. A study conducted on pacemaker acceptance by patients, however, found that patients accepted their loss and did not perceive themselves as disabled.l? Speculation about possible factors affecting acceptance revealed that these patients received their follow-up care in a pacemaker clinic where ongoing professional treatment, education, and support were provided. The major implication from this study is that nurses should treat patients with pacemakers individually. Factors that may affect the patient's acceptance of the pacemaker should be considered including a patient's support system, environment, or socioeconomic status. At Fairfax Hospital, Falls Church, Va. patient assessment and teaching are done by an RN when 735
AORh JOIlRhAL. -~
.
.
OCTOBER -~
1988, VOL 48. NO 4
~
Although the patient is awake throughout the procedure, he or she will not feel pain, only some pressure.
the patient comes in for blood work and x-rays. After introducing himself or herself to the patient and/or family members, the nurse conducts an interview with the patient to obtain medical history, current drug therapies, and history of allergies. The nurse assesses the patient’s and the family’s understanding of the procedure and educates them about battery replacement. Instructions given to the patient include: being NPO after midnight. arriving at the hospital one hour before the procedure, wearing comfortable clothes and shoes. avoiding wearing makeup. nail polish or jewelry, and having an escort who is available to stay with him or her for 24 hours. On the day of surgery, a nurse completes an outpatient checklist and collects data from the patient’s chart such as results from the laboratory. the physical examination, and ECG. The nurse also notes whether an x-ray confirming lead position has been taken. After helping the patient change into appropriate surgical attire, the nurse administers preoperative medication. Anesthesia personnel start an intravenous line and monitor the patient’s blood prcssure and heart rate during the surgery. Before the patient is called for surgery, the scrub nurse and the circulating nurse prepare the OR by providing a sterile setup. This includes a minor setup. local anesthesia of the surgeon’s choice. and a pulse generator for replacement. Equipment to monitor the patient’s ECG and blood pressure as well as fluoroscopy equipment are placed in the OR before the procedure begins. There should be supplies for administering oxygen, equipment for intubation and ventilation, an emergency drug cart. and a defibrillator available in case of an emergency. At some hospitals. a pacemaker sales representative supplies equipment such as sterile ventricular and atrial leads, guide wires, alligator cables, and a pacemaker system analysis (PSA). He o r she acts as a troubleshooter, operating the 736
PSA during threshold analysis. If the equipment is not provided in this manner, then it must be obtained from the company and kept in stock at the hospital with hospital personnel available to operate the PSA during evaluation of pacing and sensing thresholds.
Intraoperative Procedure
T
he circulating nurse escorts the patient into the OR and assists him or her onto the OR bed. Equipment for continuous ECG and blood pressure monitoring are placed on the patient, who will be monitored during the procedure by the registered nurse or anesthesia personnel. The OR should be kept as quiet as possible to keep the patient’s anxiety at a minimum and to enhance the effectiveness of the preoperative medication. Either the circulating nurse or anesthesia personnel are available at all times during the procedure to answer questions and reassure the patient and make him or her more comfortable by placing a pillow under the knees or head. Because the OR is kept cool, the nurse may cover the patient with a blanket. The patient’s hands are restrained during surgery to protect the sterile field. The circulating nurse preps an area from the patient’s mid-chest to the midaxillary line and from the jaw to the costal margin. This includes shaving the chest (if ordered by the physician) and applying a germicidal solution. Skin electrodes should not be placed near the pacemaker site. After the patient is prepped, the scrub nurse and the surgeon drape the perimeters of the sterile field with sterile towels and cover the field with sterile impervious drapes. The surgeon administers local anesthesia at the incision site. Although the patient is awake throughout the procedure, he or she will not feel pain, only some pressure. The surgeon makes the new incision imme-
OCTOBER 1988, VOL. 48,NO 4
AORN JOURNAL
Rate 89.8 Int 667
Fig 3. An electrocardiogram strip showing a heart rate of 89 in a patient with a ventricular pacemaker in place.
diately over the previous incision. The pacemaker should be gently pushed cephalad so that the body of the pacemaker, with no intervening lead, is directly under the incision. He or she must take care not to cut the lead. A fibrous sheath will have formed around the pacemaker. The old pacemaker is passed through the incision and disconnected from the lead. The surgeon tests the lead by using alligator cables as done at the time of the initial implant. Stimulation thresholds less than 2 cm are acceptable for a chronic lead. If the threshold is excessively high, a lead replacement is considered.l 3 The surgeon attaches a new pulse generator to the pacemaker lead and inserts the generator into the pocket. Using reabsorbable sutures, he or she closes the pacemaker capsule, subcutaneous layers, and skin. Dressings are placed over the incision and the patient is transported to the postanesthesia care unit (PACU). The circulating nurse completes the surgical data sheet and notes data the pacemaker manufacturer has supplied. He or she also notes the location of the pulse generator, programmed mode rate, atrioventricular delay, and the stimulation threshold (Fig 3). A copy of the surgical sheet is inserted in the patient’s chart, and another copy is sent to the pacemaker manufacturer. At this time, the nurse also fills out the warranty form for the new battery.
Postoperative Care
I
n the PACU, the nurse monitors the patient’s vital signs and heart rhythms. The patient is ready for discharge as soon as he or she has stable vital signs, is able to void, and is oriented to time, place, and person. The patient must be able to stand without dizziness or nausea and must be able walk. Before discharge, the nurse checks the patient’s dressing for drainage and provides assistance and reassurance. Written discharge instructions including pain or reactive medications prescribed by the surgeon are given to the patient. The patient also is given the set rate of the pacemaker and phone numbers of the hospital, clinic, or surgeon. Patient education in the follow-up treatment of patients with pacemakers is crucial to adequate follow-up and patient understanding of the functions and limitations of the pacing device. (See “Protecting Pacemakers from Electromagnetic Interference.”) Wound care. The patient assesses the wound and reports any signs or symptoms of infection around the incision (eg, redness, tenderness, discharge, heat) to the surgeon. Usually, the patient returns to the surgeon for one postoperative visit for wound care, and then he or she refers to the cardiologist for management care. The patient keeps the incision clean and dry and avoids taking showers until healing is 737
AOR 4 J 0 (1 R h A L -______
OCTOBER 1988, VOL 48, NO 4
Protecting Pacemakers from Electromagnetic Interference Electromagnetic interference (EMI) is any electromagnetic disturbance, emission, or signal that causes a compromise in normal pacemaker function. Conducted interference can cause permanent pacemaker damage when a person has accidental physical contact with an uninsulated electrical wire, electrocautery, or electrical cardioversion. Radiated interference occurs when an electrical device produces an electromagnetic field. The patient only has to come in contact with the electromagnetic field, not the source of the interference. Sources of interferences include: magnets-can cause pacemakers to revert to a fixed-rate mode, magnetic resonance imaging-may cause the pacemaker to convert to a fixed-rate mode or false inhibition, x-rays-may cause pulse generator complementary metal-oxide semiconduccomplete; tub baths are acceptable. He or she should not wear tight-fitting clothing (eg, bras) around the area of pacemaker implantation until the wound has healed. The patient cannot manipulate the area around the pulse generator because it may malfunction. Activity. The patient should not move his or her arms and shoulders vigorously or lift weights greater than five to 10 pounds because such activity may cause the pacemaker to dislodge. After six weeks, normal activities can be resumed. Medication. The patient receives written information regarding medication, dosage, and schedule. The nurse or physician discusses with the patient and the family the purpose and possible side effects of the prescribed medications. Identification. The patient wears a special identification bracelet and card that lists his or her pacemaker type, rate, physician’s name, and address of the hospital where the pacemaker was inserted.
tor chips (used most commonly in modern pacemakers) to malfunction, and electrocautery-can cause the pacemaker to convert to an synchronous mode. See physicians’ manuals for list of sources that manufacturers consider to be potential hazards for each model. Ways of protecting the patient from EM1 include: placing the electrocautery current pathway perpendicular to the pacemaker and lead and putting the electrosurgical dispersive pad so that the current flows away from the pulse generator and as close as possible to the active electrocautery tip, using triggered or synchronous mode of demand pacing, educating the patient to move away from the source when he or she feels tachycardia caused by the demand pacing, and shielding the pulse generator with titanium metal.
Pacemaker management. The patient takes his or her pulse daily and notifies the cardiologist if the pulse is slower than the set rate or if there is any increase in palpitations, vertigo, or syncope. The patient should avoid: areas with high voltage, magnetic fields or radiation, large running gas or electric motors. Riding in a car is safe, but the patient with the pacemaker should not come within six to 12 inches of the distributor and coil of a running engine,I4 standing near high-tension wires, power plants, large industrial magnets, and arc welding machines, activities than can produce blunt trauma over the pulse generator such as football or firing a rifle with the butt-end against the affected shoulder, and antitheft devices in stores. If radiation therapy has been prescribed to the
OCTOBER 1988, VOL. 48, NO 4
area in which the pulse generator was implanted, the pulse generator must be relocated. If dizziness occurs, the patient should move five to 10 feet away from the suspected source and check his or her pulse. The pulse should return to normal.
Conclusion
T
he nurse stresses the importance of regular physician or clinic visits for evaluation of pacemaker function and possible reprogramming. He or she also discusses the availability of telephone evaluation on an outpatient basis. Telephone check-up is especially helpful for the elderly or for people who have to travel long distances to pacemaker clinics. The patient should be reassured that telephone checks do not use power from the pacemaker generator. Telephone monitoring may not be covered by third-party payers. 0 Notes 1. H W Moses et al, “Indications for pacing,” in A Practical Guide to Cardiac Pacing, first ed (Boston: Little, Brown and Co, 1983) 1. 2. R Elmquist, A Senning, “An implantable pacemaker for the heart,” Proceedings of the Second International Conference of Medical-Electrical Engineers (London: Iliffe and Sons, Ltd, 1959). 3. M Marmulstein, M A Papp, “A clinical approach to pacemaker identification and follow-up,” Comprehensive Therapy 13 (April 1987) 19-25. 4. R G Hauser et al, “Twelve years of clinical experience with lithium pulse generators,” Pacing and ClinicalElectrophysiology (PACE) 9 (November 1986) 1277-1281, 5. 1987 Annual Report (Minneapolis: Medtronic, Inc, 1987). 6. Ibid. 7. Ibid. 8. Ibid. 9. Medtronic Currents:An Overview of Pacing, third ed (Minneapolis: Medtronics, Inc, 1979) 60, 77. 10. Moses et al, A Practical Guide to Cardiac Pacing. 11. L R Klein, “Temporary AV sequential pacing,” Critical Care Nurse 3 (May/June 1983) 36-41. 12. S Wingage, “Levels of pacemaker acceptance by patients,” Heart & Lung: The Journal of Critical Care 15 (January 1986) 93-100. 13. A G Tilkian, E K Daily, Cardiovascular Procedures: Diagnostic Technique and Therapeutic Procedures (St Louis: C V Mosby Co, 1986) 304-305.
AORN J O U R N A L
14. Cordis Sequicor III Manual (Miami: The Cordis Corp, 1983) 46. Suggested reading Domino, K B; Smith T C. “Electrocautery-induced reprogramming of a pacemaker using a precordial magnet.” Anesthesia and Analgesia 62 (June 1983) 609-612. Erlebacher, J A, et al. “Effect of magnetic resonance imaging on DDD pacemakers.” American Journal of Cardiologv 57 (Feb 15, 1986) 437-440. Fetter, J, et al. “The effects of nuclear magnetic resonance imagers on external and implantable pulse generators.” Pacing and Clinical Electrophysiology (PACE) 7 (July 1984) 720-727. Finkelmeier, B A; Salinger, M H. “Dual-chamber cardiac pacing: An overview.” Critical Care Nurse 6 (September/October 1986) 12-18. Katzenberg, C A, et al. “Pacemaker failure due to radiation therapy.” Pacing and Clinical Electrophysiology (PACE) 5 (March 1982) 156-159. Pourhamidi, A H. “Radiation effect on implanted pacemakers.” Chest 84 (October 1983) 499-500. Quertermous, T, et al. “Pacemaker failure resulting from radiation damage.” Radiology 148 (July 1983) 257258. Sager D. “Current facts on pacemaker electromagnetic interference and their application to clinical care.” Heart& Lung 16 (March 1987) 211,213,216. Serwer, G A; Mericle, J M. “Evaluation of pacemaker generator and patient longevity in patients aged I day to 20 years,” American Journal of Cardiology 59 (April 1, 1987) 824-827. Zimmerman, B H; Faul, D D. “Artifacts and hazards in NMR imaging due to metal implants and cardiac pacemakers.” Diagnostic Imaging in Clinical Medicine 53( 1) (1984) 53-56.
739
GCTOBER 1988, VOL. 48, NO 4
Pacemaker Battery Change AN OUTPATIENT PROCEDURE Mariece Huffman, RN
T
he most common indication for a permanent pacemaker is complete heart block, which has causes including sick sinus syndrome, Stokes-Adams syndrome, trauma, surgery, and myocardial infarction. Another indication is certain rapid dysrhythmias, but pacemakers usually are inserted for people whose heart rates are too slow to maintain an adequate cardiac output. Slow cardiac output may be demonstrated by fainting, dizziness, or fluid accumulation (eg, swollen ankles).' A permanent pacemaker system consists of a power source called the pulse generator,which houses the battery, circuitry electrodes that deliver an electrical impulse to the myocardium, and a lead that connects to the generator and electrodes (Fig 1). Pacemaker activity (firing) is indicated on the electrocardiogram(ECG) by a pacemaker spike. Elective battery (ie, pulse generator) replacement is a relatively simple procedure and can be performed on an outpatient basis. Battery depletion is the most frequent indication for battery replacement, but lead problems and pacemaker erosion or infection also can lead to reoperation. This article describes the development of pacemakers, the technique for battery replacement, and perioperative nursing care of the patient.
including atrial and ventricular pacing, atrioventricular sequencing, hysteresis, rate smoothing, overdrive suppression, and defibrillation.3 When the first artificial pacemakers were developed in the early 1950s, the mercuric-oxide batteries that operated them had to be replaced every 18 to 36 months; the battery was not reliable and did not achieve the longevity that was expected. The need for frequent replacement increased the cost of pacemakers, added significantly to morbidity, and increased the psychological burden of frequent clinical visits and hospitalization! In the 197Os, lightweight lithium batteries were developed for use in pacemakers. The pulse generator battery is a hermetically sealed metal
History
Mariece Huffman, RN, CNOR, is a clinician III, cardiac unit, Fairfax Hospital, Falls Church, Va She received her nursing diploma from Barnes Hospital School of Nursing, St Louk. The author acknowledges Patricia C. Seifert, RN,MSN, CNOR; Pat Casey, RN,MSN CCRN; and Sharon Thiebautfor their assistance.
T
he first artificial pacemaker was implanted in Stockholm in 1958 by R Elmquist and A Senning.2 Since its clinical introduction in the early 1950s, the cardiac pacemaker has been updated with many complex functions,
733
_ 4 0 K h JOL _K h A L _
~~
~
~
~
~
OCTOBER 1988. VOL 48. NO 4
-
Fig 1. Typical pacemaker pulse generator with ventricular lead attached. (Phofograph courtesy of Medtronic, Inc, MinncJapolis)
container and weighs approximately 25 to SO grams. These batteries last eight to 12 years. substantially reducing the frequency of battery replacement. In 1987, approximatelq 275,000 pacemakers were implanted worldwide. an increase of 35 over 1 986.5There are now more than 1 million people with pacemakers. The worldwide sales of pacemakers is estimated at approximately $1 billion (Fig 2).h Approximately 85,000 new single-chamber (ventricular) pacemakers are implanted in the United States each year, or about one in every 3,000 people.; Dual-chamber (atrial/ventricular) pacemakers currently make up approximately 20% to 259; of sales in the United States.h Atrial and ventricular 7
.u
electrodes are capable of sensing and pacing in either or both chambers. The most important advantage of a dual-chamber system is its ability to maintain the normal atrioventricular sequence of the electrical depolarization in the heart.
Assessing the Need for Battery Change
W
hen the pulse generator is near depletion, the patient’s heart rate will decrease and his or her pulse width as seen on the ECG will increase. Each change occurs gradually and s i m u l t a n e ~ u s l y . The ~ increased pulse width offsets the reduced battery voltage, thus keeping total energy output relatively constant. When the voltage in a lithium battery
OCTOBFR I Y X 8 , VOI.. 48, NO 4
AORN J O U R N A L
-pack'g
Total $1.9 6dfion 1987
Fig 2. Chart of 1987 expenditures of cardiovascular devices. Slightly more than half of the $1.9 billion expenditure are for pacing systems. (Adapted from 1987 Medtronic Annual Report, with permission from Medtronic, Inc, Minneapolis) drops to a certain point, the pacemaker automatically decreases the rate of stimulation by five to 10 beats per minute.'" Computers also help monitor rate change. A printout is sent to each physician at regular intervals. Physicians and nurses should note that the height of the pacer spike is not a reliable indicator of battery power." Transmitters are routinely given to patients at the time their pacemakers are implanted. When the transmitter is used, the heart's electrical impulses are converted to electronic signals that can be transmitted over the telephone. A receiver records the patient's ECG. Many models incorporate a switch that is activated by placing a magnet on the skin over the pulse generator. The magnet puts the pacemaker in the fixed-rate mode, so that the pulse rate will reflect pacemaker function. Because the postimplantation period is unpredictable, frequent telephone transmissions are recorded, initially as often as every week and later about once every three months.
Preoperative Care
A
pacemaker can be viewed as an artificial organ, but unlike an artificial limb, the pacemaker controls function of the patient rather than the patient controlling it. A study conducted on pacemaker acceptance by patients, however, found that patients accepted their loss and did not perceive themselves as disabled.l? Speculation about possible factors affecting acceptance revealed that these patients received their follow-up care in a pacemaker clinic where ongoing professional treatment, education, and support were provided. The major implication from this study is that nurses should treat patients with pacemakers individually. Factors that may affect the patient's acceptance of the pacemaker should be considered including a patient's support system, environment, or socioeconomic status. At Fairfax Hospital, Falls Church, Va. patient assessment and teaching are done by an RN when 735
AORh JOIlRhAL. -~
.
.
OCTOBER -~
1988, VOL 48. NO 4
~
Although the patient is awake throughout the procedure, he or she will not feel pain, only some pressure.
the patient comes in for blood work and x-rays. After introducing himself or herself to the patient and/or family members, the nurse conducts an interview with the patient to obtain medical history, current drug therapies, and history of allergies. The nurse assesses the patient’s and the family’s understanding of the procedure and educates them about battery replacement. Instructions given to the patient include: being NPO after midnight. arriving at the hospital one hour before the procedure, wearing comfortable clothes and shoes. avoiding wearing makeup. nail polish or jewelry, and having an escort who is available to stay with him or her for 24 hours. On the day of surgery, a nurse completes an outpatient checklist and collects data from the patient’s chart such as results from the laboratory. the physical examination, and ECG. The nurse also notes whether an x-ray confirming lead position has been taken. After helping the patient change into appropriate surgical attire, the nurse administers preoperative medication. Anesthesia personnel start an intravenous line and monitor the patient’s blood prcssure and heart rate during the surgery. Before the patient is called for surgery, the scrub nurse and the circulating nurse prepare the OR by providing a sterile setup. This includes a minor setup. local anesthesia of the surgeon’s choice. and a pulse generator for replacement. Equipment to monitor the patient’s ECG and blood pressure as well as fluoroscopy equipment are placed in the OR before the procedure begins. There should be supplies for administering oxygen, equipment for intubation and ventilation, an emergency drug cart. and a defibrillator available in case of an emergency. At some hospitals. a pacemaker sales representative supplies equipment such as sterile ventricular and atrial leads, guide wires, alligator cables, and a pacemaker system analysis (PSA). He o r she acts as a troubleshooter, operating the 736
PSA during threshold analysis. If the equipment is not provided in this manner, then it must be obtained from the company and kept in stock at the hospital with hospital personnel available to operate the PSA during evaluation of pacing and sensing thresholds.
Intraoperative Procedure
T
he circulating nurse escorts the patient into the OR and assists him or her onto the OR bed. Equipment for continuous ECG and blood pressure monitoring are placed on the patient, who will be monitored during the procedure by the registered nurse or anesthesia personnel. The OR should be kept as quiet as possible to keep the patient’s anxiety at a minimum and to enhance the effectiveness of the preoperative medication. Either the circulating nurse or anesthesia personnel are available at all times during the procedure to answer questions and reassure the patient and make him or her more comfortable by placing a pillow under the knees or head. Because the OR is kept cool, the nurse may cover the patient with a blanket. The patient’s hands are restrained during surgery to protect the sterile field. The circulating nurse preps an area from the patient’s mid-chest to the midaxillary line and from the jaw to the costal margin. This includes shaving the chest (if ordered by the physician) and applying a germicidal solution. Skin electrodes should not be placed near the pacemaker site. After the patient is prepped, the scrub nurse and the surgeon drape the perimeters of the sterile field with sterile towels and cover the field with sterile impervious drapes. The surgeon administers local anesthesia at the incision site. Although the patient is awake throughout the procedure, he or she will not feel pain, only some pressure. The surgeon makes the new incision imme-
OCTOBER 1988, VOL. 48,NO 4
AORN JOURNAL
Rate 89.8 Int 667
Fig 3. An electrocardiogram strip showing a heart rate of 89 in a patient with a ventricular pacemaker in place.
diately over the previous incision. The pacemaker should be gently pushed cephalad so that the body of the pacemaker, with no intervening lead, is directly under the incision. He or she must take care not to cut the lead. A fibrous sheath will have formed around the pacemaker. The old pacemaker is passed through the incision and disconnected from the lead. The surgeon tests the lead by using alligator cables as done at the time of the initial implant. Stimulation thresholds less than 2 cm are acceptable for a chronic lead. If the threshold is excessively high, a lead replacement is considered.l 3 The surgeon attaches a new pulse generator to the pacemaker lead and inserts the generator into the pocket. Using reabsorbable sutures, he or she closes the pacemaker capsule, subcutaneous layers, and skin. Dressings are placed over the incision and the patient is transported to the postanesthesia care unit (PACU). The circulating nurse completes the surgical data sheet and notes data the pacemaker manufacturer has supplied. He or she also notes the location of the pulse generator, programmed mode rate, atrioventricular delay, and the stimulation threshold (Fig 3). A copy of the surgical sheet is inserted in the patient’s chart, and another copy is sent to the pacemaker manufacturer. At this time, the nurse also fills out the warranty form for the new battery.
Postoperative Care
I
n the PACU, the nurse monitors the patient’s vital signs and heart rhythms. The patient is ready for discharge as soon as he or she has stable vital signs, is able to void, and is oriented to time, place, and person. The patient must be able to stand without dizziness or nausea and must be able walk. Before discharge, the nurse checks the patient’s dressing for drainage and provides assistance and reassurance. Written discharge instructions including pain or reactive medications prescribed by the surgeon are given to the patient. The patient also is given the set rate of the pacemaker and phone numbers of the hospital, clinic, or surgeon. Patient education in the follow-up treatment of patients with pacemakers is crucial to adequate follow-up and patient understanding of the functions and limitations of the pacing device. (See “Protecting Pacemakers from Electromagnetic Interference.”) Wound care. The patient assesses the wound and reports any signs or symptoms of infection around the incision (eg, redness, tenderness, discharge, heat) to the surgeon. Usually, the patient returns to the surgeon for one postoperative visit for wound care, and then he or she refers to the cardiologist for management care. The patient keeps the incision clean and dry and avoids taking showers until healing is 737
AOR 4 J 0 (1 R h A L -______
OCTOBER 1988, VOL 48, NO 4
Protecting Pacemakers from Electromagnetic Interference Electromagnetic interference (EMI) is any electromagnetic disturbance, emission, or signal that causes a compromise in normal pacemaker function. Conducted interference can cause permanent pacemaker damage when a person has accidental physical contact with an uninsulated electrical wire, electrocautery, or electrical cardioversion. Radiated interference occurs when an electrical device produces an electromagnetic field. The patient only has to come in contact with the electromagnetic field, not the source of the interference. Sources of interferences include: magnets-can cause pacemakers to revert to a fixed-rate mode, magnetic resonance imaging-may cause the pacemaker to convert to a fixed-rate mode or false inhibition, x-rays-may cause pulse generator complementary metal-oxide semiconduccomplete; tub baths are acceptable. He or she should not wear tight-fitting clothing (eg, bras) around the area of pacemaker implantation until the wound has healed. The patient cannot manipulate the area around the pulse generator because it may malfunction. Activity. The patient should not move his or her arms and shoulders vigorously or lift weights greater than five to 10 pounds because such activity may cause the pacemaker to dislodge. After six weeks, normal activities can be resumed. Medication. The patient receives written information regarding medication, dosage, and schedule. The nurse or physician discusses with the patient and the family the purpose and possible side effects of the prescribed medications. Identification. The patient wears a special identification bracelet and card that lists his or her pacemaker type, rate, physician’s name, and address of the hospital where the pacemaker was inserted.
tor chips (used most commonly in modern pacemakers) to malfunction, and electrocautery-can cause the pacemaker to convert to an synchronous mode. See physicians’ manuals for list of sources that manufacturers consider to be potential hazards for each model. Ways of protecting the patient from EM1 include: placing the electrocautery current pathway perpendicular to the pacemaker and lead and putting the electrosurgical dispersive pad so that the current flows away from the pulse generator and as close as possible to the active electrocautery tip, using triggered or synchronous mode of demand pacing, educating the patient to move away from the source when he or she feels tachycardia caused by the demand pacing, and shielding the pulse generator with titanium metal.
Pacemaker management. The patient takes his or her pulse daily and notifies the cardiologist if the pulse is slower than the set rate or if there is any increase in palpitations, vertigo, or syncope. The patient should avoid: areas with high voltage, magnetic fields or radiation, large running gas or electric motors. Riding in a car is safe, but the patient with the pacemaker should not come within six to 12 inches of the distributor and coil of a running engine,I4 standing near high-tension wires, power plants, large industrial magnets, and arc welding machines, activities than can produce blunt trauma over the pulse generator such as football or firing a rifle with the butt-end against the affected shoulder, and antitheft devices in stores. If radiation therapy has been prescribed to the
OCTOBER 1988, VOL. 48, NO 4
area in which the pulse generator was implanted, the pulse generator must be relocated. If dizziness occurs, the patient should move five to 10 feet away from the suspected source and check his or her pulse. The pulse should return to normal.
Conclusion
T
he nurse stresses the importance of regular physician or clinic visits for evaluation of pacemaker function and possible reprogramming. He or she also discusses the availability of telephone evaluation on an outpatient basis. Telephone check-up is especially helpful for the elderly or for people who have to travel long distances to pacemaker clinics. The patient should be reassured that telephone checks do not use power from the pacemaker generator. Telephone monitoring may not be covered by third-party payers. 0 Notes 1. H W Moses et al, “Indications for pacing,” in A Practical Guide to Cardiac Pacing, first ed (Boston: Little, Brown and Co, 1983) 1. 2. R Elmquist, A Senning, “An implantable pacemaker for the heart,” Proceedings of the Second International Conference of Medical-Electrical Engineers (London: Iliffe and Sons, Ltd, 1959). 3. M Marmulstein, M A Papp, “A clinical approach to pacemaker identification and follow-up,” Comprehensive Therapy 13 (April 1987) 19-25. 4. R G Hauser et al, “Twelve years of clinical experience with lithium pulse generators,” Pacing and ClinicalElectrophysiology (PACE) 9 (November 1986) 1277-1281, 5. 1987 Annual Report (Minneapolis: Medtronic, Inc, 1987). 6. Ibid. 7. Ibid. 8. Ibid. 9. Medtronic Currents:An Overview of Pacing, third ed (Minneapolis: Medtronics, Inc, 1979) 60, 77. 10. Moses et al, A Practical Guide to Cardiac Pacing. 11. L R Klein, “Temporary AV sequential pacing,” Critical Care Nurse 3 (May/June 1983) 36-41. 12. S Wingage, “Levels of pacemaker acceptance by patients,” Heart & Lung: The Journal of Critical Care 15 (January 1986) 93-100. 13. A G Tilkian, E K Daily, Cardiovascular Procedures: Diagnostic Technique and Therapeutic Procedures (St Louis: C V Mosby Co, 1986) 304-305.
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14. Cordis Sequicor III Manual (Miami: The Cordis Corp, 1983) 46. Suggested reading Domino, K B; Smith T C. “Electrocautery-induced reprogramming of a pacemaker using a precordial magnet.” Anesthesia and Analgesia 62 (June 1983) 609-612. Erlebacher, J A, et al. “Effect of magnetic resonance imaging on DDD pacemakers.” American Journal of Cardiologv 57 (Feb 15, 1986) 437-440. Fetter, J, et al. “The effects of nuclear magnetic resonance imagers on external and implantable pulse generators.” Pacing and Clinical Electrophysiology (PACE) 7 (July 1984) 720-727. Finkelmeier, B A; Salinger, M H. “Dual-chamber cardiac pacing: An overview.” Critical Care Nurse 6 (September/October 1986) 12-18. Katzenberg, C A, et al. “Pacemaker failure due to radiation therapy.” Pacing and Clinical Electrophysiology (PACE) 5 (March 1982) 156-159. Pourhamidi, A H. “Radiation effect on implanted pacemakers.” Chest 84 (October 1983) 499-500. Quertermous, T, et al. “Pacemaker failure resulting from radiation damage.” Radiology 148 (July 1983) 257258. Sager D. “Current facts on pacemaker electromagnetic interference and their application to clinical care.” Heart& Lung 16 (March 1987) 211,213,216. Serwer, G A; Mericle, J M. “Evaluation of pacemaker generator and patient longevity in patients aged I day to 20 years,” American Journal of Cardiology 59 (April 1, 1987) 824-827. Zimmerman, B H; Faul, D D. “Artifacts and hazards in NMR imaging due to metal implants and cardiac pacemakers.” Diagnostic Imaging in Clinical Medicine 53( 1) (1984) 53-56.
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