1. 心臟植入性電子儀器(CIED)
護理照護指引-術中護理照護
中國醫藥大學附設醫院
心臟內科
護理師 洪佩琪

2. Pacemaker 術前準備
•核對病人 檢查同意書
•Check 前一天抽血 data
•術前一小時給予Cefazolin and
Gentamycin
•3 lead ECG monitor/recorder
•TCP
•Vital sign
•O2

3. 準備用物

5. 生理系統監視儀

8. Subclavian Vein
vs.
Cephalic Vein
Approach

9. Access - Blood Vessels
Subclavian
Artery Subclavian
Vein
Cephalic
Vein
Aorta
Pulmonary
Artery
External Jugular
Internal Jugular
Superior
Vena Cava
Inferior
Vena Cava
Diaphragm
Lung

10. Cephalic Vein Approach

11. Ellenbogen KA et al. Clinical cardiac pacing, defibrillation, and resynchronization therapy 3th ed.
Cephalic Vein Approach

12. Cephalic Vein Approach

13. Subclavian Vein

14. Subclavian puncture

15. VVI upgrade to DDD

16. Access - Cardiac Chambers
Left Atrium
Mitral Valve
Aortic Valve
Left Ventricle
Right Ventricle
Tricuspid Valve
Right Atrium
Pulmonary Valve

17. Transvenous Leads
Passive fixation
(tined)
The tines become lodged in the
trabeculae of the apex or the
pectinate of the appendage
which are fibrous meshworks of
heart tissue
Active fixation (screw-in)
The helix, or screw, extends
into the endocardial tissue
– Allows for lead positioning
anywhere in the heart’s
chamber
– The helix is extended using
an included tool

18. Tined lead and Screw lead

19. Single Chamber System
• One lead
– Atrium
– Ventricle (most common)
• May be used for patients in chronic AF (VVI
pacemaker) or patients with sinus node
dysfunction and no history of AV block (AAI
pacemaker)
AAI PacemakerVVI Pacemaker

20. Dual Chamber System
• Two leads
– One lead implanted in the atrium
– One lead implanted in the ventricle
• Provides AV synchrony and pacing support in
both atrium and ventricle if needed
DDD Pacemaker

21. Dual Chamber Pacemaker
RV Lead at the Apex
RA Lead in Appendage

22. Triple Chamber System
• Three Leads:
– Right Atrium
– Right Ventricle
– Left Ventricle (via the Coronary Sinus vein)
• Most commonly called a Bi-Ventricular Pacemaker but also called
Cardiac Resynchronization Therapy (CRT–P)
• Paces both ventricles together to “resynchronize” the beat
DDD BiV Pacemaker

23. Knowledge Checkpoint

24. 術中注意事項
• 嚴謹遵守無菌原則
• 注意vital sign

25. Programmer

26. defibrillation threshold (DFT)
testing
• Diazepam or midazolam
• TCP 200J
• Check Vital sign

27. defibrillation threshold (DFT)
testing

28. pacemaker implantation test

29. Cont/.....
• Measurements
– 1.Sensing threshold
• Amplitude (Minimum : “P” - 2mV , “R” - 5mV)
• Slew rate
Pacemaker Implantation

30. • Measurements
– 2.Pacing threshold
• (Measured amplitude at various pulse widths)
• Paced rate > = 20 ppm above spontaneous rate
• Decrement variable output : Threshold < 1V @ 0.5ms
• Impedance measurement : 300 - 1000 ohms
tined: 500-2000 ohms
Cont/.....
Pacemaker Implantation

31. Cont/.....
• Measurements
– 3.Lead stability
– 1V output, or 2X diastolic threshold (min. 1V)
– 10V output for diaphragm stimulation test
– Lead sutured in position
– Re-measure sensing / pacing characteristics
– Dual-chamber system
- Measure Retrograde Conduction Time
Pacemaker Implantation

32. Sensing
• Sensing is the ability of the pacemaker to
“see” when a natural (intrinsic)
depolarization is occurring
• Pacemakers sense cardiac depolarization by measuring
changes in electrical potential of myocardial cells between
the anode and cathode
0.5 mV signal
2.0 mV signal

33. Acceptable Sensing Values (mV)1
Acute Chronic
Atrium >1.5 >1.0
Ventricle >7.0 >5.0
Sensing
1Curtis, Anne B. (2010). Fundamentals of Cardiac Pacing. Massachusetts: Jones and Bartlett
Publishers. (pg. 98).

34. Sensitivity
Amplitude(mV)
Time
5.0
2.5
1.25

35. 1. Set RATE at least 20 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 to previous value.
Stimulation Threshold Procedure
Medtronic, Inc., Minneapolis, MN December 2007

36. Strength Duration Curve
Example
Safety Margin = 2 x Amplitude Threshold
OR
3 x Pulse Width Threshold

37. Knowledge Checkpoint
What is the threshold?
1.25 V 0.05 V0.75 V1.00 V
A. 0.05 V
B. 0.75 V
C. 1.00 V
D. 1.25 V

38. Typical Lead Impedance Range
• Most important that ead impedance is
stable over the lifetime of the device.
Typical Impedance range = 200 to 1,000 Ohms.*
*Impedance is higher for specially designed high impedance leads.
Hayes, David L., et. al. (2000). Cardiac pacing and defibrillation: a clinical approach. New York: Blackwell
Publishing. (pg. 398).

39. Programming Outputs
•Primary goal: Ensure patient safety and
appropriate device performance
•Secondary goal: Extend the service life of
the battery
–Typically program amplitude to < 2.5 V, but
always maintain adequate safety margins
–Amplitude values greater than the cell
capacity of the pacemaker battery (usually
about 2.8 V) require a voltage multiplier,
resulting in markedly decreased battery
longevity

42. 術後交班
• Pacemaker 設定
• Bed rest 12- 24 hours
•Cefazolin and Gentamycin
• Compression with 2kg sandbag over
chest wound for 2-4 hours

43. Thanks For Your Attention!