PACEMAKER

SUBMITTED TO, SUBMITTED BY,

MRS.BINDHU K SHANKAR ASWATHY R C

ASSISTANT PROFESSOR 1ST YR MSC NURSING

GOVT COLLEGE OF NURSING GOVT COLLEGE OF NURSING

THRISSUR THRISSUR
INTRODUCTION

The cardiac pacemaker is an electronic device used to pace the heart when the normal
conduction pathway is damaged or diseased. The basic pacing circuit consists of a power source
(battery-powered pulse generator), one or more conducting leads (pacing leads), and the
myocardium. The electrical signal (stimulus) travels from the pacemaker, through the leads, to
the wall of the myocardium. The myocardium is "captured and stimulated to contract. Recent
advances in technology have been applied extensively to pacemakers. This has resulted in
sophisticated, non-invasive programmable single- and dual-chambered pacemakers with
specialized circuits. Pacemakers have been developed that are more physiologically accurate,
pacing the atrium and one or both of the ventricles." Pacemakers were initially indicated for
symptomatic brady dysrhythmias. However, advances now include tachycardia and overdrive
pacing. Tachycardia pacing involves the delivery of a stimulus to the ventricle to terminate
tachydysrhythmias (e.g., VT). Overdrive pacing involves pacing the atrium at rates of 200 to
500 impulses per minute in an attempt to terminate atrial tachycardia (e.g., atrial flutter, atrial
fibrillation). Multiple other indications for pacemakers have evolved.

PACEMAKER

DEFINITION

“A cardiac pacemaker is an electronic device used to pace the heart when the normal
conduction pathway is damaged or diseased.”

“A pacemaker is an electrically charged medical device which is implanted under the skin to
help manage irregular heartbeats called arrhythmias.”
HISTORY

In 1889, John Alexander MacWilliam reported in the British Medical Journal (BMJ) of his
experiments in which application of an electrical impulse to the human heart in asystole caused
a ventricular contraction and that a heart rhythm of 60–70 beats per minute could be evoked by
impulses applied at spacings equal to 60–70/minute.

In 1926, Mark C Lidwill devised a portable apparatus which "plugged into a lighting point"
and in which "One pole was applied to a skin pad soaked in strong salt solution" while the other
pole "consisted of a needle insulated and was plunged into the appropriate cardiac chamber".
"The pacemaker rate was variable from about 80 to 120 pulses per minute, and likewise the
voltage variable from 1.5 to 120 volts". In 1928, the apparatus was used to revive
a stillborn infant at Crown Street Women's Hospital, Sydney whose heart continued "to beat
on its own accordingly", "at the end of 10 minutes" of stimulation.

In 1932, American physiologist Albert Hyman described an electro-mechanical instrument of

his own, powered by a spring-wound hand-cranked motor. Hyman himself referred to his
invention as an "artificial pacemaker", the term continuing in use to this day.

Transcutaneous

In 1950 John Hopps designed and built the first external pacemaker . A substantial external
device using vacuum tube technology to provide transcutaneous pacing, it was somewhat
crude and painful to the patient in use and, being powered from an AC wall socket, carried a
potential hazard of electrocution of the patient and inducing ventricular fibrillation.

The development of the silicon transistor and its first commercial availability in 1956 was the
pivotal event that led to rapid development of practical cardiac pacemaking.

Wearable

In 1958, Earl Bakken produced the first wearable external pacemaker. This transistorized
pacemaker, housed in a small plastic box, had controls to permit adjustment of pacing heart
rate and output voltage and was connected to electrode leads which passed through the skin of
the patient to terminate in electrodes attached to the surface of the myocardium of the heart.

The early Swedish-designed devices used rechargeable batteries, which were charged by an
induction coil from the outside. It was the first pacemaker implanted in America.
Transvenous

Transvenous catheter pacing was introduced by S. Furman in 1958. Transvenous pacing, in

which the electrode is passed down a vein to the interior of the heart, permitted the development
of intracardiac diagnosis of arrythmias. This was an important step towards the implantable
pacemaker. The first use of transvenous pacing , procedure involved incision of a vein into
which was inserted the catheter electrode lead under fluoroscopic guidance, until it was lodged
within the trabeculae of the right ventricle. This method was to become the method of choice
by the mid-1960s.

Lithium battery

The preceding implantable devices all suffered from the unreliability and short lifetime of the
available primary cell technology which was mainly that of the mercury battery. Development
in 1971 of the lithium iodide cell battery by Wilson Greatbatch. Lithium-iodide or lithium
anode cells became the standard for future pacemaker designs.

On July 9, 1974, Manuel A. Villafaña and Anthony Adducci founders of Cardiac Pacemakers,
Inc. (Guidant) in St. Paul, Minnesota, manufactured the world's first pacemaker with a lithium
anode and a lithium-iodide electrolyte solid-state battery.

Intra-cardial

In 2013, multiple firms announced devices that could be inserted via a leg catheter rather than
invasive surgery. The devices are roughly the size and shape of a pill, much smaller than the
size of a traditional pacemaker. Once implanted, the device's prongs contact the muscle and
stabilize heartbeats

Reusable pacemakers

Thousands of pacemakers are removed by funeral home personnel each year all over the world.
They have to be removed post-mortem from bodies that are going to be cremated to avoid
explosions. It is a fairly simple procedure that can be carried out by a mortician. Pacemakers
with significant battery life are potentially life-saving devices for people in low and middle
income countries .
DEVELOPMENT OF PACEMAKER

The development of the artificial pacemaker began in the early 20th century. In France, M.
Marmorstein first stimulated the sinoatrial node and the right and left ventricles in dogs in
1927.An Australian physician, Mark Lidwill, along with physicist Edgar Booth, built a portable
pace making unit in 1931.

The First Implantable Pacemakers

Since Hyman, pacemaker technology has dramatically evolved to correct the limitations of his
original device to develop a more practical and less painful implantable pacemaker. The first
attempts to create an implantable pacemaker occurred in 1958 in Sweden by Ake Senning and
Rune Elmqvist. In their design, silicon transistors were used to generate a pulse within a device
that was small enough to be placed in the epigastrium under the skin. Arne Larsson, a 43-year-
old man, was the first patient to have this device implanted. Since a nickel-cadmium battery
powered this early pacemaker device, it had a limited lifespan. By the end of Larsson’s life at
86 years old, he had received a total of 26 different pacemakers.

In 1960, American scientist Wilson Greatbatch and cardiologist William Chardack developed
a novel implantable pacemaker device that was instead powered by zinc-mercuric oxide battery
cells. The lithium battery was encapsulated in epoxy to provide a 17-year long battery life,
which significantly improved the longevity of the implantable pacemaker as compared to
Senning and Elmqvist’s device.

Greatbatch’s implantable pacemaker was designed to treat patients diagnosed with complete
atria-ventricular heart block. The pacemaker circuit was designed to generate an electrical
impulse with a repetition rate of 60 beats per minute, which mimicked the natural rhythmical
heartbeat that typically ranges between 60 and 100 beats per minute. Their cardiac pacemaker
was comprised of a blocking oscillator that created an electrical wave, whereas the transistor
to the blocking oscillator is used throughout the pulse sent to the heart muscles. During the
time in which a pulse is generated, a voltage is applied to switch on the oscillator, which then
allows the pulse to make contact with the transistor and ultimately increase the electrical
current of the heart.
Heart beats

The heart is a muscular, fist-sized pump with four chambers, two on the left side and two on
the right. The upper chambers (right and left atria) and the lower chambers (right and left
ventricles) work with your heart's electrical system to keep your heart beating at an appropriate
rate usually 60 to 100 beats a minute for adults at rest.

The heart's electrical system controls heartbeat, beginning in a group of cells at the top of the
heart (sinus node) and spreading to the bottom, causing it to contract and pump blood. Aging,
heart muscle damage from a heart attack, some medications and certain genetic defects can
cause an abnormal heart rhythm.

Importance of pacemaker

 Pacemakers are implanted to help control your heartbeat.

 They can be implanted temporarily to treat a slow heartbeat after a heart attack, surgery
or medication overdose.

 They can be implanted permanently to correct a slow or irregular heartbeat or, in some
people, to help treat heart failure.

PACEMAKER DESIGN

An implanted electronic pacemaker mimics the action of your natural electrical system. A
pacemaker comprises two parts:

 Pulse generator. This small metal container houses a battery and the electrical
circuitry that regulates the rate of electrical pulses sent to your heart.

 Leads (electrodes). One to three flexible, insulated wires are each placed in a
chamber, or chambers, of your heart and deliver the electrical pulses to adjust
your heart rate.

Pacemakers work only when needed. If heartbeat is too slow (bradycardia), the pacemaker
sends electrical signals to the heart to correct the beat.
Also, newer pacemakers have sensors that detect body motion or breathing rate, which signal
the pacemakers to increase heart rate during exercise, as needed.

TYPES OF PACEMAKERS

1.PERMANENT PACEMAKER

A permanent pacemaker is one that is implanted totally within the body. The permanent
pacemaker power source is implanted subcutaneously, usually over the pectoral muscle on the
patient's nondominant side. It is attached to pacing leads, which is threaded trans venously to
the right atrium and one or both ventricles. A specialized type of cardiac pacing has been
developed for the management of Heart Failure. More than 50% of HF patients have
intravenous secular conduction delays causing abnormal ventricular activation and contraction
and subsequent desynchrony between the right and left ventricles. This can result in reduced
systolic function, pump inefficiency, and worsened HF. Cardiac resynchronization therapy
(CRT) is a pacing technique that resynchronizes the cardiac cycle by pacing both ventricles,
thus promoting improvement in ventricular function. Several devices are available that have
combined CRT with an ICD for maximum therapy.

There are three basic types of permanent pacemakers, classified according to the number
of chambers involved and their basic operating mechanism.

 Single chamber pacemaker. This type usually carries electrical impulses to the right
ventricle of your heart.
 Dual chamber pacemaker. This type carries electrical impulses to the right ventricle
and the right atrium of your heart to help control the timing of contractions between the
two chambers.
 Rate responsive pacemaker: This pacemaker has sensors that detect changes in the
patients physical activity and automatically adjust the pacing rate to fullfill the body’s
metabolic needs.
 Biventricular pacemaker. Biventricular pacing, also called cardiac resynchronization
therapy, is for people with heart failure with abnormal electrical systems. This type of
pacemaker stimulates the lower chambers of the heart (the right and left ventricles) to
make the heart beat more efficiently
INDICATIONS FOR PERMANENT PACEMAKER THERAPY

 Acquired AV block
 Second-degree AV block
 Third-degree AV block
 Bundle branch block
 Cardiomyopathy
 Dilated
 Hypertrophic
 Heart failure
 Hypersensitive carotid sinus syndrome
 SA node dysfunction
 Tachydysrhythmias

2.TEMPORARY PACEMAKER.

The pulse generator remains outside the body and the electrical stimulation is conveyed to the
heart through the pacing catheter. The external pacemaker are always temporary pacemaker.

There are three types of temporary pacemakers: transvenous, epicardial, and

transcutaneous.

1.TRANSVENOUS PACEMAKER:

A transvenous pacemaker consists of a lead or leads that are threaded trans venously to the
right atrium and/or right ventricle and attached to the external power source. Most temporary
transvenous pacemakers are inserted in critical care units in emergency situations. They are
used until a permanent pacemaker can be inserted or the underlying cause of the dysrhythmia
has been resolved.

2.EPICARDIAL PACEMAKER:

Epicardial pacing is achieved by attaching an atrial and ventricular pacing lead to the
epicardium during heart surgery. The leads are passed through the chest wall and attached to
the external power source.
3. TRANSCUTANEOUS PACEMAKER :

A transcutaneous pacemaker (TCP) is used to provide adequate HR and rhythm to the patient
in an emergency situation. Placement of the transcutaneous pacemaker is a non- invasive
procedure that is used temporarily until a transvenous pacemaker can be inserted or until more
definitive therapy is available. The TCP consists of a power source and a rate- and voltage
control device that is attached to two large, multifunction electrode pads. One pad is positioned
on the anterior part of the chest, usually on the V, or Vs lead position, and the other pad is
placed on the back between the spine and the left scapula at the level of the heart. Before
initiating TCP therapy, it is important to tell the patient what to expect. The uncomfortable
muscle contractions that the pacemaker creates when the current passes through the chest wall
should be explained. The patient should be reassured that the therapy is temporary and that
every effort will be made to replace the TCP with a transvenous pacemaker as soon as possible.
Whenever possible, analgesia and/or sedation should be provided.

INDICATIONS FOR TEMPORARY PACING

 Maintenance of adequate HR and rhythm during special circumstances such as surgery

and postoperative recovery
 Cardiac catheterization or coronary angioplasty
 During drug therapy that may cause bradycardia
 Before implantation of a permanent pacemaker
 As prophylaxis after open heart surgery
 Acute anterior MI with second-degree or third-degree AV block
 Bundle branch block
 Acute inferior MI with symptomatic bradycardia and AV block
 Electrophysiologic studies to evaluate patient with bradydysrhythmias and
tachydysrhythmias.
WORKING OF PACEMAKER

Pacemakers do not take over the work of the heart. Pacemaker merely helps to regulate the
timing and sequence of heartbeat.

METHOD OF PACING

1.PERCUSSIVE PACING

Ventricular contraction is achieved by means of thin wired electrodes inserted directly into the
myocardium by way of a needle introduced through the chest wall. Another electrode is placed
externally on the chest wall to complete the circuit. The major advantage of this method is the
rapidity with which the pacing can be started. Therefore, this technique is of much use in the
time of emergency. This is an old procedure used only as a life saving means until an electrical
pacemaker is brought to the patient.

2.TRANSCUTANEOUS PACING

Transcutaneous pacing also called external pacing is recommended for the initial stabilization
of hemodynamically significant bradycardias of all types. The procedure is performed by
placing two pacing pads on the patient’s chest, either in the anterior/lateral position or on the
anterior/posterior position. It act as an emergency procedure that act as a bridge until
transvenous pacing or other therapies can be applied.

3.EPICARDIAL PACING

The epicardial pacemaker leads were placed after the patient collapsed during aortic valve
surgery. Temporary epicardial pacing is used during open heart surgery. The electrodes are
placed in contact with the outer wall of the ventricle to maintain satisfactory cardiac output
until a temporary transvenous electrode has been inserted.

4.TRANSVENOUS PACING

The heart can be effectively stimulated from a small electrode placed within the right ventricle.
This pacing electrode is introduced into a superficial vein and then advanced through the vena
cava into the right atrium until it is lodged against the endocardial surface of the right ventricle.
The electrical stimulus is delivered from a small battery powered pulse generator. Transvenous
pacing is often used as a bridge to permanent pacemaker placement. It can be kept in place
until a permanent pacemaker is implanted or until there is no longer a need for a pacemaker
and then it is removed.

5.SUBCLAVIAN PACING

The pacemaker is implanted inside the skin under the clavicle. The procedure is performed by
incision of a suitable vein into which the electrode lead is inserted and passed along the
vein,through the valve of the heart until positioned in the chamber.

PACING LEADS

The pacing lead is an insulated wire used to transmit the electrical current from the pulse
generator to the myocardium

 A unipolar lead contains a single wire and a bipolar lead contains two wires that are
insulated from each other

 Fixation devices

- Permanent leads have some type of fixation device on the end of the lead that helps
to keep the tip in contact with myocardium

 Passive fixation leads usually have tines on the end that get caught in the trabeculae of
the right ventricle and keep the lead in position

 Active fixation leads have a screw on the end that is screwed into the ventricular
muscle to hold the lead in place

 Temporary transvenous pacing leads are insulated wires with no fixation device,
making them more prone to dislodgement

PACEMAKER MODES

There are two basic kinds of pacemakers:

1. Fixed-rate (non-demand or asynchronous).

Fixed rate pacemakers are designed to fire constantly as a pre-set rate without
regard to the electrical activity of the client's heart. This mode of pacing is appropriate in
 the absence of any electrical activity (asystole) but is dangerous in the presence of an
intrinsic rhythm because of the potential of the pacemaker to fire during the vulnerable
period of repolarization and initiate lethal ventricular dysrhythmias.

2. Demand pacemakers

Demand pacemakers contain a device that senses the heart's electrical activity and
fires at a present rate only when the heart's electrical activity drops below a predetermined
rate level

PARTS OF A CARDIAC PACEMAKER

The main part of an artificial pacemaker comprise a pulse generator and pacing catheter. The
parts of the cardiac pacemaker vary according to its type .

OUTPUT: This determines the current delivered to the heart to stimulate the myocardium. The
usual setting is 3-5 milliamperes. It may be increased or decreased as desired.

RATE: This setting determines the heart rate and the escape interval for the pacemaker in the
demand mode. “Escape interval” is the time limit set at which the pacemaker will fire if no
ventricular contraction occurs within that period.

SENSITIVITY: When the indicator is turned to asynchronous, the pacemaker will function in
the fixed pacing modes. When set on demand, spontaneous depolarization of ventricles will be
sensed and the pacing impulse will be inhibited suitably.

SENSE PACE: This control indicates whether the pacemaker is functioning properly or not.
Whenever the pacemaker senses ventricular depolarization, it is indicated by the flashing of a
light or by deflection of a needle indicator.

ON OFF SWITCH: This is used to turn the pacemaker on or off. It locks to prevent accidental
turnoff.

CONNECTOR TERMINALS: The pacing catheter terminals are attached here after the
electrodes are implanted in the heart.

CATHETER ELECCTODES: There are two basic types of electrodes:one with a single
electrode incorporated in the tip of the catheter and the other with two electrodes about 1 cm
apart from the distal end of the catheter. In order to stimulate the heart, the electrical impulses
from the pulse generator must flow between two poles to create an electrical circuit.

HANDLES: These can be used to strap the pacemaker to the patient’s body.

How does it work?

It replaces the heart's defective natural pacemaker functions.

 The sinoatrial (SA) node or sinus node is the heart's natural pacemaker. It's a small mass
of specialized cells in the top of the right atrium (upper chamber of the heart). It
produces the electrical impulses that cause your heart to beat.
 A chamber of the heart contracts when an electrical impulse or signal moves across it.
For the heart to beat properly, the signal must travel down a specific path to reach the
ventricles (the heart's lower chambers).
 When the heart's natural pacemaker is defective, the heartbeat may be too fast, too slow
or irregular.
 Rhythm problems also can occur because of a blockage of your heart's electrical
pathways.
 The pacemaker's pulse generator sends electrical impulses to the heart to help it pump
properly. An electrode is placed next to the heart wall and small electrical charges travel
through the wire to the heart.
 Most pacemakers have a sensing mode that inhibits the pacemaker from sending
impulses when the heartbeat is above a certain level. It allows the pacemaker to fire
when the heartbeat is too slow. These are called demand pacemakers.

PACEMAKER CODES

In order to communicate all the functions of the individual pacemakers, international

codes were developed. Pacemakers are identified with a five-digit letter code. Although the last
two letters contain pertinent information, commonly a pacemaker is referred to only by its first
three letters.

PACING CODES

1) The first letter of the code identifies the chamber or chambers being paced. The letter
characters for this code are A (atrium), V (ventricle), or D (dual, meaning both A and
V).
2) The second letter describes the chamber or chambers being sensed by the pacemaker
generator. The letter characters are A (atrium), V (ventricle), D (dual), and O (indicating
that the sensing function is turned off).

3) The third letter of the code describes the type of response by the pacemaker to what is
sensed. The possible letter characters used to describe this response are I (inhibited),
T (triggered), D (dual, inhibited and triggered), and O (none).

Inhibited response means the pacemaker will not function when the patient’s heart beats
but will pace if no beat is sensed.

Triggered response means that the pacemaker will provide a response (pace the heart)
when it senses intrinsic heart activity.

4) The fourth and fifth letters are used only with permanent pacemaker generators. The
possible letters are

M (multiprogrammability- ability to change at least three factors, such as the rate at

which pacing is initiated, the rate of pacing, and the amount of energy delivered)

C (communicative or telemetry ability; information about the generator may be

obtained)

R (rate responsive capabilities; the ability of the pacemaker to change the rate from
moment to moment based on parameters such as physical activity, acid-base changes,
temperature, rate and depth of respirations, and oxygen saturation).

5) The fifth letter of the code indicates that the permanent generator has anti-tachycardia
and/or defibrillation capability.

The possible letters are P (anti-tachycardia pacing), S (shock; defibrillation), D (dual—

anti-tachycardia pacing and shock), and O (none).
PREPARATION OF PACEMAKER

Before receiving a pacemaker, several tests are performed. These tests can ensure that a
pacemaker is the right choice for the patient.

 An echocardiogram uses sound waves to measure the size and thickness of the heart
muscle.

 For an electrocardiogram, a nurse or doctor places sensors on skin that measure the
heart’s electrical signals.

 For Holter monitoring, wear a device that tracks heart rhythm for 24 hours.

 A stress test monitors heart rate while doing exercise.

If a pacemaker is right for you, need to plan for the surgery. Your doctor will give you complete
instructions on how to prepare.

 Don’t drink or eat anything after midnight the night before your surgery.

 Follow your doctor’s instructions about which medicines to stop taking.

 If your doctor prescribes medicines for you to take before the test, take them.

 Shower and shampoo well.

How is pacemaker surgery performed?

 Implanting a pacemaker typically takes one to two hours. A sedative to relax patient
and a local anaesthetic to numb the incision site. Patient are awake during the
procedure.

 A small incision near the shoulder must be made. They’ll guide a small wire through
the incision into a major vein near your collarbone. Then the surgeon will lead the wire
through your vein to your heart. An X-ray machine will help guide the surgeon through
the process.
  Using the wire, the surgeon will attach an electrode to the heart’s right ventricle. The
ventricle is the lower chamber of the heart. The other end of the wire attaches to a pulse
generator. This contains the battery and electrical circuits.

 Surgeon will implant the generator under the skin near the collarbone.

 If getting a biventricular pacemaker, the surgeon will attach a second lead to the heart’s
right atrium, and a third lead to the left ventricle. The atrium is the upper chamber of
the heart.

 At the end, surgeon will close the incision with stitches.

What happens after pacemaker surgery?

The patient may go home that evening, or you could stay in the hospital overnight. Before
going home, doctor will make sure the pacemaker is programmed properly for the heart’s
needs.

Over the next month, avoid rigorous exercise and heavy lifting. May also need to take over-
the-counter medications for any discomfort.

Every few months, hook your pacemaker up to a phone line using special equipment provided
by doctor. It allows doctor to receive information from pacemaker without the need for an
office visit.

Modern pacemakers are not as sensitive to electrical devices as the old ones, but certain devices
could cause interference with your pacemaker. For example, you should avoid:

 keeping a cell phone or MP3 player in the pocket over your pacemaker

 standing for too long near certain appliances, such as microwaves

 long exposures to metal detectors

 high-voltage transformers
Electrocardiography of Paced Beats

The ECG appearance of a paced rhythm differs from that of a normal sinus rhythm, A
pacing artifact is seen. With atrial pacing, a P wave follows the artifact but may be hidden in
some leads. Examination of leads II and V, is best for deciding whether a P wave follows a
pacer spike. The QRS complex appears normal with atrial pacing; the impulse travels through
usual conduction systems. The ECG with ventricular pacing shows an abnormal QRS complex
because the impulse begins in the ventricle. With right ventricular endocardial pacing, a
pseudo- LBBB ECG wave is created. If the left ventricle is paced, a pseudo-RBBB is created.

Assess the ECG strip for pacer spikes followed by the expected appearance of a P wave
or QRS complex. Spikes not followed by depolarization waves or paced beats that appear too
early or too late may signal pacemaker failure.

Pacemaker Failure

1. Failure to sense: An inability of the sensor to detect the client's intrinsic beats; as a result,
the pacemaker sends out impulses too early. The failure may be due to improper position of
the catheter, tip or lead dislodgment, battery failure, the sensitivity set too low, or a fractured
wire in the catheter.

2. Failure to pace: A malfunction of the pulse generator. The ECG shows an absence of any
impulse. Component failure to discharge (pace) can be due to battery failure, lead dislodg-
ment, fracture of the lead wire inside the catheter, disconnections between catheter and
generator, or a sensing malfunction.

3. Failure to capture: A disorder in the pacemaker electrodes; the impulse does not generate
depolarization. This complication can result from low voltage, battery failure, faulty
connections between the pulse generator and catheter, improper position of the catheter,
catheter wire fracture, fibrosis at the catheter tip, or a catheter fracture.

Clinical manifestations associated with pacemaker malfunctioning include syncope,

bradycardia or tachycardia, and palpitations. When these manifestations occur, the
malfunctioning leads or pacemaker must be replaced.

COMPLICATIONS

Complications of invasive temporary ( transvenous) or permanent pacemaker insertion

include infection and hematoma formation at the site of insertion of the pacemaker power
source or leads pneumothorax failure to sense or capture with possible symptomatic
bradycardia perforation of the atrial or ventricular septum by the pacing lead and appearance
of “end-of-life” battery parameters on testing the pacemaker.

 Local infection at the entry site of the leads for temporary pacing, or at the
subcutaneous site for permanent generator placement
 Bleeding and hematoma at the lead entry sites for temporary pacing, or at the
subcutaneous site for permanent generator placement
 Hemothorax from puncture of the subclavian vein or internal mammary artery
 Ventricular ectopy and tachycardia from irritation of the ventricular wall by the
endocardial electrode
 Movement or dislocation of the lead placed transvenously (perforation of the
myocardium)
 Phrenic nerve, diaphragmatic (hiccupping may be a sign of this), or skeletal
muscle stimulation if the lead is dislocated or if the delivered energy is set high
 Rarely, cardiac tamponade from bleeding resulting from removal of epicardial
wires used for temporary pacing
PREVENTION OF COMPLICATIONS

 Several measures are taken to prevent or assess for complications and include
prophylactic IV antibiotic therapy before and after insertion postinsertion chest x-ray to
check lead placement and to rule out the presence of a pneumothorax careful observation
of insertion site and continuous ECG monitoring of the patient's rhythm
 . After pacemaker insertion the patient is permitted out of bed once stable. Arm and
shoulder activity is limited to prevent dislodgement of the newly implanted pacing leads.
 The nurse observes the insertion site for signs of bleeding and to check that the incision
is intact.
 Any temperature elevation should be noted and pain at the insertion site should be treated.
Most patients are discharged the next day if stable.

GUIDELINES FOR PATIENT’S AFTER PACEMAKER IMPLANTATION

For the first 24 hours after surgery :

Wear a sling: After 24 hours this can be taken it off. But it’s better to wear for the patient’s
comfort. If wearing sling take it off every two hours and stretch the elbows and shoulder.

For the first 30 days after surgery:

With the arm that is on the same side of surgery

 Do not lift anything that weighs more than 10-15 pounds. Do not wear any garment that
requires to reach behind the patient
 Do not lift the elbow higher than the shoulder
 Do not put the arm behind the back
 Do not make any sudden movements with the surgical arms

Activities

Standing up from sitting:

 Do not push off with the arm that is on the same side of surgery

Putting on shirt blouse or jacket:

  Slide the surgical arm into the sleeve

Taking off shirt, blouse, jacket, or coat:

 Carefully remove the sleeve from non surgical arm

 Using non surgical hand gather the garment onto the side of the surgery

Bathing:

 For one week: Do not get incision wet

 When taking shower wash incision, gently massage. Do not scrub the skin or wound.

NURSING MANAGEMENT OF CLIENTS WITH PACEMAKERS

ASSESSMENT

Assess the client for :

 Subjective clinical manifestations of dysrhythmias and alterations in cardiac output.

These include palpitations, syncope, fatigue, shortness of breath, chest pain, or skipped
beats felt in the chest. The client may also feel anxiety about the heart disorder and may
manifest nervousness, fear, sleeplessness, uncertainty, or hopelessness.
 Objective clinical manifestations may include diaphoresis, pallor or cyanosis,
variations in radial and apical pulses such as bradycardia or tachycardia, rhythm
changes, hypotension, crackles, and decreased mental acuity. The client may be fearful
of being left alone. Monitoring is begun, and the heart rhythm is observed continuously
by a nurse, a computer, and an ECG technician. Rhythm strips are examined at least
every shift.

After insertion, monitor vital signs and pacemaker function. Pain can usually be
managed with oral analgesics if the transvenous approach has been used. Initially, instruct the
client to avoid excessive extension or abduction of the arm on the operative side. Perform
passive range-of-motion exercises on the arm. Obtain paced and non-paced ECGS. A magnet
may be placed over the pulse generator, converting it to a fixed- rate pacing mode, so that the
client's intrinsic rhythm can be determined. The location of the pacemaker electrodes is
determined by x-ray. The model and serial numbers of the pulse generator and leads along with
the date of implantation and programmed functions of the initial implant are recorded.
Self-Care

 It may be necessary to teach about the nature of the disorder several times, because the
client may have an attention span shorter than normal as a result of severe anxiety.
 Before discharge, make certain clients appreciate the importance of taking
antidysrhythmic agents as prescribed. Include details concerning medication
administration, dosage, and side effects in the discharge plan.
 If discharged too early and in an unstable condition, many clients risk further
exacerbations or additional complications. Make sure that nursing discharge criteria are
met and documented,
 When a client is at risk for development of a life-threatening dysrhythmia, ascertain
whether the client's housemates and significant others know how to perform CPR. Refer
them to community agencies that provide CPR training.
 Sometimes clients with serious, chronic, or potential dysrhythmias use portable
telemetry units for self-monitoring at home after discharge. This allows resumption of
daily activities while providing continuous 24-hours surveillance of cardiac rhythm.
Nurses are often responsible for instructing clients in the use of these units.
 Ask the client to keep a diary of daily activities so that clinicians can correlate factors in
the client's life that may be contributing to the development of dysrhythmias.
 Instruct clients concerning the importance of regular medical follow-up. Advise them to
keep regular appointments with their physician after discharge. Explain to the client and
significant others how to obtain emergency medical attention if necessary.
 Living under the constant threat of sudden death provokes anxiety, depression, and,
occasionally, dependent behavior. In some cases, psychological counselling may booster
coping resources. Recommend community and private counselling services for the client
and significant others.

Patient Monitoring.

 Patients with temporary or permanent pacemakers will be ECG monitored to evaluate

the status of the pacemaker. Pacemaker malfunction primarily is manifested by a
failure to sense or a failure to capture.
  Failure to sense occurs when the pacemaker fails to recognize spontaneous atrial or
ventricular activity and it fires inappropriately. Failure to sense may be caused by
pacer lead damage battery failure or dislodgement of the electrode.
 Failure to capture occurs when the electrical charge to the myocardium is insufficient
to produce atrial or ventricular contraction. Failure to capture may be caused by pacer
lead damage battery failure dislodgement of the electrode or fibrosis at the electrode
tip.

NURSING DIAGNOSES

 Ineffective tissue perfusion related to dysrhythmias/ heart block/ pacemaker battery

failure
 Impaired skin integrity related to insertion of pacemaker/ alteration in activity
 Impaired physical mobility related to limb immobilization/pain
 Risk for injury related to pacemaker failure/ puncture or perforation of heart tissue
 Risk for infection related to pacemaker lead or generator insertion
 Risk for ineffective coping related to loss of control of heart function
 Disturbed body image related to presence of pulse generator and battery
 Deficient knowledge regarding self-care program

NURSING INTERVENTIONS

Promoting tissue perfusion

Monitor ECG for changes in rhythm, rate, and presence of dysrhythmias, monitor vital
signs every 15 minutes then every 2 hours. Ensure that all electrical equipment are grounded.
Avoid touching equipment and patient at the same time. Monitor for muscle twitching or
hiccups, instruct to avoid electro magnetic fields

Promote wound healing

Inspect pacemaker insertion site for redness, edema, warmth, drainage, or tenderness.
Change dressing daily, or as per hospital protocol, using sterile technique. Instruct on wound
care to pacer site and to avoid taking showers for 2 weeks post insertion. Instruct patient to
avoid wearing constrictive clothing until site has healed completely.
Regaining physical mobility

Evaluate patient’s perception of his degree of immobility. Maintain bedrest following

pacemaker insertion for 24-48 hrs or depending on protocol. Immobilize extremity proximal to
pacer insertion site with arm board, sling,etc, it prevents dislodgement of leads. Resume ROM
exercises one week after permanent pacemaker insertion to affected extremity. Provide ROM
to unaffected extremity immediately after pacer insertion.

Preventing injury

Monitor patient for bleeding at pacemaker site.Monitor for presence of pulses at site
distal to pacer insertion. Monitor vital signs observe for diaphoresis, dyspnoea, and
restlessness, because this may indicate puncture of subclavian vasculature and potential
hemothorax. Watch for hypo tension also. Instruct patient and family to notify physician for
redness, swelling, or drainage at site of pacemaker battery insertion.

Preventing infection

The nurse changes the dressing regularly and inspects the insertion site for redness,
swelling, soreness, or any unusual drainage. An increase in temperature should be reported to
the physician. Changes in wound appearance are also reported to the physician.

Promoting effective coping

The patient treated with a pacemaker experience not only lifestyle and physical changes
but also emotional changes. At different times during the healing process, the patient may feel
angry, depressed, fearful, anxious, or a combination of these emotions. Although each patient
uses individual coping strategies (eg, humor, prayer, communication with a significant other)
to manage emotional distress, some strategies may work better than others. Signs that indicate
ineffective coping include social isolation, increased or prolonged irritability or depression,
and difficulty in relationships.

To promote effective coping strategies, the nurse must recognize the patient's emotional
state and assist the patient to explore his or her feelings. The nurse may help the patient to
identify perceived changes, the emotional response to the change (eg, anger), and how the
patient responded to that emotion. The nurse reassures the patient that the responses are normal,
then assists the patient to identify realistic goals (eg, develop interest in another activity) and
to develop a plan to attain those goals. The nurse may also teach the patient easy to-use stress
reduction techniques (eg, deep-breathing exercises) to facilitate coping.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

After pacemaker insertion, the patient's hospital stay may be less than 1 day, and follow-
up in an outpatient clinic or office is common. The patient's anxiety and feelings of
vulnerability may interfere with the ability to learn information provided. Nurses often need to
include home caregivers in the teaching and provide printed materials for use by the patient
and caregiver.

The nurse must provide patient teaching in addition to observation for complications
after pacemaker insertion. The patient with a newly implanted pacemaker may have questions
about activity restrictions and fears concerning body image after the procedure. The goal of
pacemaker therapy should be to enhance physiologic functioning and the quality of life. This
should be emphasized to the patient and the nurse should give specific advice on activity
restrictions.

Patient and family teaching for the patient with a pacemaker is outlined in:

1. Maintain follow-up care with primary care provider to check the pacemaker site and begin
regular pacemaker function checks.

2. Report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to
the primary care provider immediately.

3. Keep incision dry for 4 days after implantation.

4. Avoid lifting arm on pacemaker side above shoulder until approved by primary care
provider.

5. Avoid close proximity to high-output electric generators or large magnets such as an MRI
scanner. These devices can interfere with the function of the pacemaker.

6. Travel without restrictions is allowed. The small metal case of an implanted pacemaker
rarely sets off an airport security alarm.
7. Carry pacemaker information card at all times.

8. A Medical Alert ID or bracelet should be worn at all times.

After discharge pacemaker function is checked on a regular basis. This can include
outpatient visits to a pacemaker interrogator/programmer or home monitoring using telephone
transmitter devices. Another method to evaluate pacemaker performance is noninvasive
program stimulation. This procedure is done on an outpatient basis in the electrophysiology
lab.

RELATED RESEARCH STUDIES

1. Safety of Permanent Pacemaker Implantation: A Prospective Study by M Reyes

Carrion Camacho, Ignacio, and Jose Rafael González-Lopez

Although pacemaker implantation is considered to be low risk, it is not exempt from

complications and technical failures during the procedure, both in the short and long term, and
the complications that such patients may present remain unknown. The aim has been to analyze
the complication rates associated with permanent pacing and to identify if these differ between
patients with or without previous antithrombotic therapy. They used a prospective, single
center, observational study of 310 adult patients with indications of permanent pacing. They
were hospitalized from 1 January to 31 December 2014 and followed up for 6 months after the
pacemaker implant. The participants were distributed into two groups according to the
antithrombotic therapy prior to the implant. The most frequent major complications were
pneumothorax (3.87%) and lead dislodgement (8.39%), while superficial phlebitis (12.90%)
and uncomplicated hematomas (22.58%) were presented as the most recurrent minor
complications. Hematomas were the most frequent minor complication in the antithrombotic
therapy cohort, and shoulder pain was reported as the most recurrent minor complication in the
non-exposed group. Finding out about complications in pacemaker implants enables a
complete view of the process, and hence the prioritization of actions aimed at improving safety
and reducing associated risks

2. Risk Factor for Cardiac Permanent Pacemaker Infection by Hammad Shah et al

Cardiac pacemaker infections have increased globally due to increase in demand and
lack of adequate knowledge about its significantly contributing risk factors. This study was
therefore aimed to determine the prevailing causative microbes and risk factors of both single
and dual chamber permanent pacemaker infections.

This was a retrospective case control study. Cases were selected as culture positive
swab, Temporary pacemaker wire or catheter were matched with three controls for each
variable using chi square test. Multivariate regression analysis was done to determine risk
factors. It is found that Temporary pacemaker/Central line placed >24hours before permanent
pacemaker implantation, remnant pacemaker leads, corticosteroid use, no antibiotic
prophylaxis, diabetes, smoking and use of non-absorbable stitches are risk factors for
permanent pacemaker infection. Staph aureus is the most prevalent microorganism causing
infection.

CONCLUSION

A pacemaker is an electronic device that provides electrical stimuli to the heart

muscle. Pacemakers are usually used when a patient has a slower-than-normal impulse
formation or a conduction disturbance that causes symptoms. They may also be used to control
some tachydysrhythmias that do not respond to medication therapy. Biventricular (both
ventricles) pacing may be used to treat advanced heart failure that does not respond to
medication therapy. Pacemakers can be permanent or temporary. Permanent pacemakers are
used most commonly for irreversible complete heart block. Temporary pacemakers are used
(eg, after MI, after open heart surgery) to support patients until they improve or receive a
permanent pacemaker.

BIBLIOGRAPHY

 Brunner &Suddarth ‘s Text book of medical surgical nursing 10 th edition wolter

Kluwer India New Delhi page no:690-700
 Joyce M Black, jane hokanson hawks, anabelle m keene. Medical surgical nursing. 8 th
edition. Published by Elsevier. Page no: 1220-1240
 Sharon mantik lewis, margarete Mc Lean heitkemper. Medical surgical nursing. 10 th
edition. Published by mosby. Page no: 700-720
 Susan. L. Woods etat, Cardiac Nursing, 6th edition, Wolters Kluwer Publications, Page
no: 680-700