Pacemaker Pacemaker managementmanagement

2009.07.032009.07.03홍은미홍은미 ,, 박미정박미정

HICU ConferenceHICU Conference

Atrial muscle

SA node Left atrium

Descending aortaInferiorvena cava

Ventricluar

Pulmonaryveins

Superiorvena cava

Tricuspid valve

Mitral valve

AV node

Purkinjefibers

muscle

Specializedconducting

tissue

Cardiac conduction Cardiac conduction systemsystem

SA node 에서 시작해서 심방 전체로 퍼짐

AV node 에 전기를 전달

His Purkinje system 에 의해 우심실 , 좌심실 activation

Cardiac Cardiac cconduction onduction systemsystem

Pacemaker cells Pacemaker cells - SA node, AV node- SA node, AV node

Specialized Specialized conducting tissues –conducting tissues –His bundle, Purkinje His bundle, Purkinje fibers fibers

Myocardial cellsMyocardial cells

ARTIFICIAL CARDIAC ARTIFICIAL CARDIAC PACINGPACING

심장 고유한 전기적 체계가 심장 고유한 전기적 체계가 효과적으로 적절한 박동을 유지하지 효과적으로 적절한 박동을 유지하지 못하는 경우 심장박동을 유발할 수 못하는 경우 심장박동을 유발할 수 있도록 고안된 전기적 기구로 있도록 고안된 전기적 기구로 bradyarrhythmia and bradyarrhythmia and tachyarrhythmiatachyarrhythmia 의의 치료 치료

목적으로 사용목적으로 사용

PacingPacing 의 종류의 종류Permanent pacing (implantation)

Temporary pacing

External subcutaneous (zoll patch)

Epicardial pacing

인공심박조율기의 기능 설정

MODE

Pacemaker ComponentsPacemaker Components

Pulse generator: Pulse generator: power source or power source or batterybattery

Leads or wiresLeads or wires Cathode (-ve Cathode (-ve

electrode)electrode) Anode (+ve Anode (+ve

electrode)electrode) Body tissueBody tissue

IPG

Lead

Anode

Cathode

The NASPE/BPEG The NASPE/BPEG Generic Pacemaker CodeGeneric Pacemaker CodeI II III IV V

Chamber Paced

Chamber Sensed

Response to Sensing

Rate Modulation, Programmability

Anti-tachycardia Features

A=Atrium A=Atrium T=Triggered

P=Simple P=Pacing

V=Ventricle

V=Ventricle

I=Inhibited M=Multi-programmable

S=Shock

D=Dual D=Dual D=Dual R=Rate Adaptive D=Dual

O=None O=None O=None C=Communicating

O=None

North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group

Temporary Pacing Modes Temporary Pacing Modes Used after Heart SurgeryUsed after Heart Surgery

Code positions Description

I II III

A O O Asynchronous atrial pacing

A A I Atrial demand pacing

V O O Asynchronous ventricle pacing (do not use)

V V I Ventricle demand pacing

D O O Asynchronous AV pacing

D V I AV sequential pacing(ventricle demand)

D D D AV pacing

AOO

AAI

AAT

VOO

VVI

VVT

Single Chamber Pacemaker

VVII *

Single Chamber Pacemaker

VATVDDDOODVIDDIDDD

Dual Chamber Pacemaker

DDDT / I

*I*

Dual Chamber Pacemaker

Pacemaker importance of Post Cardiac Pacemaker importance of Post Cardiac SurgerySurgery

- Optimal hemodynamics are achieved at a Optimal hemodynamics are achieved at a heart rate of 90 beats/min in the heart rate of 90 beats/min in the postoperative period. Use of pacing wires to postoperative period. Use of pacing wires to increase the heart rate is preferable to the increase the heart rate is preferable to the use of positive chronotropic agents that use of positive chronotropic agents that have effects on myocardial function.have effects on myocardial function.

- Reentrant rhythms can be terminated by - Reentrant rhythms can be terminated by rapid pacingrapid pacing

Manual of perioperative care in cardiac surgery(P275)

Pacemaker Pacemaker 종류 종류 (HICU )(HICU )

Demand DDD New 2

NEW 1 AV Overdrive

Pacing mode Pacing mode Commonly Encountered Pacing Modes

Mode Advantages Disadvantages Clinical uses

AAI(R) Requires only single lead simple

Slow ventricular rate s may develop if AV block occures

Sinus node dysfunction without AV node dysfunction

VVI(R) Requires only single lead simple

During pacing, AV synchrony is not preserved

AV block in a patient with a-Fib

DDD(R) AV synchrony is maintained for patients with sinus node and AV node disease

Requires two lead More complex

Bradycardia caused by sinus node and AV node disease

Atrial pacingAtrial pacing AOO mode (asynchronous atrial pacing) AOO mode (asynchronous atrial pacing) AAI mode (atrial demand pacing) AAI mode (atrial demand pacing)

Indication Indication ((sinus node dysfunction without AV node sinus node dysfunction without AV node

dysfunction)dysfunction) a) sinus bradycardiaa) sinus bradycardia b) slow junctional rhythm b) slow junctional rhythm

c) suppressIon of PVC, PACc) suppressIon of PVC, PAC d) overdriving PSVT d) overdriving PSVT

Atrial pacingAtrial pacing

Atrial pacing 80bpm, 7mA (demand type)

Ventricular pacingVentricular pacing

VVI mode (ventricular demand pacing)VVI mode (ventricular demand pacing) * Ventricular pacing* Ventricular pacing 은 절대 은 절대

asynchronous (VOO type) asynchronous (VOO type) 로 하지 않을 로 하지 않을 것것 !!

IndicationIndication a) a slow ventricular response to a- a) a slow ventricular response to a-

fib/flutter fib/flutter b) atrial pacingb) atrial pacing 이 안 되는 경우이 안 되는 경우 c) ventricular tachycardia (overdrive c) ventricular tachycardia (overdrive

pacing)pacing) * * 단점 단점 : AV synchrony: AV synchrony 가 되지 않음가 되지 않음

Ventricular pacingVentricular pacing

Ventricular pacing 80bpm, 20mA

Ventricular pacing 80bpm, 20mA

AAI Pacing

Pacing failure junctional rhythm change

VVI Pacing

Ventricular pacing

Atrioventricular pacingAtrioventricular pacing

DVI mode (AV sequential pacing = DVI mode (AV sequential pacing = ventricular demand)ventricular demand)

DDD mode (AV pacing) DDD mode (AV pacing)

보통 보통 atrial , ventricular outputatrial , ventricular output 은 은 10~20mA, 10~20mA, PR intervalPR interval 은 은 150ms150ms 으로 으로 setting setting 함함

Indication (a-fib/ flutter Indication (a-fib/ flutter 일 때는 부적합일 때는 부적합 )) a) heart block (1a) heart block (1 도도 , 2, 2 도도 , 3, 3 도도 ) ) b) heart block b) heart block 이 있는 이 있는 fast atrial rate fast atrial rate 일 때 일 때

Atrioventricular pacingAtrioventricular pacing

A-V sequential pacing 14mA(a), 10mA(v), 78bpm,

150ms

Overdrive pacingOverdrive pacing

800800 회회 //분까지 분까지 pacing pacing 가능한 가능한 pacemaker pacemaker 필요 필요

Full mA (20)Full mA (20) 로 로 tachycardia, fluttertachycardia, flutter 보다 보다 1010 회회 //분 가량 빠른 속도로 분 가량 빠른 속도로 pacing pacing 시작 시작

-> capture -> capture 되면되면 , flutter , flutter 모양 바뀔 때까지 모양 바뀔 때까지 rate rate 증가 증가 (20~30%)(20~30%) 시킨 후 약 시킨 후 약 11 분 가량 분 가량 pacing pacing

-> -> 갑자기 갑자기 pacing off (NSR, pause, A-fib, pacing off (NSR, pause, A-fib, flutter flutter 가능가능 ) )

Overdrive pacingOverdrive pacing

Potential problemsPotential problems

Failure to function : Failure to function : 연결 미흡연결 미흡 , , 베터리 부족베터리 부족 , , a-fiba-fib 이 이 atrial capture atrial capture 방해방해 , epicardium, epicardium 에서 에서 wire wire 헐거워진 경우 등헐거워진 경우 등

Threshold Threshold 변화 변화 환자의 환자의 rhythmrhythm 과 경쟁 과 경쟁 (asynchronous (asynchronous 경우 경우 --

> pacing off > pacing off 시 문제 해결시 문제 해결 )) Undersensing/oversensingUndersensing/oversensing V-tach/fib V-tach/fib 발생발생 : Asynchronous Ventricular : Asynchronous Ventricular

pacing pacing 시시 (demand type-DVI, VVI, DDD-(demand type-DVI, VVI, DDD- 으로 으로 해야해야 ))

Mediastinal bleedingMediastinal bleeding Wire Wire 제거 불능 제거 불능

Nursing CareNursing Care

ICU ICU 심박동기 사용법심박동기 사용법

Overdrive pacemakerOverdrive pacemaker

Overdrive pacemaker Overdrive pacemaker

Overdrive pacemakerOverdrive pacemaker

Overdrive pacemakerOverdrive pacemaker

Overdrive pacemakerOverdrive pacemaker

Single Single chamberchamber pacemaker pacemaker

Single chamber pacemakerSingle chamber pacemaker

Single chamber pacemakerSingle chamber pacemaker

Single chamber pacemakerSingle chamber pacemaker

Single chamber pacemakerSingle chamber pacemaker

Dual chamber pacemaker1 Dual chamber pacemaker1

Dual chamber pacemaker 1Dual chamber pacemaker 1

Dual chamber pacemaker 1Dual chamber pacemaker 1

Dual chamber pacemaker 1Dual chamber pacemaker 1

Dual chamber pacemaker 1Dual chamber pacemaker 1

Dual chamber pacemaker 2Dual chamber pacemaker 2

Dual chamber pacemaker 2Dual chamber pacemaker 2

Dual chamber pacemaker 2Dual chamber pacemaker 2

Dual chamber pacemaker 2Dual chamber pacemaker 2

Dual chamber pacemaker 2Dual chamber pacemaker 2

Dual chamber pacemaker 3Dual chamber pacemaker 3

Dual chamber pacemaker 3Dual chamber pacemaker 3

Dual chamber pacemaker 3Dual chamber pacemaker 3

Dual chamber pacemaker 3Dual chamber pacemaker 3

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