CIED implant trouble shoot in cath room

台北榮民總醫院

護理師 郭宜蘭

Venogram

Subclavian vein

cephalic vein

Acute Venous Stenosis Limiting Access

Implantation Techniques - Acute

Pneumothorax

Hemothorax

Pneumo- hemothorax

Brachial plexus injury

Arterial puncture

Chylothorax

Infection

Pocket Hematoma / Seroma

Pneumothorax

In PASE Trial: 1.97%

Management for Pneumothorax

withdraw the needle, wait a moment or two to make certain that a rapid-onset, large, markedly symptomatic pneumothorax is not occurring, and then proceed

If a pneumothorax does develop, it may do so in this setting over a matter of hours and may not even be apparent radiographically at the end of the procedure.

If a lung puncture has occurred, obtaining another upright chest radiograph 6 hours after completion of the procedure is advisable. If a pneumothorax has developed, a chest tube or catheter evacuation procedure may be necessary, although frequently, a small to moderate pneumothorax that is not expanding can be managed conservatively without evacuation.

Avoid air embolism (esp. for large-bored sheaths)

press proximal end of sheath and instruct patient to hold breath during pacing lead insertion

use of introducer sheath with hemostatic valve

Myocardial Perforation

When recognized, lead MUST be pulled back

Be prepared for tamponade

May require open procedure to manage but heart usually seals itself.

Diaphragmatic Stimulation Lead in Cardiac Vein

Lead inadvertently placed into Post.Cardiac V

Management of Pocket Hematoma

Observation and close follow-up – Soft

– Minimal to no tenderness

Surgical evacuation – Tense pocket threatening suture

line

– Weeping suture line

– Severe pain

– Immunocompromised host

Causes of Open Circuit Due to Implant Technique

Loose set screw

Improperly seated lead terminal pin

Conductor fracture – Rib Clavicle Crush

– Tight ligature

“Dry” pocket - air in pocket with unipolar configuration – Replacement

Pulse Generator Pocket Chronic

Pain - pocket neuralgia

– Incorrect tissue plan – Incorrect location - too lateral – Smoldering infection

Erosion

– Pressure necrosis – Smoldering infection

Migration Twiddler’s Syndrome

Pressure Necrosis

Thinning and discoloration at lateral margin

Total breakdown and 2° Infection

Smoldering Pocket Infection with draining fistula

Presented 2 years post implant

Eschar and draining fistula at edge of incision, surrounding erythema

Waxed and waned on oral antibiotics

Local cultures were negative

January 24, 2002

Improper Location of Pulse Generator

If the pacemaker is placed too lateral, it will cause discomfort every time the patient rotates arm forward

Loose Anchoring Sleeve Twiddler’s Syndrome

Conductor Fractures

Occurs at stress points – Rib-Clavicle Crush – Tight Anchoring sleeve

ligature – Angulation of lead – Traction on lead

If external conductor of bipolar lead, conversion to unipolar will allow for elective management

Tight Anchoring Sleeve Damage to Lead

Conductor Coil Fracture

Insulation Damage

Thanks for your listening:)

See you next time.

It’s time to wake up!!