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Fa: Methods 2 > 10. Pacing & CIEDs > Flashcards

10. Pacing & CIEDs Flashcards

1
Q

temporary cardiac pacing 4

A

transcutaneous
transesophageal
transvenous
epicardial

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2
Q

transcutaneous is preferred when?

A

an emergency

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3
Q

3 disadvantages to transcutaneous pacing

A

painful
least effective capture
ventricular only pacing

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4
Q

transcutaneous pacing CI

A

severe hypothermia

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5
Q

two placement options for transesophageal pacing

A

pill electrode swallowed
flexible catheter

flexible catheter can be inserted

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6
Q

what does transesophageal pacing pace? atria? ventricle?

A

atria

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7
Q

what current does transesophageal pacing require

A

high current
>20 mA

>20mA

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8
Q

advantage to transesophageal

A

no need for xray or cath lab

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9
Q

disadvantage to transesophageal

A

uncomfortable and requires sedation

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10
Q

when is transvenous pacing indicated?

A

stable or transcutaneous isnt working (inability to capture)

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11
Q

why does transvenous pacing take longer?

A

central line must be placed

pacing leads must be inserted through central line guided with balloon

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12
Q

how is transvenous pacing function controlled?

A

external pacemaker box

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13
Q

advantages to transvenous pacing 3

A

can place atrial and ventricular leads
more effective capture
doesnt require as much energy

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14
Q

what is the energy requirement for capture for transvenous pacing

A

1.5-3mA

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15
Q

disadvantages to transvenous pacing 2

A

more time consuming to establish (cant in emergency)
expert placement required

requires expert placement

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16
Q

epicardial pacing

A

common with cardiac surgery
leads are sewn into myocardium
controlled with external box

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17
Q

what do we pace at during cardiac surgery?

A

20mA

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18
Q

CIEDs

A

cardiovascular implantable electronic devices

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19
Q

what is a CIED

A

permanent pacemaker

placed into pocket by surgeon

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20
Q

what does a CIED consist of?

A 
pulse generator (new SA node)
pacing wires that have been inserted through subclavian vein into heart
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21
Q

what does the pulse generator act like

A

SA node

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22
Q

3 types of CIEDs

A

pacemaker
automated implantable cardioverter defibrillators (AICDs or ICDs)
chronic resynchronization therapy (CRT)

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23
Q

biventricular devices are typically

A

ICDs

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24
Q

two reasons for patients to receive a pacemaker

A

pace pts with slow heart rates
improve timing of atrial or ventricular beats in complete heart block

improve timing of atrial and ventricular beats for pts with complete heart block

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25
single chamber
pacing lead in either RA or RV
26
single ventricle lead will pace
both ventricles
27
shocking coils allow
defibrillation
28
dual chamber
pacing lead in both RA and RV
29
what is an ICD?
CIED with specialized pacing lead placed in right ventricle that has a built in shocking coil
30
what can ICDs sense
arrythmias heart contractions
31
intravascular ICD provide
pacing synchronized cardioversion antitachycardia pacing defib
32
subcutaneous ICDs indication
only indicated for defib (cannot pace or sync cardioversion)
33
biventricular pacemakers or cardiac resynchronization therapy device
instead of the ventricles being paced by one lead they are paced by by two leads: 1 in RV 1 in coronary sinus to pace LV
34
what is the advantage of biventricular pacemakers?
2 ventricular leads improves ventricular synchrony in patients with a history of heart failure
35
5 intravascular CIED placement method
1- skin above subclavian is localized 2- a pouch under skin is created 3- pacing wires placed through subclav vein via fluoroscopy 4- pulse generator is programmed by pacemaker rep, then leads are attached 5- device is sewn underneath skin
36
what do you need to do if the device is an ICD
the shock function may need to be tested when they test the ICD, give a small propofol bolus prior to shock
37
capture
cardiac cells responding to pacemaker stimulation
38
insert capture ecg
capture
39
pacing threshold
minimum current that capture is observed
40
transvenous/epicardial approach capture current
1.5-3mA
41
transcutaneous approach capture current
40-80mA
42
why do we want to avoid high voltages?
cause discomfort incr risk of myocardial damage | myocardial damage
43
pacing threshold
the current that you found capture
44
maintenance threshold
10% higher than pacing threshold to decrease chance of losing capture
45
sensitivity threshold
how sensitive the pacemaker is to sensing electrical activity in heart
46
if the sensitivity is too high?
not pace as much as it should
47
if the sensitivity is too low?
it may pace when it is not supposed to
48
intrinsic heart rate
HR set by SA node 60-100bpm
49
paced HR
HR that comes from battery operated pacemaker ~60bpm
50
how can you tell on ecg if the beat is paced?
there is a pacer spike prior to a p wave or qrs complex
51
will pacemaker spikes automatically come up on the ecg?
no you must enable the pacemaker setting on the monitor
52
insert pacer spike ecg
pacer spike
53
two potential sources of heart beat in pt with pacemaker
SA node (intrinsic HR) pacemaker (paced HR) | pacemaker
54
why is it dangerous to have two potential sources of heart beats?
if they both go off it can be mistimed and lead to r-on-t phenonmenon and lead to vfib/vtach
55
insert R on T phenomenon ecg
R on T phenomenon
56
Insert R on T Vfib
R on T leading to Vfib
57
what is demand mode
a pacing mode that makes it so that only one source (SA or pacemaker) is providing current to the heart
58
demand mode senses
the intrinsic heart rate
59
in demand mode, is the pacer always pacing
no pacer only paces if needed
60
what prevents mistimed beats and arrhythmias?
sensing by the pacemaker in demand mode
61
when the pacemaker can sense it is
in demand mode
62
in demand mode the pacemaker will
stop pacing when they can sense start pacing when they cannot sense
63
if the intrinsic rate is faster than the paced rate, the pacemaker will?
be suppressed
64
if the paced rate is faster than the intrinsic rate then the intrinsic rate will
be suppressed
65
effect of cautery on pacemaker
pacemakers sense surgical cautery and interpret it as electrical activity of the heart
66
will pacemakers pace during cautery?
nope
67
pacemaker dependent
whenever a patient is reliant on their pacemaker to have a normal cardiac output
68
asynchronous mode
pacemaker cannot sense anything and they start pacing constantly
69
asynchronous pacers will pace
constantly regardless of intrinsic rate
70
advantage of asynchronous mode
pacemaker cannot sense cautery pacemaker will not stop during cautery
71
problem with asynchronous mode
it is possible for the two sources to be simultaneously pacing can lead to r-on-t phenomenon and vfib
72
when is asynchonous mode safe?
when the intrinsic rate is slower than the paced rate
73
pacemakers should only be placed in asynchonous mode if
pacing rate is high the pt's intrinsic HR is slow | patients intrinsic HR is slow
74
pacing rate in asynchronous mode
programmed for pace rate to increase to 80-100 bpm
75
before putting in asynchronous mode what should the anesthetist check?
confirm intrinsic rate is slower than asynchronous rate | consider beta blocker
76
when could asynchronous mode be necessary?
pacemaker dependent pt is experiencing profound cautery induced bradycardia
77
how to convert pacemaker to asynchronous mode
place magnet over it or pacemaker rep can reprogram prior to surgery
78
why is rate modulation programed into pacemaker?
the pacemaker can sense incr movement or minute ventilation and incr the rate to provide higher CO during exercise
79
antitachycardia pacing (ATP)
senses tachycardia and paces faster than intrinsic rate to suppress it
80
what rhythms can ATP be effective for
afib aflutter svt monomorphic vtach
81
if several attempts at ATP prove ineffective what will the pacemaker do?
shock the heart
82
indications for pacemaker 5
``` sinus brady sick sinus syndrome (malfunctioning SA node) 3rd degree av block mobitz type II heart block afib with slow ventricular response ```
83
what pacemaker should be used for chronic sinus brady or SSS
atrial pacing
84
what type of pacemaker should be used for afib with slow ventricular response?
ventricular because atrial wouldnt work because it has constant electrical activity
85
pacing spike before QRS is what type of pacing
ventricular pacing
86
where is the ventricular lead placed
close to septum and causes left and right ventricles to contract
87
Leadless right ventricular pacemaker location
RV via femoral access
88
Leadless pacemaker advantages
decr risk of: - lead infection - vascular thrombosis - lead dislodgement - lead fracture
89
leadless pacemaker disadvantages
no defib does not respond to magnets
90
what type of pacemaker should be used for 3rd degree av block?
dual chamber | atrial lead senses when there is activity and signals for ventricular pace
91
how does dual chamber pacemaker fix complete heart block 2
atrial lead senses when atria contract ventricular leads programmed to pace | ventricular lead pace 120-200 msec after atria contracts
92
when dos the ventricular lead pace in dual chamber for heart block?
120-200 msec after every atrial contraction
93
newer pacemaker for complete heart block
single chamber pacemaker where it has sensing portion in RA and the pacing portion in the RV
94
insert DC pacemaker w/DC pacing
DC pacemaker w/DC pacing
95
DC pacemaker w/both atrial and ventricular pacing spikes
patient has both: SA node dysfunction slow AV conduction
96
DC pacemaker w/atrial pacing
DC pacemaker w/atrial pacing
97
DC pacemaker w/atrial pacing
SA node is slow AV node is normal
98
DC pacemaker w/ventricular pacing
DC pacemaker w/ventricular pacing
99
DC pacemaker w/ventricular pacing
SA node is normal AV conduction is slow
100
ventricular only pacing w/o P waves
underlying afib
101
ventricular only pacing w/p waves
underlying complete heart block
102
DC pacemaker w/normal ECG
SA node is normal AV node conduction is normal
103
will you see a atrial pacing spike with the single chamber pacemaker for complete heart block?
no
104
biventricular pacemakers are AKA
cardiac resynchronization therapy (CRT)
105
what do biventricular pacemakers have in addition to a normal RV lead
LV lead inserted via coronary sinus
106
advantage of having a lead in both ventricles in biventricular pacemakers
improves timing of ventricular beats incr SV/CO decr myocardial O2 demand
107
what does an ICD have?
specialized ventricular pacing lead that has a built in shocking coil that senses and shocks tachyarrhythmias
108
who are ICDs usually placed in?
CHF pts bc they are more prone to tachyarrhythmias
109
what are ICDs capable of?
pacing and defibrillating
110
traditional ICD
RV lead capable of pacing and shocking
111
S-ICD
CANNOT pace only indicated for defib | only defibtrillate
112
advantage to S-ICD
no need to replace fibrosed leads | just as effective as transvenous
113
disadvantages to S-ICD
not indicated in pts who require antibrady pacing, CRT, or antitachycardia pacing higher energy requirements not for ventricular arrhythmias at rates lower than 170bpm
114
why are ICDs dangerous
can be inappropriately triggererd to shock whenever cautery is used
115
an ICD thinks cautery is
vfib it will defibrillate
116
what are ICDs programmed energy to shock
15-35 J
117
two ways to prevent accidental shock from an ICD during surgery
1 disable the shock function of the ICD (programmer or magnet over the ICD) 2 keep electrical current away from the ICD
118
how many cm should the grounding pad be placed away from ICD
15cm
119
what are alternatives to unipolar cautery
bipolar or harmonic scalpel
120
harmonic scalpel
cuts via vibration and seals tissue with protein denaturation
121
advantages to harmonic scalpel
cuts thicker tissue than bovie less smoke less thermal damage
122
disadvantages to harmonic scalpel
takes longer to cut and coagulate tissue can only coagulate as it cuts | can only coagulate as it cuts
123
magnet on ICD does what
diable the shock function only
124
does the magnet on ICD convert the pacing to asynchronous mode?
no
125
can cautery induced bradycardia occur with magnet on ICD?
yes
126
how to prevent cautery induced bradycardia during surgery for pacemaker dependent pts with ICD?
ask pacemaker rep to reprogram ICD before surgery to allow it to become asynchronous with magnet placement
127
when should the shock function of an ICD be disabled?
if surgeon plans on using cautyer if surgical site is above the umbilicus
128
pacemaker dependent patient has a magnet placed over their ICD what will happen during cautery
no shock, possible brady or asystole
129
pacemaker interrogation
15min procedure that checks the function and battery life of pacemaker waves wand and connects to computer
130
pacemaker checks are
scheduled at regular intervals over the pts life | recommended by doctor prior to elective procedure
131
how often should pacemaker be checked
every year
132
how often should ICDs be checked?
every 6mo
133
preop management of CIED
obtain/document results of last pacemaker interrogation and intraoperative recommendations by calling number on card in wallet or bracelet
134
9 things for anesthesia to know in preop CIED pts
``` 1 type of device (pacemaker vs ICD) 2 programmability of device 3 underlying rhythm 4 pacemaker dependent? 5 does it have rate modulation 6 pacemaker capture effectively 7 what is magnet response? 8 adequate battery life 9 manufacturers perioperative recommendations? ```
135
normal battery life
7-10 years
136
adequate battery life for surgery
>3-6mo
137
intraoperative management supplies and drugs CEID
external pacemaker magnet atropine epi
138
postop management CEID
all devices should be interrogated or reprogrammed to original function after surgery not discharged until interrogated
139
study;s have shown that magnet application over ICD have not always:
suspended antitachyarrythmic function produce asynch pacing for demand pacemaker produce safe asynch pacing
140
a male pt has a regular demand pacemaker w/the following ECG is he pacemaker dependent?
No
141
a male pt has a regular demand pacemaker w/the following ECG what is the effect of cautery on HR?
no change
142
a male pt has a regular demand pacemaker w/the following ECG what will magnet placement do?
change to asynchronous mode incr pacing to 80-100 bpm
143
a male pt has a regular demand pacemaker w/the following ECG should we place a magnet?
no
144
this pt has an intravascular ICD with the following ECG. Cautery is planned. What is magnet placement most likely to do?
disable shock
145
this pt has an intravascular ICD with the following ECG. Cautery is planned. should a magnet be placed on this patient?
yes
146
a male pt has a regular demand pacemaker and he goes asystolic when cautery is used. How should he be managed during surgery?
place a magnet
147
a female pt w/intravascular ICD is pacemaker depended. Shock function was disabled by pacer rep prior to surgery. During surgery she becomes asystolic when cautery is used. How should she be managed?
switch to bipolar cautyer or reprogram ICD
148
a male pt has a regular demand pacemaker and his ECG is showing all P waves are preceded by pacing spikes. If cautery is not being used, how do you explain the ECG?
perhaps the rate modulation was not disabled? we expect constant HR
149
first letter chamber classification
what chambers have pacing leads
150
second letter chamber classification
what chambers can sense electrical activity
151
third letter chamber classification
how pacemaker responds after it senses electrical activity
152
fourth letter chamber classification
programmability
153
fifth letter chamber classification
antitachyarrhythmia function
154
options for first letter
``` a= atria v= ventricle d= dual ```
155
options for second letter
``` a= atria v= ventricle d= dual o= none ```
156
what does it mean when the second pacemaker letter is O?
it is in asynchronous mode
157
options for third letter
``` I= inhibits T= triggered D= Dual (t+i) O= none ```
158
third letter I
inhibit itseld from pacing (demand mode)
159
third letter T
triggered to pace
160
third letter D
dual = pacemaker is triggered and inhibited
161
when can the pacemaker be triggered and inhibited
complete heart block - atrial lead inhibits iself from pacing - atrial lead triggers ventricular to pace
162
third letter O
if the 2nd letter is O the 3rd letter will also be O indicates asynchronous mode
163
pacemaker code for pt with sinus brady
AAI
164
pacemaker code for pt with slow afib/aflutter
VVI
165
pacemaker code for pt with complete heart block
DDD
166
right ventricular pacemaker code for pt with complete heart block
VDD
167
pacemaker code for pt with sinus brady and magnet on pacemaker
AOO
168
AAI
single lead in RA for pts demand pacing
169
AAI indications
sinus brady SSS
170
AOO
asynchronous pacing from RA activated by magnet
171
VVI
single lead in RV demand pacing
172
VVI indication
a fib
173
VOO
asynchronous pacing with the lead in the RV activated by magnet
174
DDD
leads in RA and RV for pts with complete heart block
175
DOO
asynchonous pacing with leads in RA and RV activated by magnet
176
DOO RV is programmed to pace when
120-200 msec after each atrial beat
177
VDD
specialized lead in RV that has a sensing portion in the RA
178
VDD indication
complete heart block with normal functioning SA node
179
can pt with pacemaker have MRI
NO
180
CT scan and pacemaker
some ICDs receive interference
181
are ICDs or pacemakers more sensitive to radiation therapy?
ICDs
182
what to do if pt with ICD and radiation therapy
shielded as much as possible and moved if it lies directly in radiation field
183
radiofrequency ablation
waves to ablate areas of the heart/terminate arrhythmias | acceptable with certain precautions
184
emergency defibrillation for pt with pacemaker
place the defib pads away from pacemaker
185
TENS
transcutaneous electrical nerve stimulation | used to relieve acute or chronic pain
186
TENS and CIEDs
reported to interfere with ICDs to cause inappropriate shock | cautioned about use
187
ECT
electroconculsive therapy transcutaneous electrodes placed on head to induce a tonic clonic seizure treat depressio
188
how often is ECT performed
twice weekly for usually 3-4 weeks
189
what is too short or too long of seizure?
too short: < 10s too long: > 120s | >120 sec
190
which is more important the length or seizure or current delivered?
current delivered
191
cardiovascular effects of ECT
initial parasympathetic discharge (brady and hypotension) then sympathetic response
192
how long does initial parasympathetic discharge last in ECT?
10-15 s
193
when does secondary sympathetic response peak in ECT?
3-5 mins
194
cerebral effects of ECT
incr cerebral oxygen consumption incr blood flow incr ICP
195
what are the more popular induction agents for ECT
brevital or etomidate
196
methohexital
pro convulsant does not change duration blunt sympathetic response
197
etomidate
longest seizure duration does not blunt the sympathetic response
198
propofol
decreases seizure duration does blunt the sympathetic response
199
ketamine
longer seizure duration incr ICP | ICP elevates
200
airway management for ECT
usually not ETT unless indicated mask ventilation | hyperventilate to lower the threshold for seizure and prolong the duration
201
neuromuscular blocking agents and ECT
reduce muscular convulsions and decrease risk of serious injury (sux most common)
202
CIED implications for ECT 4
1 skeletal muscle potentials during seizure may trigger pacemaker 2 regular demand should be asynchronous 3 shock function of ICD deactivated 4 risks are low bc small amounts of electricity reach device
203
ESWL
extracorporeal wave lithotripsy | transcutaneous ultrasonic shock waves breaks up kidney or ureteric stones
204
synchronized litho shocks
triggered by the R wave delivered in refractory period
205
advantage to synchronized shock
carries lower risk of PVCs and arrhythmias
206
disadvantage to synchronized shock
procedure is slower
207
non synchronized litho shocks
shocks delivered at specific rate
208
advantage of non synchronized litho shock
procedure is faster
209
disadvantage to non synchronized litho shock
more likely to cause PVCs or arrhythmias
210
ESWL and CIEDs
may interpret shocks same as cautery | magnets should be placed on ICD pt or pacemaker dependent pt
211
what can happen in atrially paced pts with ESWL?
the synchronized shock can read the atrial pace as the R wave and deliver a shock prior to the R wave causing arrhythmia
212
atrially paced CIEDs during ESWL
avoid synchronized shocks
213
regular demand pacemakers during ESWL
place in asynchronous mode if pt is pacemaker dependent
214
ICD during ESWL
disable shock function

Fa: Methods 2 (16 decks)

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