PERMANENT PACEMAKER IMPLANTATION – Definition, Purpose, Equipment, Pre-PPI Care, Post-PM Care and Patient Education
DEFINITION
Pacemaker is an electronic device that provides repetitive electrical stimuli to heart muscles. Permanent pacemaker implantation (PPI) is a procedure in which pacemaker is implanted surgically in the deltopectoral pouch when conduction defect is irreversible
PURPOSE
- To transmit impulses from sinus node to ventricles
- To generate impulses spontaneously
- To maintain primary control of pacing function of heart
EQUIPMENT
- Electronic cardiac monitor
- Pacemaker
- Catheter
- PPI tray with articles such as forceps, scissors, retractors
- Local anesthesia, scalpel blade, cleaning solution
- Dynaplast and emergency resuscitation equipment
PRE-PPI CARE
- Explain procedure to patient and relative with help of audiovisual aids and handouts
- Get consent for procedure
- Explain that procedure will be performed in cardiac catheterization laboratory and patient will be transferred to CCU for 1 day for close monitoring
- Explain about starvation required for 8 to 10 hours prior to procedure
- Enquire whether patient has allergy to drug or food and report to doctor if any
- Shave following areas:
Anterior chest from neck to umbilicus
Nape of neck to loins of back
Both arms and axillae
- Advise to take bath with antiseptic scrub and water for 2 days before procedure and on day of procedure
- Provide clean gown
- Remove jewelry, dentures/contact lens if any
- Start IV line with heparin lock
- Administer pre-medications and first dose of antibiotics
- Explain that one relative can stay in CCU waiting area
- Send patient to cath lab with following items:
Normal saline 1 pint, disposable needle 21 G, Dynaplast 1 roll, Betadine solution 100 ml multiply 2 bottles, injection gentamicin and injection cefazolin 1 dose, if not administered with premeditation
POST-PM CARE
- Keep patient in supine position and ask to maintain adduction of affected extremity
- Explain about bed rest for 24 hours and reduced activity for another 48 hours
- Connect patient to cardiac monitor and check rhythm
- Take 12 leak ECG with and without magnet
- Check wound for excess swelling or bleeding
- Get chest X-rays done
- Be alert for complications of procedure
Bleeding
Infections
Cardiac tamponade
Diaphragm stimulation
Failure to capture
- Inform the doctor if any complication occurs
- Check vital signs and observe wound hourly 4 hours then if stable, 4 hourly for 24 hours
- Discourage patient from vomiting, coughing or rolling into affected side
- Patient may gently roll into left side for pressures care
- Roll a patient immediately onto left side, if failure to capture occurs. If unsuccessful and patient is asymptomatic inform and administer IV atropine 0.6 mg as ordered
- Allow the patient to sit up slightly to eat (30 to 45 degrees)
- Administer analgesic as ordered
- Administer IV antibiotics usually 3 doses then remove IV cannula
- Transfer to ward after 12 to 24 hours
- Remove tight bandage after 48 hours and change dressing if required
- Allow to walk after 48 to 72 hours of rest
- Assist and encourage beginning range of motion exercises for affected shoulder as ordered, usually 5 to 7 hours after pacemaker insertion
- Remove sutures after 72 hours and patient is discharged with proper follow-up arranged
- Patient usually does not require any follow-up drugs
PATIENT EDUCATION
- Report to physician as recommended, so that rate of pacemaker and its function can be monitored. This is especially important during first month after implantation
- Check pulse daily. Report immediately of any sudden slowing increasing of pulse rate occurs. This may indicate pacemaker malfunction
- Resume weekly monitoring when battery depletion is anticipated
- Wear loose fitting clothing around area of pacemaker
- Inform reason for slight bulge over implantation site
Notify physician if area becomes red or painful
Avoid trauma to area of pacemaker
- Study operating instructions and become familiar with pacemaker
- Resume normal physical activity after 6 weeks, including sexual activity
- Avoid moving affected hand and shoulder vigorously for 6 weeks
- Avoid heavy sport
- Avoid carrying >5-10 pounds weight on affected side
- Carry an identification card indicating, manufacturer’s name, pacemaker model and hospital where pacemaker was inserted
- Avoid close exposure to microwave ovens, MRI and other sources of magnetic fields
- Show identification card and request scanning by hand scanner when passing through security gates, e.g. at airports, government buildings
- Avoid using cell phone on same side where implantation has been done
