Pacemakers

Have questions about administering therapy or a unique patient? Discuss EECP techniques with other clinicians.

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Pacemakers

Postby penguin » Wed Jan 21, 2009 4:25 am

Hi
I am hoping that people can share their experiences with treating patients with pacemakers.
Problems that can occur include:-
*Inaccuracy of inflation/deflation timing due to irregular looking rhythm
*Spiking on the ECG leading to the machine interpreting this as a heart rate above 120bpm
*The machine interpreting the rhythm as irregular so it cuts out regularly
*All the above lead to an uncomfortable experience for the patient
Do any EECP therapists encounter this problem and have found a great way to decrease the issues?
Many thanks :|
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Re: Pacemakers

Postby eecpjoanne » Wed Jan 21, 2009 1:19 pm

I have almost 11 years years experience in treating EECP patients and many have pacemakers.

1. If you have a patient with the 'rate response mode" turned on , usually you need to cancel that particular setting for the treatment hour. If not, usually a few minutes after you start treatment their PM rate will slowly climb to >100 bpm since the pacemaker mistakenly thinks that the patient is up and exercising due to the chest wall movement during EECP. Eg: Set a DDDR pacer to DDD for the hour, VVIR to VVI, etc. You then return them to their original mode after each traeatment, unless your physician agrees to keep the rate response off for the whole 35 treatments. Of course you have to have the PM programmer available to do this. If you do not, then talk to your physician about placing a magnet over the PM during the ytraetment. This will also change the setting. Discuss these changes with your physician before attempting them. Also make sure the patient understanding that you are "changing" some settings to give them a better experience with EECP. Avoid telling them you are "shutting off or turning off or deleting" something. Many patients don't understand and think you have turned off their pacemakers and they are panicky during treatment, but may not verbalize that to you.

2. Another problem can be a PM patient with a competing intrinsic rhythm or underlying AF. They can often have a "rough ride". Often in addition to cancelling rate response for treatment, often you can "override" the intrinsic rhythm by increasing the PM base rate. For instance, A DDDR patient with a base rate of 60 -70 (most common settings) may improve with a setting of DDD - rate 80 - 85. Again your physician will have to approve. Return to original settings post-treatment.

3. Patient with or without PM who have either a changing rhythm or frequent APCs / PVCs may also benefit from trying different lead placements or configurations. I try to find the lead placement for the underlying rhythm that best "resembles" the arrhythmia. I use all possible combinations of black & white electrodes either on shoulders, below breast line & mid-sternal to "mimic" the shape, width &/or upward / downward slope of QRS. The patient may still have pauses her and there but the machine tends not to totally stop so often and give them the "big squeeze" they all complain about.

I hope these ideas help you. Please also visit the IETA (International ECP Therapists Association) website at www.ietaonline.com for other information & membership.
Joanne Giordano, LPN, CET
IETA President
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Re: Pacemakers

Postby spacheco » Wed Jan 21, 2009 2:03 pm

We have found that flipping leads and moving lead sites usually resolves the issues you describe. We have a patient currently with a pacer and place the white lead on the lower left and the black in the upper right....it gives us a clearer wave form and the machine's interpretation does not create
such a difficult treatment. Change the direction of current and usually it solves the problem..
Hope that helps,
Suzanne
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Re: Pacemakers

Postby swinn » Thu Jan 22, 2009 6:45 am

Thank you for the advise on 'flipping the leads'. I have a patients with a bi vent pacemaker (without rate response) who is having a really bad time with 'multi focal ectopics. He has a SR of about 4 beats and its becoming more and more uncomfortable for him. I have changed the leads and I have now found that the machine does not completley stop anymore although the patient is still having a rough time, it doesn't seem so bad. :D
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Re: Pacemakers

Postby skiersid2 » Fri Jan 23, 2009 4:17 pm

My name is Cindy Watts and I am a Clinical Application Specialist for Vasomedical, Inc. I have had many, many calls over the years regarding treating patients with EECP Therapy who have pacemakers. The issues with pacemakers are listed in order of occurence:

1. Lead Placement: I have found the best lead placement for a patient who has a pacemaker is to place the leads directly up and down the sternum, about a half an inch apart, white on top, green in the middle, and black on the bottom. After doing this, if you have a negative R wave, flip the white and the black leads, this changes the polarity of the entire complex, and the R wave will now be positive. The system seems to trigger with more ease with a positive R wave. Having the leads straight up and down on the sternum seems to help the QRS complex not to appear so wide and bizarre looking and allows the system to trigger with more ease. Some patients with pacemakers may trigger fine with the traditional lead placement (white on right clavicle, green on right 4th to 5th rib at mid-clavicular to axillary line and black on left 4th to 5th rib mid-clavicular to axillary line). Also, as previously mentioned by a poster, some patients may benefit from flipping the black and white leads using this lead configuration.

2. Rate Response Mode Activation of Pacemakers: As Joanne mentioned, the rate response mode of patients with pacemakers is often activated during EECP Therapy because the pacemaker thinks the patient is exercising and drives up the heart rate to accomodate the patient's cardiac output. If the rate response mode is activated during EECP, the heart rate may increase to greater than 120 BPM which is outside the safety feature limit of the system, thus, making treatment impossible. The rate response mode can be turned off and back on with every EECP treatment if a programmer is available. For EECP centers without a programmer, the rate response mode can be turned off for the entire course of treatment. Having the rate response mode off for the entire course of treatment should not present any problems in a sedentary patient. If a patient is very active and the rate response mode is left off, the patient could experience fatigue due to the patient's heart rate not increasing during exercise to accomodate the patient's cardiac output. The use of a magnet over a pacer will automatically convert it to a fixed rate pacer. I would not recommend the use of a magnet in patients who have an ICD (Internal Cardiac Defibrillator). Placing a magnet over the pulse generator of an ICD/pacer combo or an ICD alone blocks the ability of the device to sense a potentially lethal arrhythmia if one should occur and it would not be able to deliver the necessary shock to the patient. As always, any adjustment to a patient's pacemaker by using either a programmer or a magnet should only be done as ordered by the patient's cardiologist.

3. Patient's Intrisic Rhythm Interference with the Pacemaker: Some patients have their own heartbeats that compete with their pacemaker, making triggering of the EECP system interupted from time to time. As posted by Joanne, overdrive pacing can be done to increase the BPM, to attempt to not allow the patients underlying rhythm the opportunity to kick in, making treatment much more consistent and comfortable for the patient. Again, any adjustments to the patient's pacemaker should only be done as ordered by the patient's cardiologist.

Hope this info is helpful to all,
Cindy

Cindy Watts, RN, BSN, CET
Senior Clinical Application Specialist
Vasomedical, Inc.
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Re: Pacemakers

Postby spacheco » Tue Jan 27, 2009 10:31 am

I'd like to expand a bit on patients with rate response issues. We have experienced many different situations with patient tolerance of having rate response turned off. We were able to turn it off for the entire 7 weeks on occasion, but later found turning it off for the week and on for the week-end when the patients are generally more active was a better solution. We have had some patients that did not tolerate leaving the R off post tx and became symptomatic. My recommendation is to treat each patient individually. We have the capability to program ( in-hospital) and have been trained to manage the R components ourselves.
Suzanne Pacheco RN
631 444-8420
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Re: Pacemakers

Postby mrae » Tue Mar 03, 2009 1:51 pm

On our device pts we make sure the response rate is turned off before we do any treatment. Then it is turned back on afterwards. :idea:
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Re: Pacemakers

Postby audreya » Wed Mar 09, 2011 5:59 am

What is the new pacemaker that heals the heart? My dad was just telling me about a pacemaker that was recently created by either central Michigan university or michigan state university that heals the heart. What is this called? I would like to see if there is a way for my dad to get it.
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Re: Pacemakers

Postby woneeza » Tue Apr 12, 2011 3:02 am

Can a person with a pacemaker use hot tubs or hot springs? My mom is 83 and just had a pacemaker put in and we would like to go to a couple of hot springs in Montana. Is it safe?
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Re: Pacemakers

Postby brookexy » Tue Dec 06, 2011 6:14 am

Why pacemaker paces the Atrial and ventricle in the same time? I just curious why the pacemaker has to pace the Atrial and ventricle in the same time? If Sick Sinus Symptom or A-Fib happen, why can't just pace the Atrial and leave the ventricle alone?
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