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Pacemakers (permanent), ICDs and device implants

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Contact details

On call Pacemaker Technologist : Ph 021808605

Pacemakers

Usual Indications

  • Long QT associated with bradycardia
  • Congenital complete heart block with rates less than 50bpm, a history of syncope, poor ventricular function or other conductive tissue disease.
  • Post surgical complete heart block.
  • A small number are due to sinus node problems

Types of Pacemakers

  • Epicardial systems are the most common due to the size of the patients. In the tiniest patients unipolar leads are used. In the bigger infants - bipolar leads. In Fontan patients endocardial systems are unable to be used as there is no venous access to the right ventricle.
  • Endocardial systems are often used in the larger children/teenagers.
  • Devices can be single, dual chamber or biventricular depending on the pacing indication.

Guidelines for organising a permanent pacemaker implantation

It is not adequate to only forward a patients name "for a pacemaker" because:

  • pacemakers vary in complexity (single versus dual chamber)
  • with different lead options (epicardial vs endocardial), patient size and co-existing heart disease, that impact on decision making
  • Management of children with pacemakers is co-ordinated by Dr Jon Skinner where possible.
  • Surgeons usually do implantation in small children or those requiring epicardial systems due to complex congenital heart disease).
  • In older children where endocardial systems are indicated, implantation is done by one of the adult cardiologists (Nigel Lever or Margaret Hood), these doctors and Warren Smith are happy to be consulted in Dr Skinner's absence.

Reveal Devices

Monitors implanted under the skin which continuously monitor the ECG but discard the information unless the device is activated. Patients carry an activator with them and if they have symptoms they place the activator over the device which will save (usually 10 mins) the ECG recording. Automated capture parameters can also be set up but these are unreliable and can often fill up with artefact and overwrite actual episodes.

Usual Indications

  • Syncope of unknown origin
  • Palpitations

ICDs : (Internal Cardiac Defibrillator)

Devices designed to treat VT or VF by using either shock therapy or anti-tachycardia pacing. These are rarely implanted in very small children or babies because of the large size of the device and leads.

Usual indications

  • Survival of cardiac arrest with documented VT or VF
  • Long QT with significant risk factors (i.e. syncope or non sustained VT.)
  • Documented VT and a risk of further events
  • Hypertrophic cardiomyopathy with significant risk factors

AEDs: (Automatic External Defibrillator)

A few very young children and babies who are still too small or unsuitable for ICDs have an AED which their caregivers are trained to use. These patients are seen routinely in Pacemaker Clinic for education and to check device function.

Usual indications

  • Survival of cardiac arrest with documented VT or VF
  • Long QT or Brugada syndrome with significant risk factors and ICD contraindicated
  • Documented VT and a risk of further events

Patient & Family Education

The physiology department will provide all education for families about pacemaker, ICDs and Reveal devices.

Procedure for Pacemaker and ICD Implantation

Contact details: On call Pacemaker Technologist: Ph 021808605

Investigations Pre Implant

Patients will require a general anaesthetic. The usual tests for this are required

  • CXR
  • ECG
  • ECHO
  • Bloods - serum electrolytes, full blood count, group and hold and coagulation studies if on aspirin or Warfarin
  • Blood ordered: usually x1 adult pack or 2 paediatric packs, occasionally blood for bypass may be ordered -check with surgeon or cardiologist

Education:

Can be given prior to an implant but decisions on device type and system are often formalised in the operating theatre. Booked patients have usually had a consultation with their specialist prior to coming into hospital. Acute patients generally have little warning so often there is no time to do this prior to implant. If a patient or parent requires education / information prior to implant then please call the On-Call Physiologist and they can ensure that appropriate information is given.

It is not appropriate for the children or parents to watch the standard adult pacemaker implant video as these types of systems are not routinely used in children.

ICD patients will always have education prior to implant. The decision to proceed with this therapy is always made in a multidisciplinary meeting that involves the Electrophysiologist, Surgical Team and Cardiac Physiologists.

Implant

Physiologists will document the type of pacemaker/device and programmed settings in the patient chart.

Post Implant

Medications:

  • Pain relief: please avoid the use of non steroidals in the immediate post operative period
  • Restarting anticoagulant therapy: please discuss with surgeon and cardiologist


Wound Care:

  • Should Leave hospital with an occlusive dressing covering surgical site (e.g. Comfeel Plus)
  • Dressings over pacemaker surgical sites need to stay in place for 14 days. Parents and child need to be instructed not to get area wet for 7 days after surgery (can sponge over wound dressing but not to immerse in water for three weeks)
  • If any problems with surgical site (i.e. redness/ inflammation): family should be instructed to contact the nearest pacemaker clinic as soon as possible (contact details will be given to family by the Pacemaker Clinic prior to discharge from hospital). If they are experiencing any problems accessing their local Pacemaker clinic they will need to go to the nearest Emergency department not the local GP.

Education:

Where possible contact the Pacemaker Physiologist prior to pacemaker insertion and they will do a pre operative education session with the family. A Pacemaker Physiologist will automatically come and see the patients the next morning to check the pacemaker and discuss the following points with the caregiver and patient.

  • Wound care and when to seek further advice - i.e. if any signs of infection they must contact the Pacemaker Clinic and we will organise for medical review if indicated.
  • Arm movement restrictions - all patients who have endocardial systems implanted will be asked not to make extended arm movements or raise their arms above the shoulder on the side that the pacemaker or ICD is implanted on. This is to prevent dislodgement of the pacing lead. Patients must move their arms otherwise a frozen shoulder can occur. This does not apply to patients with Reveal devices implanted.
  • A booklet from the manufacturer about the device which outlines the potential for interference with the device will be given to the patient. It covers use of cell phones and other common equipment around the home and medical environment that may impact on device settings.
  • Patients will also be given an instruction sheet outlining the above points that have been discussed with them.

Follow Up Pacemaker Checks

  • Day post surgery - Pacemaker Physiologist will review pacemaker settings /parameters. Automatically organised by the Pacemaker Clinic.
  • Pre discharge - to fine tune programming of the device. Ward to contact pacemaker clinic prior to discharge.
  • Post discharge - At first post surgery check patients will be advised on follow up arrangements. Local patients are seen at Auckland Hospital Pacemaker Clinic 2 weeks post implant. For all out of town patients Pacemaker Clinic staff will send all relevant information to the nearest Clinic and arrange for a 2 week check.

When to call the Pacemaker Clinic

  • If the patient does not understand the educational material and wishes to have further education.
  • If the patients heart rate is slower than the programmed rates documented in the patient notes.
  • If an ECG shows pacing spikes in the wrong place i.e. not before a p wave or a QRS.
  • If the patient has an abdominal twitch in time to their pulse.
  • If there is a syncopal episode
  • If an ICD patient has a shock inappropriate or appropriate.
  • If a Reveal patient has an episode. If the patient has not used the activator the Pacemaker Clinic Staff must be called as soon as possible.
  • If the surgical site looks red and inflamed

Procedure for Reveal device Implantation

  • Is usually just a day stay procedure
  • Will require a nursing and medical admission
  • May have bloods done / ECG & CXR (although this may have been done in preadmit clinic)
  • Requires minimal work up - check with surgeon / anaesthetist first
  • Education about the reveal device and how to use the activator will be provided by the physiology department

Contact details: On call Pacemaker Physiologist 021808605

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Document Control

  • Date last published: 01 August 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Cardiology
  • Author(s): Jon Skinner, Marion Hamer, Susan Sinclair
  • Editor: Marion Hamer
  • Review frequency: 2 years