Device diagnostics for heart failure: identifying eligible patients

The prevalence of heart failure has increased by 500% over the past 30 years, creating a significant burden on the health care system. Traditional means of detecting worsening heart failure, such as subjective assessment, symptoms, and physical examination, lack sensitivity and specificity. Many nurses who manage heart failure patients have become interested in the role implantable cardiac devices play in monitoring patients' clinical status. In addition to providing therapies, some devices track and report diagnostic information that allows clinicians to more closely and effectively monitor patients, with the possibility of helping to prevent hospitalizations and improve patient outcomes. Optimal use of device diagnostics requires clinics to establish systems for recognizing patients who are eligible for device monitoring. This paper highlights various methods clinics have used to identify patients with implantable cardiac devices so that their device data can be used in conjunction with clinical evaluations to help guide patient care.

Bedside nurses removing epicardial pacer wires: from concept to practice

Epicardial pacer wires inserted at the time of cardiac surgery are routinely removed prior to discharge. Traditionally, in most centres in Canada, this task has been carried out by physicians. Delays in discharge, insufficient patient preparation and inadequate monitoring practices post-wire removal have led to a need for a change in practice. The aim of this article is to present the development, implementation and evaluation of a project in which all bedside nurses on a post-operative cardiac surgery unit remove patients' epicardial pacer wires.

Cardiac resynchronisation therapy for patients with heart failure

Cardiac resynchronisation therapy (CRT) is a non-pharmacological treatment for heart failure. The method 'resynchronises' the contraction of the right and left ventricles, resulting in better cardiac output, thus improving symptoms. This article discusses symptoms, morbidity and mortality of heart failure; potential benefits of CRT to patients' quality of life; and the implications of CRT for nursing practice.

[Practical nursing guide in the critical patient]

Nursing staff that have recently arrived to the ICU, nurses and students, may feel anxiety and fear due to lack of skill and/or knowledge of the techniques, the service's organization and the diseases treated.

OBJECTIVES

1. To know the intensive care aspects that pose greater difficulties to the professionals newly incorporated into the ICU of the Hospital General Universitario of Alicante 2. To provide these professionals with a written guide that responds to the needs and situations that they face day to day. 3. Inform the nursing students, prior to the onset of their practice activities in the ICU, on a combination of basic procedures that make it possible to take better advantage of them. 4. Communicate and facilitate access to the information contained in the guide to the maximum.

MATERIAL AND METHODS

The professional workers who had recently received their degress and who worked in the ICU during the summery were surveyed to determine the techniques or procedures that posed the greatest difficulties. A <<practice nursing guide in the critical patient>> was designed in paper and electronic form.

RESULTS

The respiratory, Swan-Ganz catheter, defibrillation, cardiac arrhythmias and insertion of temporal pacemakers were the subjects posing the greatest difficulty. A total of 92% of the colleagues would re-chose their practices in the ICU; 33% liked working as a team most.

CONCLUSIONS

1. The technology used in the ICU poses problems for the recently arrived colleagues. 2. The guide may be used by the new professionals and students as work tool and contribute to communication between the university and the hospital. 3. The use of Internet to communicate the work done by the Nursing professionals offers great advantages and should be used as one more tool.

Cardiac Resynchronization Therapy

Heart failure is a major health problem in the United States, associated with high morbidity, mortality, and economic burden. Despite recent advances in pharmacological treatments to attenuate disease progression, medications become relatively ineffective, resulting in worsening congestive symptoms and increased exercise intolerance. Cardiac resynchronization therapy provides a new adjunct for heart failure patients who remain symptomatic despite optimized medical therapies. This article discusses cardiac resynchronization therapy and measures that should be considered to ensure proper functioning of the device and improved quality of life for patients.

Mastering temporary invasive cardiac pacing

Competent management of patients with an invasive temporary pacemaker is an important skill for nurses who provide care for critically ill patients with cardiac disease. Such management requires familiarity with normal cardiovascular anatomy and physiology, conduction system defects, and rhythm interpretation. With an understanding of the basic concepts of rate, output, chambers, sensitivity, and capture, pacing can be done with ease. Care of patients with a temporary invasive pacemaker requires monitoring cardiac tissue and hemodynamic status, observing for changes that would indicate the need for modifications in the pacemaker settings. Nursing interventions include physical assessment, care of the insertion site, routine threshold testing, and management of the pulse generator.

Implications for Nursing Care of Patients With Atrial Fibrillation

Atrial fibrillation is the most common sustained cardiac dysrhythmia treated in North America and Europe. As such, it is one of the current epidemics in cardiovascular disease. Findings from the AFFIRM (Atrial Fibrillation Follow-up: Investigation of Rhythm Management) and RACE (RAte Control versus Electrical cardioversion for persistent atrial fibrillation) clinical trials are presented and the current evidence for the management of atrial fibrillation using anticoagulation, rate-control, and rhythm-control strategies is outlined. Implications for nurses are discussed including physiologic and psychosocial interventions.

An overview of permanent and temporary cardiac pacemakers

As pacemaker technology comes closer to mimicking the heart's own pacing system, patients in need of such devices can hope to live increasingly normal and productive lives. This article outlines common types of cardiac pacing and indications for pacemaker insertion. Nursing considerations are outlined both during and following the insertion of a pacemaker.

Cardiac resynchronization therapy through biventricular pacing in patients with heart failure and ventricular dyssynchrony

Cardiac resynchronization therapy provides a new adjunct in the armamentarium of therapies available to patients who remain symptomatic despite optimized standard therapies. It does not cure heart failure; patients must maintain evidence-based therapies promoted by the American Heart Association and American College of Cardiology. Therapy benefits can be influenced by lead placement and device programming, so it is essential that qualified personnel are consulted to initiate and monitor therapy. While we await final analysis of COMPANION and other studies that definitively answer the question of mortality benefits, substantial data support CRT in reversing left ventricular remodeling, providing hemodynamic benefits, and most importantly, imparting clinical benefits related to functional status, symptoms, quality of life, and morbidity. Acute and critical care nurses can take an active role in promoting this intervention for patients with wide QRS and cardiac dyssynchrony who are likely to benefit through improvement in cardiac function and efficiency.

Heart failure patients with ventricular dysynchrony: management with a cardiac resynchronization therapy device

Despite an array of treatment modalities, the overall prognosis for patients with severe heart failure remains bleak. Biventricular pacing, or cardiac resynchronization therapy, is gaining increasing acceptance as a compelling treatment for those individuals with advanced heart failure (New York Heart Association functional class III or IV). This article provides a brief description of the atrial and ventricular conduction disturbances common in patients with advanced heart failure. Current indications for therapy are outlined, as are recent results of cardiac resynchronization therapy trials. The implant procedure is described to provide a comprehensive overview of this innovative approach to re-establishing normal electromechanical activity and synchronous right and left ventricular contractions. Patient care, before and after device implant, is also summarized. The focus on patient education throughout this article may allow it to serve as a reference for health care providers involved in the care of patients with severe heart failure.

Present status of cardiac pacing: a nursing perspective

In this article, we focus on the nurse's role as caregiver and patient advocate for individuals requiring cardiac pacing. The history of cardiac pacing, new trends, indications for pacing, pacemaker dysfunction and complications, types of pacing, and nursing considerations will be discussed.

Noninvasive pacing: what you should know

Noninvasive pacing is a valuable therapy in emergency cardiac care. The more experience clinicians have with the noninvasive pacing procedure, the greater their confidence and the easier the job becomes. Effective troubleshooting during pacing becomes less problematic with increased experience with the therapy. Noninvasive pacing allows rapid initiation of emergency pacing and "buys time" to stabilize the patient and plan further care.

[Pacemaker implantation. The nurse's role]

This article takes an indepth look at the role of a cardiological nurse in a coronary unit of a hospital where this nurse performs an important part in treating medical emergencies which seriously affect a patient's life. To begin with, a brief introductory section presents the physiological aspects related to cardiac stimulation, followed by the possible factors which indicate the use of an artificial stimulator. Techniques for implanting various types of pacemakers are described. A nurse intervenes in different ways in these procedures: a nurse aids in the pre-operation care and technical setup; a nurse aids the doctor while the pacemaker is being implanted; and during the postoperation phase, a nurse checks on the correct functioning of the pacemaker and if the nurse detects complications, she/he strives to bring an early solution to these problems. In order to carry out these duties, prior knowledge will provide nurses with a sureness of how to act when faced with emergencies.

Temporary transvenous cardiac pacing

This article is the seventh in our Care is Critical series which continues to look at the more complex interventions nurses now have to manage in acute general wards and the community. This article considers the use of cardiac pacing and takes us through the normal conduction system, types of pacemakers, and insertion and management of the line and generator. It also outlines common problems and dangers associated with this intervention.

Care and safety of pacemaker electrodes in intensive care and telemetry nursing units

BACKGROUND

Temporary pacing leads with electrodes are a potential risk, because microshock inadvertently transmitted across the catheter or wire can paradoxically cause lethal dysrhythmias. Much attention has been paid to this complication in clinical guidelines, but little is known about actual practices used to protect patients.

OBJECTIVES

A national survey was done to describe current practices related to the care of patients with temporary epicardial or transvenous pacing catheters. The survey focused on environmental factors that affect generation of static electricity, equipment used with temporary pacing, and nursing practices used when handling temporary pacing electrodes.

METHODS

The Pacemaker Electrical Care and Safety Survey was developed, validated, and pilot tested before it was mailed to all 895 hospitals that perform cardiac surgery. Surveys were sent to the coronary care unit, cardiac surgical ICU, and telemetry units of each hospital.

RESULTS

Responses were received from 476 units representing 388 (43%) of the 895 institutions. Most respondents reported using gloves, although few hospitals had policies mandating this practice. The insulating materials used most often, in order, were a glove or finger cot, tape, and gauze. Few units (25%) use any measure to reduce static electricity generated by movement over carpeting. Little attention was paid to insulating exposed epicardial temporary pacing electrodes at the generator.

CONCLUSIONS

Temporary pacing electrodes were usually handled in an electrically safe manner; however, little attention was paid to environmental sources of microshock or connections between the generator and the cable. Although the respondents reported using a variety of insulating materials, the ideal cover for the exposed tips of the electrodes has not yet been determined.

AANA Journal course: update for nurse anesthetists--cardiac pacemakers

Pacemakers are commonly encountered in our care of patients. It is essential for clinicians to have some understanding of indications for perioperative pacing; the function, design, and classification of the different types of pacemakers; and the clinical problems which may be encountered when caring for patients who have pacemakers. This installment of the AANA Journal Course addresses these issues.

Complications of epicardial pacing wire removal

Epicardial pacing wire removal (EPWR) is a procedure performed on postoperative cardiac surgery patients. Nurses who assist with or perform this procedure need to be aware of its possible complications; these include bleeding, pericardial or mediastinal tamponade, ventricular dysrhythmias, wire fragment migration, and infection secondary to retained wire fragments. Patients undergoing EPWR should be monitored for signs of complications; appropriate emergency equipment should be readily available, and nurses should educate patients on possible problems and interventions.

Temporary DDD pacing: evaluating hemodynamic performance

Temporary DDD pacing is new technology which requires careful nursing assessment and monitoring of the patient. Although nursing care for temporary DDD pacing patients is similar to permanent DDD pacing, there are some unique aspects related to the temporary nature of this treatment.

Permanent pacemakers in children

Care of children with permanent pacemakers requires sophisticated nursing knowledge and skills. The tremendous advances in pacemaker technology and complexity of modern pacing provide challenges for nurses caring for these children and their families. Knowledge of pacing physiology, components of the pacing system, indications for pacing, post-pacemaker implant care, trouble-shooting of pacemaker problems, child and family teaching, and long-term follow-up is necessary for provision of safe, effective nursing care.

The role of the critical care nurse in noninvasive temporary pacing

Noninvasive temporary pacing is safe and easy to use, but must be utilized early to be maximally effective. Early implementation of NTP can be enhanced if the critical care nurse is given the autonomy to implement NTP from an established protocol or unit standing orders.

[Nursing care of the patient with an artificial pacemaker]

The construction of high technology electronic artificial cardiac pacemaker and its application by the medical science has changed the way and the prognosis of the diseases of the cardiac conducting system. Nursing presence is essential in care of the patient with a cardiac pacemaker. In the operating theatre the nurse creates the most ideal environment and assists at the application of the artificial pacemaker; in the ward she observes with watchful glance for prevention of complications providing individual and holistic nursing care, and helps the patient and his family with rehabilitation and adaptation to his new way of life. In addition, the nurse teaches the patient how to observe the function of his pacemaker, and emphasizes the importance of keeping the doctor's orders and regularly visiting the outpatients cardiac pacemakers control department to check his pacemaker.

Epicardial pacing after cardiac surgery

This article focuses on the use of epicardial wires, the different types of pacing therapy, troubleshooting pacemaker problems, as well as the nursing management of the patient receiving epicardial pacing therapy.

Transcutaneous pacemakers

Transcutaneous pacing (TP) is technically the fastest, easiest, and least physically invasive of the accepted modes of cardiac pacing. Although first introduced in the early 1950s, TP was abandoned because of cutaneous nerve pain, skeletal muscle contraction, and local tissue burns associated with the use of the technique. The advent of transvenous pacing caused a further decline in interest in TP. Recent investigations suggest that this pacing mode has value when immediate pacemaker therapy is needed in the prehospital or hospital setting. As a result of the renewed interest in TP, the cardiovascular nurse should be aware of this therapy. The article presents a general overview of TP with emphasis on nursing care.

Pacing for tachydysrhythmias

Advances in cardiac electrophysiology have clarified some of the mechanisms of tachydysrhythmias and have characterized tachycardias that are amenable to pace termination. Tachydysrhythmias most likely to be terminated by pacing techniques tend to be slow, re-entrant tachycardias. Although single extrastimulation can be effective, its yield is relatively low. Delivery of multiple extrastimuli or burst pacing are more effective than single extrastimulation at the expense of a higher risk of tachycardia acceleration or transformation of the rhythm to fibrillation. The use of pacing for the termination of tachydysrhythmias has primarily been limited to the acute care setting, although permanently implantable antitachycardia pacemakers are being used in increasing numbers. While these devices have been approved by the Food and Drug Administration (FDA) for the treatment of supraventricular tachydysrhythmias, their use to treat ventricular tachydysrhythmias has produced mixed results and remains investigational. In some cases of sustained ventricular tachycardia, automatic cardioverter/defibrillators have been implanted along with antitachycardia pacemakers to provide high-energy shock back-up in case of tachycardia acceleration by the pacemaker. Soon, devices will be available which will combine, in a single unit, antitachycardia pacing and high-energy cardioversion/defibrillation.

Dual-chamber pacing

Dual-chamber pacing has been available since the early 1980s, yet it is a topic with which critical care nurses consistently have difficulty. New advances in pacemaker technology have built on the principles inherent in dual-chamber pacing, making it imperative that practitioners have a basic understanding of dual-chamber pacemaker function. With dwindling clinical resources, the responsibility of the bedside nurse to evaluate appropriate pacemaker function and identify the patient's response to pacemaker therapy has increased.

Transcutaneous cardiac pacing

Pacemaker technology has experienced many advances. Today temporary pacing can be provided in several ways. This chapter examines one of these modalities, transcutaneous noninvasive pacing. In addition, this chapter reviews relevant historic milestones, describes transcutaneous pacing, state procedural aspects, and delineate important nursing aspects of care.