Page 720 - Cardiac Nursing

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696 PA R T I V / Pathophysiology and Management Disease
because it may cause permanent damage to the ICD. Inadvertent
DISPLAY 28-9 Potential Complications of Implantable contact between the generator and magnets should be avoided
Cardioverter-Defibrillator
because changes in the magnetic field may inactivate the pulse
Adverse Events Associated with Surgery generator or cause erratic functioning. 25 Tachyarrhythmia de-
tection must be programmed OFF before subjecting the patient to
Subclavian stick complications
Pneumothorax procedures that induce strong EMI. If detections are turned OFF,
Hemothorax the patient must be monitored. Once the procedure is completed,
Air embolism the ICD should be reprogrammed to the active mode. Placing a
Subclavian artery puncture magnet over the ICD will inactivate it temporarily in most cases.
Bleeding Some ICDs can be programmed to ignore a magnet, and some
Right ventricular perforation have been programmed off due to a magnet switch problem. Plac-
Thromboemboli ing a magnet over the ICD to temporarily disable shocks is also an
Venous occlusion option for disabling therapy. If a patient has a VT or VF episode,
Pericardial effusion/tamponade removing the magnet will allow the ICD to treat the arrhythmia
Pocket hematoma quickly. If the ICD were programmed off, it takes a programmer
Hypotension—hemodynamic compromise
Cerebrovascular accident and extra time to reactivate the ICD, delaying treatment time of
Proarrhythmia the arrhythmia. Close communication with the patient’s implant-
ing physician should be made before determining deactivation
Adverse Events After System in Place technique of the ICD using a magnet or programmer. The facil-
ity performing the medical procedure should have a policy re-
System related
Lead dislodgement garding preprocedure interrogation and disabling ICD therapies.
Loose setscrew Patient safety during the procedure to eliminate inappropriate
Lead fracture shocks, and postprocedure to insure that the ICD has been pro-
Lead insulation defect grammed to the initial settings is crucial.
Exit block Antiarrhythmic medications are often used in conjunction with
Premature battery depletion ICD therapy to decrease arrhythmia occurrence. The antiarrhythmic
Chronic nerve damage drugs can result in complications by changing the appearance or
Diaphragmatic stimulation rate of the arrhythmia or by altering the DFT. The arrhythmia rate
Erosion of pulse generator may be slowed below the cut-off rate so that the ICD fails to iden-
Fluid accumulation/seroma tify VT. Drugs could change the DFT, resulting in ineffective
Infection of the pocket/system
Keloid formation shocks. Amiodarone, for example, increases the threshold. Repeat
Venous thromboembolism EPS testing with the ICD may be required to reprogram VT zones
Endocarditis capable of sensing and treating different VT after the addition of an
antiarrhythmic. 93
Standard Precautions
hospital discharge occurred 3.63% of the time. Procedure related External Defibrillation
deaths were reported to be 0.02%. The two most common compli- Patients with an ICD should be treated like any other patient
cations reported were hematoma, which occurred 1.27%, and lead without an ICD when sustained arrhythmias are present. ACLS
dislodgement 1.01%. 88 Potential complications of ICD implanta- with rapid defibrillation should be initiated when the ICD is in-
tion are listed in Display 28-9. One of the most serious complica- effective or not delivering therapy. 83 ICDs are designed to with-
tions is infection of the ICD system. Removal of the entire ICD sys- stand external defibrillation. However, possible circuit damage or
tem is mandatory, and a long course of antibiotics is necessary. loss of output may occur if the external paddle is placed to close
Infection rates are higher after a generator replacement when to the device. If at all possible, the anterior–posterior approach
compared to rates with initial implants, 92 Surgical revision of the should be used for external paddle placement (Fig. 28-42). Direct
ICD system may be necessary after lead dislodgment in the early re- defibrillation could cause permanent damage to the ICD or the
covery period (24 to 72 hours) or lead fracture, which is seen in implanted leads. After external defibrillation the ICD should be
long-term follow-up. Lead-related problems have been reported to interrogated to assess device function. During cardiac resuscita-
be as high as 20% in 10-year-old leads. Patients with lead defects are tion when CPR is in progress shocks from the ICD may be felt,
often the younger more active patients. Lead fractures or insulation but will not harm rescuers. 81,93,94
issues can lead to false sensing and inappropriate shocks. 72,73
EMI can result in inappropriate discharge or inhibition of Pacemaker Interaction
the ICD. These problems can be temporary or permanent. The With the advent of dual-chamber ICDs, the problems with device
delivery of inappropriate therapy can actually produce tach- interactions between separate systems have been eliminated. If a
yarrhythmia. Sources of interference include, but are not limited patient has an older-model ICD in place and requires a temporary
to electrocautery, diathermy, hydraulic shock-wave lithotripsy, or permanent pacemaker in conjunction with the ICD, special
current-carrying conductors, arc welders, electrical smelting fur- care is required. For those patients who may still have an older sys-
naces, and radiofrequency transmitters such as radar, high-voltage tem in place, unipolar pacemakers are contraindicated because the
systems, theft prevention equipment, and high-powered electro- larger pacing pulse associated with unipolar lead systems may be
magnetic fields. Magnetic resonance imaging is contraindicated mistaken by the ICD for the patient’s intrinsic rhythm. Three