Page 723 - Cardiac Nursing

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C HAPTER 2 8 / Pacemakers and Implantable Defibrillators 699
and very little data available on interventions there is a need for a Follow-up Care
large-scale clinical trial to determine the most optimal intervention
to decrease anxiety, and increase QOL for the ICD patient. 96,100 Regular ICD follow-up is necessary to assess the patient’s clinical
status, ICD battery status, and device function. Review of stored
Automobile Driving electrograms provides diagnostic information for treated episodes
Patients with an ICD placed for secondary prevention of VT or of tachyarrhythmias. In general, there are two components of the
VF, may be restricted from driving for up to 6 months. The main follow-up: (1) assessment of the patient’s status, reviewing the car-
concern is the risk of an arrhythmic event or the delivery of a diovascular-medical condition of the patient as well as screening
shock while driving. The length of the driving restriction depends for medication changes and (2) the defibrillator and lead are as-
93
on where the patient resides and state/country regulations. The sessed for normal device function.
patient who has an ICD placed for primary prevention should be The ICD pulse generator is highly reliable but must be ob-
restricted from driving for at least 1 week, until recovered from served for battery status and charge times. When pulse generator
surgery. Thereafter, primary prevention patients would not have defects do occur, they can be manifested by early battery depletion.
any driving restrictions unless they subsequently receive therapy Battery status is monitored at each follow-up visit (Fig. 28-43). If
for VT or VF. If they receive a shock, particularly in the setting of the device is close to its ERI, more frequent visits may be required.
syncope they would be subject to the same driving restrictions as Episode data are reviewed and compared with the patient’s clinical
those patients who had an ICD placed for secondary prevention. symptoms. Stored electrograms provide trending information on
Patients with ICDs, implanted for both primary and secondary the frequency and severity, if any, of spontaneous ventricular ar-
prevention cannot be certified to drive commercially. 105 Driving rhythmias (see Display 28-11) for information regarding remote
restrictions can cause feelings of isolation, anger, and loss of au- follow-up.
tonomy, because driving is an important part of maintaining in- The lead system is evaluated by testing lead impedance, com-
dependence. 106 It is important for the patient to realize that the pleting pacing thresholds, and determining appropriate R-wave sens-
symptoms are associated with ventricular arrhythmias, not the ing. Evaluating the marker channel and real-time electrograms will
ICD, which makes driving potentially dangerous. After 6 months, identify appropriate R-wave sensing. Potential for lead problems can
if the patient has not had an ICD discharge, he or she may resume be identified if inappropriate sensing is noted. Chest radiographs
93
noncommercial driving. should be used periodically for evaluation of system integrity.
Patients may report discomfort with using a seatbelt, because the Episode data are reviewed and compared with the patient’s
shoulder strap comes across the ICD implant site for a driver with clinical symptoms. Stored electrograms provide trending informa-
a left pectoral implant and for a passenger with a right pectoral im- tion on the frequency and severity, if any, of spontaneous ventric-
plant. Seatbelt shoulder protectors are recommended and can be ular arrhythmias.
found in stores selling auto parts, or can be ordered from medical
supply companies. Simple padding can also be placed over the ICD. Troubleshooting
Patients should be encouraged to continue using seat belts. Differentiating appropriate from inappropriate device function
when a patient receives an ICD discharge or experiences symp-
Real Versus Phantom Shocks toms such as syncope or palpitations can be challenging. Eval-
Once a patient feels a shock they fall into one of three categories: uation of a single ICD shock is usually performed in the out-
(1) A shock was delivered appropriately for VT or VF. (2) A shock patient clinic, or with remote monitoring. Multiple successive
was delivered inappropriately due to sensing of a rapid supraven- shocks constitute a medical emergency and require a hospital
tricular rhythm, electrical noise from EMI, or artifact from a frac- admission for evaluation. 57,72,93 The initial approach is two
tured lead. (3) No shock was delivered and they perceived a phan- fold, identifying the problem, and comforting the patient. Are
tom shock. 107 Patients are certain that they have received a shock, the shocks appropriate? What is the arrhythmia: SVT, VT, or si-
but when the ICD is interrogated, there is no record that a dis- nus tachycardia? If the patient does not have a ventricular ar-
charge has occurred. This phenomenon is known as a phantom rhythmia the ICD needs disabled, either with a magnet or with
shock. Phantom shocks, often occur as the patient is drifting off to a programmer. If the patient is having incessant VT or VF an-
sleep and more commonly in patients with previous ICD dis- tiarrhythmics, reprogramming of the ICD and ablation could
charges. 108 It is important to spend time reassuring the patient and be helpful. 57,93
family. Patients may find it helpful to review interrogated print- Approximately 20% to 30% of patients with ICDs that use
outs. heart rate only as the detection criterion receive an inappropri-
An ICD discharge can be frightening for both the patient and ate shock, most commonly from atrial fibrillation or sinus tachy-
spouse, particularly if the shock occurs with sexual activity. The cardia. Detection enhancement criteria using stability and sud-
patient may need to have the tachycardia detection rate increased den onset have been useful in decreasing shocks. The patient’s
if sexual activity increases the heart rate enough to meet the de- medications are often adjusted. -Blockers are used to decrease
tection criteria. Education and support regarding shocks should AV conduction; antiarrhythmics are used to decrease the fre-
be provided to the patient. Professional counseling should be rec- quency of atrial fibrillation. When stored electrograms are avail-
ommended for the patient and spouse with emotional concerns. able, the appropriateness of ICD therapy can be evaluated im-
If the patient has had multiple ICD discharges during an oc- mediately. The ICD also tracks nonsustained episodes, allowing
currence of an “ICD storm,” in which they experience three or the health care provider to know the frequency and severity of
more shocks in a 24-hour period, they will likely experience arrhythmias. 93
symptoms of anxiety. These patients should be reassured, but if If the patient is receiving multiple ICD discharges and not
symptoms persist, then referral to psychiatric specialists for treat- having clinical symptoms, then dislodged lead, fractured lead, or
ment of depression and anxiety should be considered. 96 double counting of QRS and T waves should be suspected. The