老年患者永久起搏器植入术后早发型囊袋感染的处理

起搏器囊袋感染是永久起搏器植入术后较为常见的并发症之一,若不及早发现和处理,将导致囊袋破溃,迁延不愈,严重者可出现感染全身播散,甚至合并感染性心内膜炎.我院1989年10月-2006年10月共有122例患者行永久起搏器植入术,其中2例发生囊袋感染,经及时治疗后治愈,报告如下.     

运用整形外科方法治疗心脏起搏器置入术后起搏器外露围手术期的护理

安装永久起搏器是治疗严重缓慢性心律失常患者的重要手段,而术后常见并发症有电极脱位、囊袋血肿、感染、起搏器功能障碍等,而老年人安装起搏器术后并发症明显增多,已引起临床高度重视。起搏器置入术后一旦出现皮肤破溃、起搏器外露等并发症,尤其是皮肤缺损,反复感染,常规抗炎治疗很难见效,处理起来较棘手。自2008年-2009年12月我科对15例置入起搏器后外露的老年患者,     

44例永久起搏器手术临床疗效分析

目的:总结分析永久起搏器植入术后心脏功能、并发症种类及原因.方法:随访永久起搏器植入术后患者左心室射血分数(LVEF),观察并发症的种类,分析其原因.结果:右室心尖部起搏(RVA)术后6个月时LVEF明显低于术前,右室间隔部起搏(RVS)组无明显变化.发生起搏器并发症4例,起搏器囊袋血肿2例,电极移位及电极导线断裂各1例.结论:RVS更符合心脏生理起搏节律,术后心功能改善优于RVA.严格执行操作规范,术后加强随访,以降低并发症发生率.     

31例永久性心脏起搏器植入术后患者的临床护理及健康教育

目的总结安置永久性心脏起搏器植入术后患者的临床护理及健康教育措施,为提高患者术后生活质量提供客观参考。方法对31例安装永久性人工心脏起搏器的患者给予术后严密监测病情变化、加强并发症的预防和护理及规范实施健康教育等措施。结果本组患者术后1周内发生囊袋血肿2例,术后3个月发生起搏器综合征1例,经对症处理和抗心衰等综合治疗及护理后康复。未发生切口及囊袋感染、电极导线脱位、起搏阈值升高、心外肌肉收缩等其他并发症。复查起搏器感知及起搏功能良好。结论对永久性心脏起搏器植入术后患者采取系统护理和健康教育等干预,可降低术后并发症发生率,提高患者健康意识和自觉规避起搏器的不规范使用习惯,以改善其生活质量。     

永久心脏起搏器植入术后并发症的护理干预

目的分析永久心脏起搏器植入术后并发症的护理措施。方法对33例心脏起搏器植入术患者的临床护理资料进行回归性分析,总结对其术后并发症的实施综合护理的方法。结果本组33例患者均顺利植入起搏器,术后发生并发症3例(9.01%)。其中囊袋出血2例,起搏器综合征1例,经综合护理后全部康复,无电极移位等其他并发症发生。出院时患者症状明显缓解,起搏器感知及起搏功能良好。结论对实施起搏器植入术患者重视术后并发症的预防,有针对性的实施综合护理措施,可降低术后并发症发生率,提高手术效果,改善术后患者生活质量。     

自制三头包扎带预防起搏器囊袋相关并发症

目的探讨自制三头包扎带预防永久性起搏器囊袋相关并发症的效果。方法将120例放置永久性起搏器的患者随机分为对照组与观察组各60例,对照组患者术后采用传统弹力绷带加压包扎,观察组患者术后采用自制三头带加压包扎,7d后比较两组囊袋出血、破溃、感染发生率和患者舒适度。结果观察组患者囊袋血肿、囊袋破溃发生率显著低于对照组,患者术后舒适度评分显著高于对照组(P0.05,P0.01)。结论自制三头包扎带较传统弹力绷带包扎能减少永久起搏器植入术后的囊袋出血、破溃发生率,增加患者的舒适度。     

永久起搏器植入术后压迫方法的改进

目的探讨降低永久起搏器植入术后并发症、提高患者舒适度的伤口护理方法。方法将200例永久起搏器植入术后患者随机分为对照组和观察组各100例。对照组采用传统沙袋压迫法进行伤口处理,观察组采用X型加压包扎方法进行伤口处理。结果两组均未发生电极脱位,观察组伤口出血、伤口疼痛及肩背疼痛发生率显著低于对照组(均P0.01)。结论永久起搏器植入术后采用X型加压包扎不影响电极位置,可降低伤口出血发生率,提高患者术后舒适度。     

早期下床对主动电极起搏器植入患者舒适度的影响

目的探讨提高主动电极起搏器植入患者舒适度的方法。方法将88例主动电极起搏器植入患者随机分为常规组和观察组各44例。常规组术后24h下床活动,观察组术后6h即下床活动。分别于术后6h、24h、7d比较两组舒适度、电极脱位和囊袋出血发生率。结果两组患者术后6h、24h舒适度比较,差异有统计学意义(均P0.01);两组电极脱位和囊袋出血发生率比较,差异无统计学意义(均P0.05)。结论指导主动电极起搏器植入患者术后6h下床活动,能提高患者舒适度,同时并不增加电极脱位和囊袋出血的发生率。     

永久起搏器植入术后压迫方法的改进

目的 探讨降低永久起搏器植入术后并发症、提高患者舒适度的伤口护理方法.方法 将200例永久起搏器植入术后患者随机分为对照组和观察组各100例.对照组采用传统沙袋压迫法进行伤口处理,观察组采用X型加压包扎方法进行伤口处理.结果 两组均未发生电极脱位,观察组伤口出血、伤口疼痛及肩背疼痛发生率显著低于对照组（均P＜0.01）.结论 永久起搏器植入术后采用X型加压包扎不影响电极位置,可降低伤口出血发生率,提高患者术后舒适度.     

早期下床对主动电极起搏器植入患者舒适度的影响

目的 探讨提高主动电极起搏器植入患者舒适度的方法.方法 将88例主动电极起搏器植入患者随机分为常规组和观察组各44例.常规组术后24 h下床活动,观察组术后6h即下床活动.分别于术后6h、24 h、7d比较两组舒适度、电极脱位和囊袋出血发生率.结果 两组患者术后6h、24 h舒适度比较,差异有统计学意义（均P＜0.01）;两组电极脱位和囊袋出血发生率比较,差异无统计学意义（均P＞0.05）.结论 指导主动电极起搏器植入患者术后6h下床活动,能提高患者舒适度,同时并不增加电极脱位和囊袋出血的发生率.     

Permanent cardiac pacing for chronic symptomatic atrioventricular block in uremic hemodialysed patients. A prospective study

Though sudden cardiac death accounts for as much as 15% of all cause mortality in uremia, reports concerning advanced A-V block, requiring permanent cardiac pacing in end-stage renal disease (ESRD) hemodialysed (HD) patients are very few. This is the first long term prospective study reporting on systematic permanent pacemaker implantation, in a cohort of ESRD patients from a single HD unit. Between 01/06/1997 and 30/12/2001, 396 pacemakers were inserted for advanced, symptomatic A-V block in our institution, including 5 in ESRD, HD patients (M/F--4/1, age 47-73, M +/- SD--61 +/- 12 years) from a single dialysis center, treating 137 patients during the study period. Thus, the incidence and prevalence of A-V defects treated by permanent pacing in uremic patients was 0.81% and 3.65% respectively. Conversely, the incidence and prevalence of ESRD treated by hemodialysis, among patients with advanced A-V conduction disturbances, requiring permanent pacing were 0.28% and 1.26%. Mitral valve calcifications were present in all patients; 3 subjects also had extensive aortic valve calcifications. Left ventricular hypertrophy (echocardiographic Framingham criteria) was present in 4 patients, but the systolic function (ejection fraction and fractional shortening index) was normal in all cases, although a clinical picture of chronic heart failure was seen in 3 subjects preoperatively. A-V conduction defects were attributed to extensive metastatic calcifications, involving the cardiac squeleton, consecutive to severe hyperparathyroidism and inadvertent use of calcitriol and calcium carbonate as phosphate binders. No technical difficulties, short or long-term complications related to pacemaker implantation (4 VVI and 1 VVD devices) were encountered. Acute threshold and sensing values were similar with those of non-uremic patients. During follow-up, one patients died from a non cardiac death. If optimal hemodialysis is provided, benefits of permanent pacing are equal in uremic or non uremic patients and pacemaker implantation should be instituted as a prompt life-saving method in all dialysis patients with chronic symptomatic advanced A-V blocks.     

Implantation of bilateral deep brain stimulators in patients with Parkinson disease and preexisting cardiac pacemakers. Report of two cases

Deep brain stimulation (DBS) has become an important modality in the treatment of refractory Parkinson disease (PD). In patients with comorbid arrhythmias requiring cardiac pacemakers, DBS therapy is complicated by concerns over a possible electrical interaction between the devices (or with device programming) and the inability to use magnetic resonance imaging guidance for implantation. The authors report two cases of PD in which patients with preexisting cardiac pacemakers underwent successful implantation of bilateral DBS electrodes in the subthalamic nucleus (STN). Each patient underwent computerized tomography-guided stereotactic frame-based placement of DBS electrodes with microelectrode recording. Both extension wires were passed from the right side of the head and neck (contralateral to the pacemaker) to place the cranial pulse generators subcutaneously in the left and right abdomen. The cranial pulse generators were placed farther than 6 in from the cardiac pacemaker and from each other to decrease the chance of interference between the devices during telemetry reprogramming. Postoperative management involved brain stimulator programming sessions with simultaneous cardiological monitoring of pacemaker function and cardiac rhythm. No interference was noted at any time, and proper pacemaker function was maintained throughout the follow-up period. With bilateral STN stimulation, both patients experienced a dramatic improvement in their PD symptoms, including elimination of dyskinesias, reduction of "off" severity, and increase of "on" duration. With some modifications of implantation strategy, two patients with cardiac pacemakers were successfully treated with bilateral DBS STN therapy for refractory PD. To our knowledge, this is the first report on patients with cardiac pacemakers undergoing brain stimulator implantation.     

经尿道前列腺电切术治疗留置永久性心脏起搏器的前列腺增生患者

目的:探讨对于留置永久性心脏起搏器的前列腺增生患者的经尿道前列腺电切(TURP)治疗方法.方法:回顾我院1997年1月～2007年6月7例留置永久性心脏起搏器前列腺增生患者的TURP治疗.患者年龄62～75岁,留置永久性心脏起搏器1～5年,其中病态窦房结综合征4例、Ⅲ度房室传导阻滞2例、三束支传导阻滞1例,起搏器类型为房室全能型(DDD)3例、心房按需型(AAI)2例、心室按需型(VVI)2例.结果:患者手术过程顺利,术中生命体征平稳,术后恢复良好.结论:留置心脏起搏器并非TURP的绝对禁忌证,此类患者经过充分准备可以承受手术治疗.     

安置心脏永久性起搏器患者的经尿道前列腺电切治疗

目的:探讨已经留置心脏永久性起搏器患者的经尿道前列腺电切(TURP)治疗。方法:回顾性总结1997年1月~2004年9月8例留置心脏永久性起搏器患者的TURP治疗,患者年龄62~71岁,已安置永久性心脏起搏器2~7年,其中病态窦房结综合征5例、Ⅲ度房室传导阻滞2例、三束支传导阻滞1例,起搏器类型为房室全能型(DDD)4例、心房按需型(AAI)3例、心室按需型(VVI)1例。结果:患者手术过程顺利,术中生命体征平稳,术后恢复良好。结论:留置永久性心脏起搏器并非TURP的绝对禁忌证,此类患者经过充分准备可以承受手术治疗。     

Permanent Cardiac Pacemakers in Children: Technical Considerations

Placement of permanent cardiac pacemakers in children presents technical problems that are not encountered in the adult. Problems unique to pacemaker implantation in children are related to the patient's size, the relative bulkiness of pulse generators, the lack of subcutaneous tissue, and the child's growth and long life expectancy. Based on our experience with implantation of 27 permanent cardiac pacemakers in 13 children, we have found that the use of small pulse generators, placement of epicardial leads, insertion of properitoneal pulse generators, and use of rechargeable pacemakers are satisfactory methods in children.     

Pacemaker therapy

This article reviews the indications for pacemaker implantation and the techniques and devices currently in use. The management of patients who require permanent pacemakers and the potential complications involved are discussed. The article concludes with a brief synopsis of temporary pacing.     

Interaktion von frequenzadaptiven Herzschrittmachern und anästhesiologischem Management

We describe unexpected episodes of paced tachycardia in two patients with rate-responsive pacemakers during anaesthesia. Five months after a heart transplant and implantation of a pacemaker a 43-year-old patient suffered cardiac tamponade as a result of chronic pericarditis. The second case involved embolic occlusion of the femoral artery in a 33-year-old female patient previously operated on for tricuspid valve replacement and implantation of a pacemaker. In both cases induction of anaesthesia was performed with fentanyl, etomidate and vecuronium. Following intubation and mechanical ventilation, the heart rates (HR) of the two patients increased to 140 and 130 min^?1 respectively. This was interpreted as a sign of inadequate anaesthesia, and therefore additional doses of fentanyl and etomidate were given, with no effect on the tachycardia. After exclusion of other possible reasons for this complication such as hypokalaemia, hypercapnia, hypoxaemia or allergic reactions, unexpected functioning of the rate-responsive pacemakers due to thoracic impedance changes was assumed. Minute ventilation was reduced, lowering paced HR in 3–5 min. Conclusions. These case reports suggest that anaesthetic management affects the action of rate-responsive pacemakers, causing haemodynamic complications, and inadequate interventions by the anaesthesiologist. Thus, it is necessary for anaesthesiologists to make a preoperative evalution of the underlying medical disease and the type of pacemaker in order to adjust anaesthetic management accordingly and to understand the haemodynamic responses that may occur during the perioperative period. Preoperative programming to exclude the rate-responsive function is advised.     

Cardiac pacemaker in the perioperative phase

The anaesthesiologist is faced with a growing number of patients in need of cardiac pacing with systems of increasing complexity. This includes patients seen for de novo pacemaker implantation, patients with permanent pacemakers in place or patients requiring temporary pacing as an emergency or after cardiac surgery. This review article is intended to provide the anaesthesiologist with the information necessary to evaluate and treat such patients. Emphasis is laid on haemodynamic problems and possible pacemaker failure due to electromagnetic interference.     

Tunneled double-lumen silicone hemodialysis catheter placement in three patients with permanent pacemaker wires: a case study

Permanent pacemaker wires have been described as a cause of central vein stenosis. Furthermore, in hemodialysis (HD) patients with transvenous pacemakers, permanent vascular access (VA) created at the ipsilateral arm is not always successful. We report the use of tunneled double-lumen silicone HD catheters, as permanent VA in three HD patients wearing permanent transvenous pacemakers. In one patient, the catheter was inserted ipsilateral to the pacemaker site. Catheter-related infections were the most significant complications.     

Final arrest of a pacemaker after use of electrocautery

A case is reported of irreversible damage being caused to a permanent programmable pacemaker by electrocautery used in the epigastric region. The pacemaker was rapidly replaced, and the patient had no adverse effects of this accident. The use of monopolar electrocautery in patients who have one of the new generation of programmable pacemakers is very dangerous. Bipolar forceps can reduce the level of interference between electrocautery units and pacemaker electrodes. With programmable pacemakers, the generator instruction manual should be consulted before surgery, as placing a magnet on the generator may not necessarily convert it to the asynchronous mode. When the use of electrocautery is unavoidable, external cardiac pacing electrodes should be placed on the patient, with an external cardiac pacemaker ready.