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Pacemaker Information

The Pacemaker

The pacemaker is a small device inserted beneath the skin (just under the collar bone) which is used to control the rate of the heart.  It is a sophisticated device which consists of 50% battery, 50% computer.  It weighs approximately (50 gms) 2 ozs and is made from titanium.  It is attached to either one (single chamber) or two (dual chamber) leads which are placed on the wall of the heart via a vein.  It is successfully used for various conditions and has escalated in its use over recent years. It is carried out as day-case surgery and only requires a local anaesthetic.  The procedure should take approximately 1 hour, or possibly more if two leads are to be positioned.


A. When two leads are used, one lead is placed in the atrium (top chamber of the heart) and one lead in the ventricle (bottom chamber the heart) . This is called a ‘dual chamber’ pacemaker.
B. This shows the tip of the lead stimulating the heart when it senses the need, to keep the pulse rate above the setting (usually around 60 beats per minute).
C. This diagram shows one lead usually placed in the right ventricle. This is known as a single chamber pacemaker
 
Reference: http://en.wikipedia.org/wiki/Atrial fibrillation - cite note Wyndham 2000-0
Your consultant will determine whether a single or dual chamber pacemaker will be needed.  This will depend on the reason/medical condition for which the pacemaker is required.  There are many different kinds of pacemaker and your consultant will use the type best suited to your needs.
The purpose of the pacemaker is to artificially take-over the role of the heart’s natural pacemaker.  Electrical impulses are sent by the pacemaker to stimulate the heart to contract and produce a heartbeat.  Most pacemakers work just when needed – on demand, others emit impulses all the time – this is called fixed rate.  Pacemaker implantation today is minimally invasive surgery.

Pacemaker Pre-assessment Clinic

Once your consultant has referred you for a pacemaker you will receive an invitation from Chrissie Gould to attend a pre-assessment clinic.   Should you have any queries relating to an appointment, Chrissie can be contacted on 01245 514209.
The purpose of the pre-assessment is to meet our patients, gain important information to ensure we provide the best possible service, identify any special needs and give our patients the opportunity to ask any questions they may have.
We will take details of your next of kin and contact/communication details.
You will need to bring your medication/list of medication to clinic with you.
Your blood pressure, pulse, and oxygen saturation will be recorded.  You will be asked your height and your weight will be recorded. 
An ECG will be recorded and you will be given a form to have bloods taken.
The nurse or Cardiac Physiologist will go through the procedure with you and answer any queries you may have.
You will be asked if you are left or right handed.  In some cases it may be preferable to use the right shoulder.
You will be asked about any previous medical and cardiac history, your physical ability and the symptoms you experience caused by the need for the pacemaker.
You will routinely be swabbed for MRSA.
 Medication
You will be advised of any medications that you will need to stop at your pre-assessment.
Allergies
You will be asked if you have any allergies/sensitivities (including foods).
If your procedure is scheduled for the morning, you need to remain nil-by-mouth (avoiding diet and fluids) from mid-night.  If in the afternoon, you can have a light breakfast consisting of cereal or toast etc.

 

Consent
It is a legal requirement to obtain written consent prior to inserting a pacemaker.  The nurse will fully explain the procedure, the benefits and possible complications prior to obtaining your signature on the consent form.
The Procedure: Permanent Pacemaker
The Intended benefits: To regulate an irregular heart rhythm:
Complications which may consist of:-
• Swelling
• Infection
• Bruising
• Bleeding
• Haematoma
• Technical Fault
• Lead displacement
• Erosion of the pacemaker box
• Puncture to the lung
• Cardiac Arrest
You will need to sign the consent form for the procedure to go ahead.
(Reference: British Heart Foundation 18/08/11 bhf.org.uk)
During your assessment you will be asked to find your own transport to bring you to the hospital for your procedure and take you home again. You will also need a relative or friend at home to look after you following discharge.  If you are unable to make your own way there please advise the nurse.  We respectfully request that hospital transport is only requested where absolutely necessary.
You will be given a special liquid soap to use for seven days prior to your admission.  This is to help reduce the risk of any possible infection such as MRSA. Full instructions will be given via a leaflet during your assessment.  As you will see from the Infection Control details of the Unit, we have NO reported cases of MRSA.
*(Reference: Authors -Infection Prevention Team. Department - Infection Prevention (Mid-Essex Hospitals - Broomfield. Published 2010
Please leave all jewellery at home (except wedding rings which can be taped) and do not bring any valuables into hospital with you.  It is Mid-Essex Hospitals Trust Policy that we cannot accept responsibility for valuable items.  Every effort is taken to ensure the safety of personal items.  However, once again, we cannot be responsible for the loss or damage to ANY belongings.
Mobile phones must be left on silent at all times and it will not be possible to get a signal due to the lead lining of the walls etc.
Make-up should not be worn and nail polish should be removed.
During your assessment you will be given an allocated time to arrive at the unit.  Please take a seat in the Cardiac Centre reception area where we will collect you.
Please note it is not possible for friends/relatives to enter the Unit on your arrival. For infection control reasons entry into the unit is limited to strictly a `need only’ basis.
It is essential you arrange to have a responsible adult with you at ALL times for the 24 hours following your procedure.  This includes overnight.   If it is not possible for you to have an adult with you at all times, it may be necessary for you to stay over-night in hospital.   However for your own comfort and due to bed demand we ask that you make every effort to have an adult with you at home.  Please note it is possible that on the day of your procedure, if an overnight bed is required, there is a possibility that your procedure maybe cancelled if an overnight bed is not available.
The nursing staff will contact your relative/friend an hour before you are ready for discharge.
Relatives/friends collecting are advised to turn left on the roundabout, (first exit) and continue passed the main hospital entrance.  After the multi storey car park there is a right turn.  Take this turning and park close to the Chemotherapy Day Unit and Assessment Unit.  LEAVE YOUR HAZARD LIGHTS ON.  Enter through this outer doorway, follow the corridor and turn left.  Follow the walk way until you reach 210 ‘The Cardiac Dept’.  Report to reception and a nurse will escort your relative out to you.


The Day of your procedure


When you arrive at the unit you will be shown to your allocated bed space.  We ask you to undress your top half.  (A basket will be provided to store your clothes).  You will be asked to wear a hospital gown which ties at the back.  When getting up to use the toilet etc, you are required to put on your dressing gown and slippers.  We make every effort to ensure your dignity is maintained.
When you are comfortable on the bed a nurse will take your observations (blood pressure, pulse, respirations and oxygen saturation) and ask various questions to prepare you for your procedure.  Gentlemen may have their left shoulder shaved (this helps to avoid infection).  A cannula (a small plastic tube) will be inserted into your left hand/arm in order that any medication or fluids needed during the procedure can be given quickly and efficiently.
An ECG may be performed.
You will be asked again if you have any allergies or sensitivities.
We will ask contact details of the person taking you home.
The nurses will check your blood results.  This is an ideal opportunity to check on your cholesterol levels etc.
You will be seen by a doctor prior to your procedure.


The Procedure

The procedure room is adjacent to the recovery area.
You will be advised to visit the toilet just before you enter the procedure room as you will be unable to mobilise for approximately 2-3 hours.
You will be taken through to the procedure room by one of the nurses and asked to lie on the couch.  It is necessary to lie flat but you will be able to rest your head on one pillow.   Arm rests will be put in place for your comfort.  We will make every effort to make you as comfortable as possible however please note it is necessary to keep the room at a certain temperature due to the equipment present which may prove to some patients to be rather cool. 
You will notice the staff wearing protective jackets and skirts.  This is purely for the protection of the staff as, due to the number of hours staff spend in the lab (procedure room), it is necessary to avoid radiation from the equipment.

There will be a number of staff present in the room.
The Consultant 
The Doctor performing the procedure
2 nurses
Radiographer
Cardiac Physiologist
Please note
There may be other members of staff in the room in a learning capacity.  You have every right to object to this if you wish.
The staff will introduce themselves to you and various checks will be carried out (such as name, date of birth etc).  These checks may seem repetitive but this is purely precautionary and for your protection.
You will be attached to a cardiac monitor in order that you can be monitored throughout the procedure.
The scrub nurse or doctor will commence by cleaning the area around the left shoulder with iodine.  This is cold!  You will be asked to keep your hands and head down at all times to maintain the sterile area.  (If you have a problem i.e. itchy nose, need to cough etc, just let the nurse know).  You will be covered with a sterile drape which covers your entire body other than your face, head and shoulder.  Your hair/head will also be covered.
The doctor will insert a local anaesthetic into the area the pacemaker will be inserted.  As with all local anaesthetics, this will sting.
Once the anaesthetic has taken effect an incision (approximately 5-6 cms or two inches) is made.  You should feel no pain.  You will be aware of a little pushing and pulling throughout the procedure but you should not suffer any discomfort.
The Doctor has the choice of two veins through which to introduce the lead.  An x-ray type of machine will be used to assist the doctor in placing the lead in the best possible position.  You will not feel the lead travelling down the vein.  Once the lead is in position the doctor and the cardiac physiologist will take various readings to gain the optimum settings for your pacemaker. You may feel some extra beats in your heart, this is simply the cardiac physiologist varying the settings. You will be asked to perform a few simple exercises to test the stability of the lead/s i.e. you will be asked to cough, sniff through the nose and take a deep breath.
When this has been achieved the lead/s will be secured with permanent sutures.  A pocket will be made just under the skin for the pacemaker to sit.  The lead/s will be attached to the pacemaker and it will immediately start to work.  (You will not be aware that the pacemaker has started to work,).  Two rows of suturing of the skin and the procedure will be over. The last set of sutures to the skin is dissolvable and need not be removed.
The nurse and the doctor will chat to you during the procedure and keep you fully informed if you so wish.  Some of our patients take the opportunity to take a nap.  We are fully committed to you comfort.  Should you have any problems or discomfort, please let the nurse know. 
The doctor will inject an antibiotic to protect against infection.  The area will be cleaned by the nurse and a small dressing applied.  This dressing must be left on, untouched, and kept dry for 5 days, after which time it may be removed.  A further pressure dressing will be applied and secured in place with Elastoplast.  This is to help prevent bruising, bleeding and swelling.  This dressing can be removed after 24 hours.
You will be returned to the recovery area and offered tea and toast etc.  It may be necessary to have a chest X ray.

The necessity for a Chest X-Ray will depend on which approach the Doctor used.
The Chest X-Ray will allow the Doctor to check the position of the leads and ensure the lungs are in good working order.

Reference: http://en.wikipedia.org/wiki/Atrial fibrillation - cite note Wyndham 2000-0

You will have your observations (blood pressure, pulse, and oxygen saturations) taken at 15 minute intervals and you will have an ECG taken to record your pacemaker working.  We will be observing for any signs of swelling/bleeding.  You will be required to stay on best rest for two hours, after which time you may get dressed and sit in a comfortable chair for a further hour.  These times are approximate and will vary from patient to patient, but generally your recovery will be at least 3 hours.  Your family will be given one hour notice to collect you.
You will have a pacing check before you leave hospital.  This simply involves the placing of a device, about the size of your hand, over the site. The pacemaker can be interrogated and/or adjusted.  You will feel nothing.
If you are slim you may be able to see the outline of the pacemaker in your shoulder.  You cannot feel or hear it working.
Following bed-rest you will be able to get dressed and sit in a comfortable chair for a further hour following which we will contact your family to collect you.
The nurses/doctor will advise you on your medications prior to discharge.

Recovery Instructions Post Pacemaker Insertion

• We recommend you go home on strict bed rest for at least 24 hours.  You must have someone who can look after you at home.  (If you have had a box change you can relax on the sofa and rest your arm for two days).
• You must not use your arm at all for two days.  You must limit the use of your arm for two weeks not using it to carry, lift, brush hair or teeth etc.
• Do not shower or bath for five days.  Your dressing must be kept clean and dry.
• We recommend you do not drive for 2 weeks.
• You can remove the heavy outer dressing after 24 hours.  THE INNER PLASTER MUST REMAIN UNTOUCHED FOR FIVE DAYS.  DO NOT REMOVE OR REDRESS EVEN IF IT APPEARS STAINED.
• You should expect to see partially healed bruising when all dressings are removed.  You can also expect a degree of discomfort but no pain.
• You will be advised on any medications prior to discharge.
• Your stitches/sutures are soluble therefore you do not have to return to have them removed.  It may take up to 6 weeks for them to fade completely.  However, if you notice any redness, swelling or experience pain, please contact the Angio Suite on 01245 514418 for appropriate advice.


It is ESSENTIAL that the arm is not used for 48 hours.  After 48 hours the arm may be used for light duties but NO lifting the hand or arm above shoulder level or moving it away from the body for the next two weeks.  You will be at risk of dislodging the lead if you do not comply. (Do not be tempted to wear a sling – this will cause injury to the incision site).  After one month and following your pacing check at the hospital, you will be back to normal.

On reaching home you are to rest for two days doing nothing at all. Drink plenty of fluids.
 If you have any discomfort in the shoulder you may take your usual painkillers (whatever you would normally use for a headache).  If you notice any redness, inflammation or swelling, or the site becomes very painful, please contact your GP or the Angio Suite and we will be happy to advise you.
You will need to inform the DVLA and your Motor Insurance Company that you have a pacemaker fitted.  However your insurance company should not increase your premiums.
You can walk through security x-ray machines (as at airports and found in some hotels abroad) but do not loiter in the centre as this will affect your pacemaker.  You will be given an identity card you need to show staff at the airport.
On discharge you will be given an out-patient appointment (occasionally this may be sent in the post) to attend clinic for a pacemaker check one month after procedure. The checks will then be carried out six monthly then yearly.
The battery in your pacemaker should last approximately 7-10 years depending on how often it is used.  The battery wears down very slowly and your pacemaker checks will be a little more frequent when the battery is nearing the end of its life.  Replacement is fairly quick and simple as it only involves a new pacemaker – the leads although checked at this time, should last a lifetime.

After approximately one month you will be back to normal.

References:
British Heart Foundation. A registered Charity No 225971. Registered as a Company limited by guarantee in England and Wales. Registered office at Greater London House, 180 Road, London NW1 7AW. Registered as a Charity in Scotland.
Eido Healthcare 
National Institute for Health and Clinical  Excellence. Mid City Place, 71 High Holborn, London, WC1V 6NA: www.nice.org.uk. 2011.
Mayo Foundation for Medical Education and Research


 We look forward to welcoming you/your relative to the Angio Suite and hope this information has given you sufficient insight into the procedure you/your relative will be undertaking in the near future.  (This electronic information is in addition to the written and verbal instructions/information our patients are given).  However if you have ANY queries regarding the procedure, please do not hesitate to contact us on 01245 514418