A six-year-old girl gets a Permanent Pacemaker implanted!

S. Umarani 1 , T. Jasmine Rajareegam Princely 2

1Assistance Nursing Superintendent, Kauvery Heartcity, Trichy, India

2Non Critical Ward Incharge, Kauvery Heartcity, Trichy, India

Background

A Permanent Pacemaker Implantation (PPI) is a procedure in which a small device is inserted under the skin of the chest to assist the heart in maintaining a regular rhythm. PPIs consist of two main components: a small battery-powered pacemaker and leads that are attached to the heart. The pacemaker is typically placed under the skin on either the left or right side of the upper chest. The device helps regulate the heart’s electrical signals and ensures proper heart function.

Case Presentation

A 6-year-old girl was diagnosed with Complete Heart Block at the age of 2. She remained asymptomatic with normal activity levels and no episodes of syncope. She recently experienced a fever with syncope. Her heart rate was 38 beats per minute, and she was taken to a nearby hospital. From there, she was referred to Dr. Maniram Krishna at Thanjavur. The ECG showed AV disassociation with a Ventricular rate of 38 per minute and a slightly widened QRS complex indicating Left Bundle Branch Block (LBBB). She was admitted to Thanjavur and started on a low dose of intravenous Isoprenaline infusion which resulted in an increase in heart rate to 85 per minute. Her heart rate remained above 50 per minute and she was discharged with oral Tab.Orciprenaline. The parents received detailed counseling about the need for early pacemaker implantation, the associated risks and the importance of follow-up, as well as the generally positive long-term outcomes. She was then referred to Kauvery Heartcity for permanent pacemaker implantation (PPI).

Type of Heart Block

  1. First-degree AV block
  2. Second-degree Mobits I AV block
  3. Second-degree Mobits II AV block
  4. Third degree AV block

Sign and Symptoms

  1. Fever
  2. Convulsion
  3. Syncope

Indication of PPI

  1. Sinus node dysfunction
  2. Acquired Atrioventricular (AV) Block
  3. Chronic Bifascicular Block
  4. After Acute Phase of Myocardial Infarction
  5. Neurocardiogenic syncope and hypersensitive Carotid Sinus Syndrome
  6. Post Cardiac Transplantation
  7. Hypertrophic Cardiomyopathy
  8. Pacing to detect and terminate tachycardia
  9. Cardiac resynchronization therapy in patients with severe systolic Heart Failure
  10. Patients with Congenital Heart Disease.

Diagnostic Evaluation

ECG

ECHO

Before PPI ECG Report: Complete Heart Block

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Before PPI Echo Report:

three-two-six

After PPI Echo Report:

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Procedure Details

Under aseptic precautions and with the patient under local anesthesia, left subclavian access was obtained using fluoroscopic guidance. A subcutaneous pocket was created. A 7F delivery sheath and C315HIS, 3830 lead were used to position the lead for capturing the Left Bundle Branch (LBB) and left posterior fascicle. The lead’s position was confirmed using fluoroscopy and the parameters were found to be satisfactory. After achieving hemostasis the subcutaneous pocket was closed in layers.

Nursing Management   Pre Management

  1. Routine blood investigations such as CBC and RFT were performed for the PPI procedure.
  2. Informed consents were obtained after counseling the parents and explaining the risks and benefits of the procedure.
  3. Intravenous (IV) insertion was performed using aseptic technique
  4. The patient’s hemodynamic status was monitored.
  5. Skin preparation was done and the patient was given a povidone bath to minimize the risk of infection.
  6. NPO instructions were explained to the patient and maintained to ensure an empty stomach.
  7. The patient was shifted to the Cath lab after receiving prophylactic antibiotics to prevent infection.

Post Management

  1. The patient was received from the cath lab and connected to a monitor to assess the pacing function of the pacemaker.
  2. Instructions were given to the parent to observe strict bed rest for 24 hours following the procedure.
  3. Vital signs and pacing rhythm were checked every hour to monitor the patient’s condition.
  4. The wound site was observed for any signs of bleeding or complications.
  5. Precautions were taken to prevent accidental Pacemaker Malfunction.
  6. The wound was cleaned using aseptic technique to maintain a sterile environment.
  7. The patient was instructed to limit movement of the affected extremity to prevent dislodgement of the pacemaker leads.
  8. Diversional activities were provided to the patient to keep them engaged and occupied during the recovery period.

Discharge Advice

  1. Be active but restrict fast movements. Engage in light activities and avoid sudden or vigorous movements.
  2. Avoid using cell phones and wearing headphones over the side where the operation was performed.
  3. Do not lift the hand above the shoulder on the operated side to prevent strain or stress on the area.
  4. Avoid lying down on the side that underwent the operation. Sleep on the opposite side or your back.
  5. If you experience any episodes of syncope (fainting) or other concerning symptoms, visit the hospital immediately for evaluation.

Outcome

On discharge, the patient was in a stable condition. The parents expressed high satisfaction with the doctor’s treatment and nursing care provided during their stay.

uma-three-six

Ms. Umarani S

Assistant Nursing Superintendent

Jasmine-Raj-three

Ms. Jasmine Rajareegam Princely

Non-Critical Ward Incharge

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