Quiz: Temporary Pacemaker

2 year old, s/p heart surgery for complex congenital heart disease - having a difficult postoperative course. Upper panel shows a problem with pacemaker. This h been corrected in the lower panel.
1) What is the pacemaker problem in the upper panel? Can you guess the pacemaker mode in the upper panel?
2) What adjustments in the pacemaker will rectify the problem?
3) Lower panel (recorded 2 hrs later): How is the pacemaker functioning now? What are the current settings in the pacemaker i.e. Mode, Rate & AV interval setting?

(Click on the image to see a larger image)


Johan said...

Well, I'll do a try.....

In the first picture it seems there is no synchronism between atrial and ventricular activity. But in the second picture it's clear that there are atrial and ventricular leads. So maybe in the first picture there is only atrial pacing, or the mode "atrial tracking" is off?
Is this a correct answer?

(excuse me for my bad english, I'm an Pediatric ICU nurse in the Netherlands)

Bala said...

Johan, all your answers are correct. And, your English is perfect!
1) Non-capture is the problem. (Hard to say whether it is atrial pacing or ventricule pacing when there is no capture! This was set at VVI mode).
2) Solution to this problem is "increasing the output threshold in the pacemaker" to ensure capture. Ideally, output threshold should be determined and the output should be set 2-3 times the threshold.
3) Lower panel: DDD mode. Rate 110/min. AV interval is set at 140 ms.