Pacemaker is a lifelong journey for the patient – it begins soon after implantation
Follow up and aftercare of a Pacemaker
Implantation of a pacemaker is the beginning of a new journey for the patient. Unlike other implants (e.g. Hip replacements) – pacemakers have need an active follow up plan. Furthermore, the patient is physically aware of the presence of the device and also gets into trouble if the device does not do its job properly
Therefore to achieve optimal benefit of the device, pacemaker follow up has the following goals
- Ensure that the pacemaker operation has been completed without complications and the patient is ready for discharge
- Ensure the acute wound has healed well without complications
- Ensure that device parameters are optimal and the device is working as intended
- Detect issues with pacing (hardware or patient related) in a early manner to act upon them before significant morbidity has occurred
- Plan timely pulse generator replacements ( aka box changes)
- Plan timely upgrades when the patient’s clinical circumstances change. (e.g.. Upgrade to CRT or ICD)
- Take opportunistic action to promote healthy lifestyles and preventive actions for general good health
These priciples not only apply to pacemakers – they apply to any cardiac implantable electronic device (ICDs, CRTs etc)
Lets consider these in stages
Completion of current operation and prepare the patient for discharge
Once the device implantation is complete, the wound site needs a sterile dressing. This dressing should NOT be applied tightly. It should just give a protective cover to the wound from the environment. A tight dressing should not be an alternative for good surgical technique to prevent bleeding. If a bleeding occurs, it will occur despite a tight dressing.
The biggest disadvantage of a tight dressing – is significant post operative pain from the pressure of the dressing.
The dressing material itself should be a waterproof dressing – this is not to encourage bathing – but to prevent accidental water ingress during a light shower. The author advises against immersive baths until the wound is inspected in 1 week. A light shower is permissible provided the dressing is water proof. All of this is to prevent an infection. A wet wound significantly increases the change of a wound infection
Figure : An example of an appropriately placed dressing over a pacemaker wound site.
Post operative checks
The obvious thing that is not discussed here is the recovery from the sedation. Assuming that it has occurred without an issue, the next routine things to be done next are the chest x-ray and the pacemaker pre-discharge check.
Post procedure chest x-ray is routinely done in most centers (including places author has wroked). But this is not backed by solid evidence. A retrospective study in 2005 concluded that a routine post op x-ray was “unnecessary” in uncomplicated cases. Author opines that individual institutions should look at their complication rates and decide on the need for post operative x-rays. If an institution consistently achieves very low complication rates they may be better off reviewing their x-ray hit rate and decide against it. But this practice needs proper evidence.
However if an X-ray is taken, it should be delayed for few hours (again 4 hours is a routine number some institutions use – without evidence) when the patient is ambulatory. The primary goal of a chest x-ray is to exclude a pneunothorax, and this needs time to develop. Author tries to schedule the x-ray with sufficient time – but not to unduly delay the discharge of the patient.
While awaiting for the X-ray, the patient can have a repeat parameter check. This is usually done to ensure that a patient is not sent home with a dysfunctional system (e.g. dislodged lead).
Author feels that doing both is a waste of time and resources and the best would be a pacemaker check when patient is fully ambulatory and ready to discharge. At least this will eliminate radiation exposure and minimize post procedure hospital time wasted for an x-ray – but provide sufficient information to prevent a complication being sent home.
Author also feels that routine chest auscultation should be avoided if the patient is not complaining of any breathing difficulty. The left hemichest is a difficult place to listen and compare lung sounds – especially at the base because of the of the heart – invariably there will be a difference when compared to the right. On top of this, if the pacemaker wound is sore, the patient might not take full breaths – again leading to falsely impaired air entry to the left lung. Combination of these factors will present it self as a difference in air entry leading to a chest x-ray for confirmation – this is very true if the discharge doctor is a inexperienced as his mind would be in doubt ? Am I missing a pnemothorax?
If the pacemaker check is satisfactory (and the X-ray being normal) the patient can go home. Most patients can be safely discharged same day.
- There is no evidence to say that additional post operative antibiotic doses reduce infections. They just add to the cost of hospitalization and increases the risk of resistant organisms
- Injection of periclosure bupivacain to the incision edges – provides very long lasting anesthesia which helps the patient ambulate quickly and get ready to go home
- A stat dose of oral paracetamol with the first drink / meal taken after operation in the hospital – aids post operative rebound pain minimization and ambulation
The patient should receive information regarding wound care, arm care and follow up plan. They also should get the pacemaker identification card
Intermediate wound care / review
If the patient has sutures that require removal, its best done by the implanting center team. Author has seen many cases of wounds being messed up by healthcare professionals not doing the suture removal properly. Author has seen retained stitches leading to stitch abscesses and wound infections
The best protection against suture related complications is to avoid sutures that need removal. Completely buried subcutaneous sutures do this job (in addition to superior cosmetic outcome) and should be the preferred route for wound closure. (The other option is tissue glue)
Some centers where they put completely buried sutures, advise patients to self remove the dressings in 7 days time. This is also acceptable – provide that the patient can be relied upon for careful wound management.
However, the author’s personal preference is to see all wounds at 7 days – regardless whether they need suture removal or not. This because of the morbidity associated with an infected device. Sometimes early capture of wound complications might lead to successful local treatment (e.g removal of a exposed knot ) to prevent a full blown infection. This review also helps to address concerns that the patient may have.