False Asystole Alarms Post-Temporary Pacemaker Placement Due to Pseudo-fusion
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CASE REPORT
False Asystole Alarms Post‑Temporary Pacemaker Placement Due to Pseudo‑fusion Alyssa M. Vermeulen1 · Frank Zimmerman1 · Hoang H. Nguyen1,2 Received: 11 July 2020 / Accepted: 17 November 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract An infant with congenital heart block and hemodynamically significant bradycardia underwent therapeutic temporary pacing wires placement. Post-operatively, frequent “asystole” alarms were observed on telemetry causing distress to both the family and the nursing staff. Investigation of these alarms showed that pacemaker malfunction led to monitor pseudo-malfunction. The alarms were alleviated with mindful setting of the pacemaker and telemetry monitor parameters. This case highlights the challenges of pacemaker placement and monitoring of very small infants in the intensive care setting. Awareness of these challenges would help in troubleshooting pacemaker and telemetry monitor issues. Keywords Congenital heart block · Temporary pacing · Pseudo-fusion · False alarm · Alarm fatigue
Introduction
Case Presentation
Temporary cardiac pacing plays a crucial role in therapy of infants who suffer from hemodynamically significant congenital heart block yet are too small to receive a permanent pacing system. These infants remain under vigilant continuous physiologic monitoring in the intensive care unit due to high risk of decompensation. Their small size poses not only technical challenges in placing the temporary pacing wires, but may also lead to difficulties in post-operative electrocardiogram (ECG) and telemetry interpretation. In these infants, mindful setting of pacemaker and telemetry monitoring parameters is important to avoid excessive falsely abnormal ECG and telemetry recordings that in turn would lead to “alarm fatigue” and therefore possible patient harm.
A female infant was born at 34 weeks with fetal complete heart block secondary to maternal Sjögren’s syndrome type B antibodies. Birthweight was 1800 g. After birth, the infant continued to demonstrate complete heart block with the slowest ventricular rate of 40 beats per minute (range 40 to 70 beats per minute). She had evidence of decreased perfusion with cool extremities, low blood pressure, and decreasing near-infrared spectroscopy numbers. She was started on isoproterenol with improvement in heart rate and clinical status (Fig. 1). On day-of-life 6, an attempt of placing a permanent single chamber epicardial pacing system was unsuccessful due to the inability to create an adequate device pocket secondary to her small size and friable tissue. Two unipolar and a ground temporary wires were placed for each chamber. The temporary pacemaker (Medtronic 5592) was programmed in DDD mode with a lower rate limit set at 120 beats per minute. The atrioventricular delay was left at factory nominal setting of 70 ms. The patient was paced in a unipolar fashion at the surgeon’s request. The patient was transferred to the intensive care unit for further care. Shortly after surgery frequent
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