Intraoperative complications and management of pacemaker I. Complications caused by subclavian vein puncture Complications caused by subclavian vein puncture: 1. Pneumothorax: incidence 1.97%, treatment: lung compression <30%, symptoms are not serious, no treatment for the time being; compression >30%, puncture and suction or placement of closed drainage tube Huang Shen, Cardiac Arrhythmia Treatment Center, Guangdong Hospital of Traditional Chinese Medicine, Guangdong Province. 2. Mis-penetration into the subclavian artery: prevention: 1. back padding, two shoulders abduction under puncture; 2. continuous negative pressure into the needle, venous blood is mostly 3. Send the guidewire to the inferior vena cava and confirm by fluoroscopy; 4. Be alert to the patient’s pain when sending the sheath. Treatment: 1. Remove the puncture needle and re-puncture; 2. If a dilated sheath has been delivered, ask for surgical intervention and do not remove the sheath rashly. Prevention of intravenous air embolism: 1. advise the patient to breathe steadily, sedate if uncooperative; 2. remove the pillow, head low and feet high position, rehydrate if dehydrated or low intravenous blood pressure; 3. block the sheath opening with thumb when pulling out the dilatation core; 4. match the diameter of the catheter with the electrode lead 4. subcutaneous emphysema: Treatment: 1. treat the same as pneumothorax if combined with pneumothorax; 2. do not treat if there is no pneumothorax. II. Brachial plexus nerve injury: no special treatment required III. Cardiac perforation: Clinical manifestations: 1. acute pericardial tamponade; 2. sudden postoperative pacing or sensory dysfunction, cardiac arrest and pericardial friction sounds. Treatment: 1. Surgically supervised removal of electrodes and replacement of implantation site; 2. IV. Arrhythmia: Most of them disappear on their own. No pacing pulse: 1. Exclude sensory inhibition; 2. Check the pacing lead and pacemaker connection; 3. Check the polarity of the lead. VI. Others: diaphragmatic stimulation, unstable pacing threshold, coronary sinus entrapment. Recent complications and management after pacemaker implantation i. Bleeding from the capsular bag: Treatment: 1. If there is no enlargement, continue pressure bandaging for observation; 2. If there is excessive tension, puncture or incision for drainage. Prevention: 1. Intraoperative attention to hemostasis; 2. Preoperative discontinuation of anticoagulants. II. Infection: incidence 1%. Local infection: 1. Intensify antibiotic treatment; 2. Local debridement, no electrodes out, contralateral implantation of pacemaker. Systemic infection: difficult to eradicate with antibiotics, most need to remove the electrodes. III. Pacemaker syndrome: 1. Prevention: preoperative electrophysiological examination, atrial sequential dual-chamber pacemakers are recommended for those with VAC and VAC interval of 150-250 ms. 2. Improve the sequence of atrial mechanical contractions, adopt physiological pacing, and single-ventricle multi-site pacing. 3. Programmable pacing parameters: increase the pacing frequency in the presence of atrioventricular block, and programmatically slow down the ventricular pacing frequency in the absence of atrioventricular conduction in order to maximize the use of the sinus rate and prolong the recoil period and lag. 4. drug treatment, mainly symptomatic treatment, can be applied to increase the heart rate, improve cardiac function, and improve cerebral circulation drugs, if necessary, can be supplemented with hormone therapy. IV. Myoelectric interference: Bipolar pacing can avoid or reduce the misperception of myoelectric potential to the greatest extent. V. Dislocation of the electrode lead: 1. Change the pacemaker program control parameters to increase the pacing voltage and sensory sensitivity; 2. Reset the electrode. VI. Cerebral infarction: Mostly seen in elderly patients, try not to restrict the postoperative activities of the patient. vii. Venous thrombosis or venous stenosis: Treatment: 1. Encourage the patient to move the upper limbs; 2. Perform venous balloon dilation if there are obvious symptoms and anticoagulation and other treatments are unsatisfactory. Long-term complications and management after pacemaker implantation i. Premature battery depletion Premature battery depletion: Treatment: Replace the battery. ii. Skin rupture: iii. Rotational fiddling syndrome iv. Tearing of the pacing lead or failure of the insulation.