Pacemaker - Our Lady`s Children`s Hospital, Crumlin
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1. A asin 3ndnp b sui mh zs gt Luc kejag NY 1 1 asing egy suf gy ey aur jey ajgy 2189 Z CA 2 Agjdsig pue cone 18 m 40 40 g Auge arsurqui Buisuas S ay 33V d 35N3S JIM au iai paydag2e ape tuntur au ejje ayy ay o papaau y pjoysasyy AyAnisuas au AWANIE 21 S juarged ay o aayewaged ay jo ssauaArsu dsa ay IDNLNOJ ALIAILISNIS aunydea aanpoud o Japao Jo jn ysnipy pjoysasy uonenung Ld LAO 20 December 2013 Nursing Practice Committee APPENDIX Il ST JUDE MEDICAL 3085 PACEMAKER Lower mode menu display VDD wee2. Ma it 5 c 3085z CTRL OUT Figure 2 St Jude Medical 3085 Pacemaker Front Display Face Ventricular terminals Figure 3 Ventricular and Atrial Terminals Nursing Practice Committee December 2013 21 EXT PG 3065 JOURN XXX Figure 4 St Jude Medical 3085 Pacemaker Rear View Nursing Practice Committee CTRL OUT December 2013 22 APPENDIX Ill St Jude Medical Model 3085 Turning on Pacemaker 1 Press key labelled ON pacemaker will run a self test 2 When the pacemaker was previously in Standby Mode it will commencing functioning at the last saved parameter settings 3 The key Lock Unlock must be pressed and released to ensure it is functioning properly when the pacemaker was previously OFF Te Figure 6 Lock Unlock Key 4 When Lock Unlock key is not pressed and released within 30 seconds an error message will be displayed Startup timeout Press unlock and pacemaker will switch off Turn on programme commences Soft keys 1 5 will display a Menu Mode e Key 1 Mode DDD e 2 Mode VVI e Key 3 Mode NB Pacemaker Settings are set by the Medical Surgical Cardiothoracic Team Locking Unlocking 1 Pacemaker will automatically lock if no key has been pressed for 30 seconds Prevents accidental 2 Tounlock press key Lock Unlock 3 Lock symbol will indicate whether the pacemaker is locked or unlocked of Figure 7 Lock Symbol 4
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4. 2011 Wong s Nursing care of Infant s and Children 9 Edition Elsevier Mosby St Louis Johnson L G Brown O P and Alligood M R 1993 Complications of epicardial pacing wire removal Journal of Cardiovascular Nursing 7 2 32 40 Jowett V Hayes N Sridharan S Rees P and Macrae D 2007 Timing of removal of pacing wires following paediatric cardiac surgery Cardiology in the Young 17 5 512 516 Keenan J 1995 Temporary cardiac pacing Nursing Standard 9 20 50 51 Kelly F 2003 Infection Control validity and reliability in wound swabbing British Journal of Nursing 12 16 959 60 962 964 Kingsley A and Winfield Davies S 2003 Audit of wound swab sampling why protocols could improve practice Professional Nurse 18 6 338 343 Lynn McHale D Riggs K and Thurman L 1987 Epicardial pacing after cardiac surgery Critical Care Nurse 11 8 62 77 Lynn McHale D J Riggs K L and Thurman L 1998 Epicardial pacing after cardiac surgery Critical Care Nurse 11 8 62 74 Mahon L Bena J F Morrison S M and Albert N M 2012 Cadiac tampobade after removal of temporary pacer wires American Journal of Critical Care 21 6 432 440 Martin M and Aragon D 1992 Temporary DDD pacing evaluating haemodynamic performance Dimensions of Critical Care Nursing 11 4 191 200 Mater Misericordiae University Hospital 2011 Guidelines for the Care and Removal of Temporary Epicardial Pacing Wires
5. Awarning beep and lock symbol will blink for 2 seconds if keys are pressed dials turned when pacemaker is locked LED lights for Sensing and Stimulation 1 LED lights located at upper left side 2 They indicate atrial and ventricular sensing and stimulation 3 Green LED lights flashing indicate sensing 4 Yellow LED lights flashing indicate stimulation NB Lights flash brightly initially when pacemaker turned on to indicate functioning satisfactorily Emergency Key Pressing the emergency button key will commence pacemaker stimulation at emergency settings Pause Pacemaker Pressing the pause button key will disable pacemaker stimulation as long as it is pressed Turning Off the Pacemaker 1 Press lock unlock key 2 Press OFF key 3 Asoft key power off menu will display e Press key 1 OFF with no storage Actual settings are not saved e Press Key 2 Stand by with data stored NB No battery power is consumed in the stand by mode St Jude Medical 201 1 APPENDIX IV CHANGING THE BATTERY MODEL 3085 This procedure is performed by Cardiothoracic Medical Surgical Team Battery release button Button cover Battery compartment lid Figure 5 Battery Compartment 1 Turn protective cover of the battery compartment lid whilst pressing the battery release button NB This button cover prevents the release button from being unintentionally pressed Open battery lid Battery is removed from the
6. Out of Hours via switchboard Inform cardiothoracic medical surgical team via bleep or out of hour s telephone number via switch board Also contact consultant in charge Battery Use 9 volt alkaline batteries only NB DO NOT USE rechargeable batteries Record battery voltage at beginning of shift and following insertion of new battery To ensure timely replacement of pacemaker Risk of low capacity and unstable charge which may cause a pacemaker malfunction St Jude Medical 201 1 To ascertain battery status When battery is in use the battery should be changed when battery depletion symbol displays only one blinking segment and warning message Change battery appears This is repeated every 10 minutes Ask cardiothoracic team to change the battery Appendix 111 ZZ Figure 1 Battery Symbol Cardiothoracic medical surgical team change all temporary external pacemaker batteries After inserting a new battery the device Model 3085 needs 30 minutes to recharge its internal power capacitor in order to perform the bridging function again Cardiothoracic medical surgical team to change pacemaker battery e With each new patient and then minimum of every 3 days Label rear of pacemaker with date the battery was last changed nurses initials and document same in the nursing notes Ensure safe disposal of battery Have a replacement 9 volt battery available at the bedside at all times Criti
7. suoneo ipu eu esn uonepas pue ersefjeue ayy 10203010 siu pue esejeuv zy unung Jeyidsog APPENDIX VI 28 December 2013 Nursing Practice Committee APPENDIX VI PACEMAKER GLOSSARY A Arrhythmia An abnormal rhythm of the heart too slow too fast or uneven which can cause the heart to pump less effectively In pacing any rhythm disturbance Examples include bradycardia tachycardia any markedly irregular rhythm block or the presence of premature contractions A V Delay Atrio ventricular delay in a dual chamber pacing mode The AV delay is the period between an atrial event paced or sensed and a paced ventricular event In DDD pacing the AV delay is generally programmed to 120 150 milliseconds msec depending on the patient s age allowing a heart rate of up to 140 150 minute If the heart rate is higher the AV interval needs to be reduced Oslizlok 2007 Wood 2007 C Capture The successful depolarisation and contraction of a cardiac chamber caused by the pacemaker s output pulse One to one capture occurs when each pacemaker output pulse results in a contraction Cardiac Cycle One complete heartbeat Seen on the ECG as a P wave a QRS complex and a T wave Cardiac Output The volume of blood measured in litres ejected by the heart per minute Cardia
8. 2 common insertion sites in paediatrics e EPICARDIAL wires via transthoracic site TRANSVENOUS endocardial wires via CVC insertion site NB Atrial pacemaker wires traditionally exit the chest to the right of the sternum Ventricular pacemaker wires exit the chest to the left of the sternum Hickey and Baas 1991 Owen 1991 Fisher 2008 Always check the surgical notes to verify the type and location of pacing wires An exception to the rule is in cases of dextrocardia or situs inversus Aseptic Non Touch Technique ANTT is a mechanism which helps to prevent contamination of susceptible sites by micro organisms that could cause infection Hart 2007 Pratt et al 2007 ANTT is achieved by preventing contamination of external parts of the pacing wires and the insertion site Level 2 ANTT should be used if cleaning or dressing the insertion site of the pacing wires is necessary Level 3 ANTT is appropriate for handling and securing the epicardial pacing wires Action Rationale amp Reference Transvenous Site Dress as per intravenous clinical guidelines ANTT Level 2 Veniguard dressing Assess daily and redress minimum of every 7 days or as clinically indicated To prevent infection OLCHC 2007 Epicardial Wire Site Leave uncovered if dry Dress as necessary with dry dressing i e Mepore if oozing present Clean skin with 0 9 Normal Saline as clinically indicated To prevent infection Owen 1991 Over
9. Dublin 12 All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright holder Our Lady s Children s Hospital Crumlin makes no representation express or implied with regard to the accuracy of the information contained in this publication and cannot accept any legal responsibility for any errors or omissions that may be made
10. Medical 201 1 Critical battery change level has been reached and immediate battery change is required St Jude Medical 201 1 Readily available for reference Increased familiarity with pacemaker Dwyer 2001 St Jude Medical 2011 Electrical safety is especially important when caring for a patient with a pacemaker Action Overbay and Criddle 2004 Rationale and Reference Section 4 ELECTRICAL SAFETY When not in use cover pacing wires with finger stall thumb cut diagonally of a powder free non sterile examination glove i e Sempercare To prevent micro shocks Micro shocks are associated with ventricular arrhythmias and are a potential lethal hazard Temporary epicardial pacing wires provide a direct low resistance pathway to the heart for an electrical current Rubber is a poor conductor of electricity Hickey and Baas 1991 Owen 1991 Baas et al 1997 Norman 1998 Reynolds and Apple 2001 Reiswig Timothy and Rodeman 2004 Beattie 2005 Mater Misericordiae University Hospital 2011 Hazinski 2013 Appendix V Wrap the wires in finger stall with a gauze square into a small parcel and secure to chest with Tegaderm Wrap atrial and ventricular wires separately NB DO NOT USE TAPE to secure pacing wires within finger stall Label atrial and or ventricular wires separately To keep dry avoid baths showers and unnecessary contact with water Hazinski 2013 Water is an excellent conductor of elec
11. compartment Replace with new 9 volt battery Battery compartment lid is closed until audible sound of it latching into place Protective cover of battery compartment lid is rotated over the battery release button N o D e Q Dispose of old battery in an environmentally friendly manner St Jude Medical 2011 Nursing Practice Committee December 2013 25 APPENDIX V Securing Epicardial Pacing Wires when not in use Equipment e Non disposable gloves e Gauze e Tegaderm dressing e Labels 2 E 1 Cut the thumb off a non disposable glove 3 Wearing gloves wrap the two NB Thumb has a wider opening pacing wires around your 2 and 3 fingers wa y 4 and 5 Pacing wires now form a small roll 6 Insert pacing wire roll into at Bottom of the thumb of the previously cut non d J disposable glove 7 Wires in thumb of glove now _ 8 Open one sheet of gauze 9 Wrap gauze around wires in form a small parcel under the wires in the glove the glove NB Gauze protects skin and ensures comfort Nursing Practice Committee December 2013 10 The gauze forms a small parcel 11 Apply tegaderm dressing 12 Ensure tegaderm dressing around wires in the glove over the gauze Secures gauze to skin at all edges Apply second dressing PRN 13 Label wires trouser leg is 14 Repeat procedure with second NB Atrial wires are on the right set of wires if requi
12. performed post procedure if clinically indicated or there is deterioration in the patient s condition Documentation The doctor and nurse will record the procedure in medical nursing notes clinical information management system CIMS including date time who removed epicardial pacing wires number and type Also patients condition and response to the procedure Discharge Information The parents and if appropriate the child should be aware of signs and symptoms of possible complications and who to phone for advise following discharge To prevent infection O Brien 2008 Standard precautions and to reduce transmission of organisms Standard precautions To prevent injury from cardiovascular compromise secondary to bleeding arrhythmia or tamponade Johnson et al 1993 To ensure early detection and timely treatment of any potential complication Pericardial tamponade usually presents within 2 hours of removal Johnson et al 1993 Wollan 1995 Carroll 1998 Lynn McHale et al 1998 PCNA 2003 Beattie 2005 To control bleeding Beattie 2008 These patients may be at greater risk of arrhythmias Transient arrhythmias are common and often subside spontaneously Carroll et a 1998 To ensure prompt and timely treatment O Brien 2008 Mahon et al 2012 Echocardiogram may exclude or reveal pericardial tamponade Leahy 1993 Clark 2007 To ensure satisfactory documentation of the procedure and continuity
13. subsequent changes are the responsibility of the medical team ONLY and should not be changed by nursing staff Section 1 MONITORING Action Rationale and Reference Nurse child on cardiac monitor observe the heart rate and rhythm with continuous ECG recordings Assess for capture and sensing of the pacemaker Ensure ECG rate alarm is set 10pm below the pacemaker heart rate To allow for evaluation of cardiac and pacemaker function Early detection of arrhythmias or pacemaker malfunction allows for timely intervention Van Orden Wallace 1998 Boyce and Rost 2000 Overbay and Criddle 2004 Fischer 2008 Hockenberry and Wilson 2011 Yorkhill Children s Hospital 2011 Hazinski 2013 In addition monitor heart rate from an alternative source Pulse rate arterial line pulse oximetry NB The presence of satisfactory heart rate on a cardiac monitor DOES NOT ensure effective cardiac contraction and cardiac output Monitor Blood pressure e Temperature Assess for changes in responsiveness behaviour i e restlessness or irritability NB Minimum of 4 hourly or as condition indicates To establish baseline and detect changes in a timely fashion NB Decreased blood pressure is a late sign of low cardiac output Hazinski 2013 Paradoxical blood pressure changes may indicate cardiac tamponade secondary to perforated ventricle These changes may be early signs of low cardiac output Van Orden Wa
14. 4 3 23 32 Owen A 1991 Keeping pace with temporary pacemakers Nursing 21 4 58 64 Paediatric Cardiac Nurses Association PCNA 2003 PCNA National Standard for Temporary Epicardial Pacing Wire Removal in Children PCNA London Pratt R J Pellowe C M Wilson J A Loveday H P Harper P J Jones S R L J McDougall C and Wilcox M H 2007 National evidence based guidelines for preventing healthcare associated infections in NHS hospitals in England Journal of Hospital Infection 65 supplement1 S1 S49 Reade M C 2007 Temporary epicardial pacing after cardiac surgery a practical review Part 1 General considerations in the management of epicardial pacing Anaesthesia 62 264 271 Reiswig Timothy P and Rodeman R N 2004 Temporary pacemakers in critically ill patients ACCN Clinical Issues 15 3 305 325 Reynolds J and Apple S 2001 A systematic approach to pacemaker assessment AACN Clinical Issues 12 1 114 126 Roschkov S and Jensen L 2004 Coronary artery bypass graft patients pain perception during epicardial pacing wire removal Canadian Journal of Cardiovascular Nursing 14 3 32 38 Schneider Hickey C and Baas L S 1991 Temporary cardiac pacing AACN Clinical Issues 2 1 107 117 Shaikhrezai Khorsandi M Patronis M and Prasaad S 2012 Is it safe to cut pacing wires flush with he skin instead of removing them nteractive Cardiovascular and Thoracic Surgery 15 1047 1051 Shee
15. Ospid al huire na Leanai v Cromghlinn Our Lady s Children s Hospi Crumlin Nursing Guidelines on the Care of a child with a Temporary External Pacemaker Version Number 1 Date of Issue 9 January 2014 Reference Number NGCCTEP 12 2013 ETMLKF V1 Review Interval 3 yearly Approved By Name Fionnuala O Neill Title Chairperson Nurse Practice Committee Signature Date p veu b 2 3 Authorised Title Deputy Director of Nursing Signature Date VCaslolocue Author s Eileen Tiernan CNF PICU Marie Lavelle CNF St Theresa s Kathleen Fitzmaurice St Brigid s Location of Copies On Hospital Intranet and locally in department Document Review History Review Date Reviewed By Signature January 2017 Document Change History Change to Document Reason for Change Sms Nursing Practice Committee id Nursing Guidelines for the Care of a Child with a Children s Hospi Temporary External Pacemaker Crumlin 1 Edition 2008 Authors Carmel Gallagher Course Coordinator HDNS Children s Nursing Janet Coldrick Clinical Liaison Allocation Officer NPDU Eileen Tiernan Clinical Nurse Facilitator PICUs 2 Edition Authors Eileen Tiernan Clinical Nurse Facilitator PICUs Marie Lavelle Clinical Nurse Faci
16. Post Cardiac Surgery MMUH Dublin Medtronic 2001 Medtronic Dual Chamber Temporary Pacemaker Technical Manual Medtronic Minneapolis Mullins M H Roschkov M N Jensen L Moore G and Smith A 2009 Sensations during removal of epicardial pacing wires after coronary artery bypass graft surgery Heart and Lung 38 5 377 381 Norman E M 1998 Avoiding electrical hazards American Journal of Nursing 98 6 16GG 16HH Obias Mango D 2001 Unconventional applications in pacemaker therapy Advanced Practice in Acute and Critical Care 12 1 127 139 2008 Epicardial pacing wire removal Perform In Trivits Verger J T and Lebet R M eds AACN Procedure Manuel for Pediatric Acute and Critical Care Saunders Elsevier St Louis 383 389 Oslizlok P 2007 Personal Communication to Pacemaker Guidelines Project Group 13 December 2007 Our Lady s Children s Hospital Crumlin Dublin OLCHC 2007 Intravenous Guidelines for Nursing Staff Our Lady s Children s Hospital Crumlin Dublin OLCHC 2008 Guidelines on Performing a Wound Swab Our Lady s Children s Hospital Crumlin Dublin OLCHC 2012a Anti Thrombotic Central Line Guidelines Our Lady s Children s Hospital Crumlin Dublin OLCHC 20126 Procedural Analgesia and Sedation in PICU HDU Our Lady s Children s Hospital Crumlin Dublin Overbay D and Criddle L 2004 Mastering temporary invasive cardiac pacing Critical Care Nurse 2
17. al Delivers atrial and ventricular pacing in sequence thereby preserving atrial ventricular synchrony This has the advantage of atrial kick and increase in cardiac output of appropriately 20 Van Orden Wallace 2001 Classification of Pacemaker Modes Pacemakers are classified in a 3 letter generic code devised by the North American Society of Pacing and Electrophysiology NASPE and the British Pacing and Electrophysiology Group BPEG Obias Manno 2001 Reynolds and Apple 2001 Van Orden Wallace 2001 Bernstein et a 2002 NASPE BPEG Generic Code Revised 2002 CHAMBER BEING PACED CHAMBER BEING SENSED PACEMAKER RESPONSE Atrium A Atrium T Triggered V Ventricle V Ventricle Inhibited Demand Mode D Dual Atrium amp Ventricle D Dual Atrium amp Ventricle D Dual Triggered Inhibit O None O None O None Asynchrony Bernstein et 2002 Mode of Response Response to the intrinsic myocardial activity 1 Inhibit The pacemaker will not pace if it senses depolarisation thus allowing the patients own heart beat to maintain cardiac output T Triggered If the pacemaker does not sense depolarisation No Response The mode of pacing selected depends on the patient s inherent heart rate and rhythm and the function of the atria and ventricles The mode used will be the one which will best optimise cardiac output The most common temporary pac
18. ary leads may be epicardial or transvenous A temporary lead does not have a fixation mechanism allowing it to be easily removed when it is no longer required U Under Sensing Occurs if the pacemaker fails to sense the P or R wave and thus inappropriately timed impulses may result References Beattie S 2005 Epicardial wires Modern Medicine Available online www modernmedicine com modernmedicine Hands On help Epicardial wires Accessed December 3rd 2012 Medtronic 2003 Pacing Glossary Medtronic Minneapolis Oslizlok 2007 Personal Communication to Pacemaker Guidelines Project Group 13 December 2007 Our Lady s Children s Hospital Crumlin Dublin Pacesetter 2004 Glossary Available from http Awww studio delos com glossary Accessed 5 November 2007 Internet St Jude Medical 2011 Model 3085 Dual Chamber Pulse Generator User Manual Osypka Medical La Jolla California Wood F 2007 Personal Communication to Pacemaker Guidelines Project Group 15 January 2007 Our Lady s Children s Hospital Crumlin Dublin Acknowledgements We wish to acknowledge and thank all those who have been involved in developing and reviewing this guideline Approval by Cardiac Team have read and approve the Nursing Practice Committee s Nursing Guidelines on Care of the Child with an External Temporary Pacemaker Mr L Nolke Consultant Cardio Thoracic Surgeon 2013 Our Lady s Children s Hospital Crumlin
19. ave high mainly occurs in adults unless sensitivity and decrease if necessary the sense thresholds have been set too low Lynn McHale et al 1987 2 Failure to Capture Pace Capture occurs when the myocardium responds to the pacing stimulus by depolarising i e P wave or QRS wave Failure to capture occurs when the myocardium fails to respond to a pacing stimulus It will be seen as the pacing spike s not been followed by a P wave or QRS complex Contact Cardiothoracic Team medical surgical IMMEDIATELY Possible causes for increased pacing threshold e Inflammation or fibrosis at electrode site e Increased serum Potassium or Calcium e Acid base imbalances e Medications i e Verapamil or Propanolol e Fibrillation or flutter Problem Intervention Loose connection between lead wire Ensure connections are secure cables and pacemaker Fracture insulation break of lead wire Assess integrity Contact Cardiothoracic Team medical Displacement of lead wire surgical who will replace it if required NB The skin can be used as a new positive electrode Low pacemaker battery Battery replaced by Cardiothoracic Team medical surgical Failure of pulse generator Pulse generator replaced by cardiothoracic team Increased pacing threshold inadequate Contact Cardiothoracic Team medical surgical Who will output energy for depolarisation reassess pacing threshold and identify and treat the underlying physiological
20. bay and Criddle 2004 Assess insertion site for bleeding If present apply pressure dressing Notify cardiothoracic medical surgical team To detect and treat early signs of bleeding Assess insertion site for signs of infection i e redness swelling or oozing If present Notify cardiothoracic medical surgical team Clean site and obtain swab for culture and sensitivity Section 6 PSYCHOLOGICAL CARE Action Early detection of signs of inflammation infection Spread of infection along the catheter may cause septicaemia To ascertain microbiology status Lynn McHale et a 1987 Fischer 2008 Dougherty and Lister 2011 Cleaning site prior to swabbing is required to ensure accurate collection of and reduced contamination of organisms from the wound Kelly 2003 Kingsley and Winfield Davies 2003 OLCHC 2008 Rationale amp Reference Provide explanations education and emotional support to child and family Involve the multidisciplinary team including cardiac team cardiology clinical nurse specialist and play specialist as appropriate To foster understanding and relieve anxiety To provide knowledge and skills as necessary for compliance with treatment Van Orden Wallace 1998 Hockenberry and Wilson 2011 3 Trouble Shooting Most troubleshooting associated with pacemaker systems is related to changes in the patient s medical condition or misinterpretation of normal pacemaker fun
21. c output is determined by multiplying the heart rate and the stroke volume F Fibrillation A type of cardiac arrhythmia characterised by rapid unsynchronised quivering of atria or ventricles Atrial fibrillation may be asymptomatic but ventricular fibrillation is typically fatal if not corrected within minutes Intrinsic An intrinsic beat is a naturally occurring heartbeat Intrinsic rate is the patient s own heart rate Sometimes called native Inhibition The effect of pulse suppression when pacemaker in a demand mode and senses a cardac depolarization L Lead The insulated wire plus electrode s and terminal pin used to connect the pulse generator to the cardiac tissue The lead carries the stimulus from the pulse generator to the heart and in demand modes relays intrinsic cardiac signals back to the sense amplifier of the pulse generator A single chamber pulse generator requires one lead while a dual chamber pulse generator usually requires two one for the atrium the other for the ventricle Lead Dislodgement The detachment of the pacing lead from the intracardiac location to which it had been positioned M Microshock Low voltage electrical current or static electricity which can pass from the nurse and into the patient As little as 0 1mA has the potential to cause ventricular fibrillation O Output The electrical stimulus delivered by the pulse generator and usually defined in terms of pulse amplitude V and pulse widt
22. cal Battery Depletion The nurse should avoid this occurring by organising battery change earlier When critical battery depletion occurs the battery symbol will be empty and blinking The warning message Hurry up Change battery will display This is repeated every 2 minutes Battery will need to be replaced immediately Ensure manufacturer s user manual is always available for reference in an area that all staff are aware of and have access to To allow cardiothoracic medical surgical team to replace battery in a timely fashion Battery change level is reached There is approximately 24 hours reserve of battery life on Model 3085 if pacemaker mode set on standard setting St Jude Medical 2011 To minimise risk and create a safe environment should interruption of pacing complications occur during the procedure NB during battery changeover the pacemaker provides a minimum of 30 seconds additional power for extra safety Battery change should take place WITHOUT DELAY but avoid undue haste Jude Medical 201 1 To ensure fully charged battery in situ NB AV sequentional pacing exhausts a battery more quickly than ventricular demand pacing Hazinski 2013 To have replacement in case of battery failure Dwyer 2001 Mater Misericordiae University Hospital 2011 Yorkhill Children s Hospital 2011 Hazinski 2013 To minimise risk and ensure the infant child receives continuous and uninterrupted pacing St Jude
23. ce lock on Document make and model of external pacemaker and any changes Appendix II and III NB pacing spikes may not be visible on telemetry PICU only Assists in tracking pacemaker malfunction d 3 PACEMAKER AND WIRES Action Assess integrity and security of pacing wires ensuring no loose connections or wire fractures minimum once per shift NB Take extra care when moving patient Ensure wires are secure and pacemaker box and leads are supported Rationale and Reference To ensure good pacemaker connection and prevent disconnection To prevent accidental changes to settings Appendix IV Martin and Aragen 1992 Hazinski 1999 Dwyer 2001 Reynolds and Apple 2001 Dwyer and Bauer 2010 Ensure the pacemaker box is secure Ensure the cables are secure NB Pacemaker should be visible at all times If pacemaker is dropped or becomes damaged it should be replaced immediately by the medical team and sent to clinical engineers for evaluation To prevent strain and accidental disconnection or dislodgement of pacing wires and damage to the pacemaker box Keenan 1995 Cottle 1997 Dwyer 2001 Overbay and Criddle 2004 Reiswig Timothy and Rodeman 2004 To ensure the pacemaker is functioning correctly If alternative pacemaker is required contact PICU 2 Floor first and then theatre dept or clinical engineer for replacement Clinical Engineers Bleep 465 008 Ext 6465
24. ction In all instances it is vital to assess the patient and identify the cause It is essential for nurses to contact the cardiothoracic medical surgical team IMMEDIATELY for early and timely intervention There are four potential problems which can exist during pacing 1 Failure to Fire 2 Failure to Capture Pace 3 Under Sensing 4 Over Sensing 1 Failure to Fire Failure to fire is characterised by the loss of output from the pulse generator which is identifiable by an abnormally slow heart rate or asystole Intervention should be specific to the problem found in the pacemaker system If failure to fire cannot be corrected emergency measures may need to be initiated Failure to fire related to pacemaker malfunction is rare It is more likely to be related to settings connections or changing thresholds Contact Cardiothoracic medical surgical Team IMMEDIATELY Problem Intervention Loose connection or disconnection between Ensure connections are secure lead wire cables and pacemaker Fracture dislodgement of lead wire Assess integrity of lead wires and replace as necessary NB Remember the skin can be used as a new or extra positive lead Low pacemaker battery Insert new battery Failure of pacemaker pulse generator Replace pacemaker generator Contact Cardiothoracic Team medical surgical Over sensing not common in paediatrics i e Contact Cardiothoracic Team medical surgical to assess P w
25. development of pericardial tamponade Wollan 1995 PCNA 2003 Beattie 2005 Jowett et al 2007 O Brien 2008 Pacing wires should only be removed after therapeutic heparin has been discontinued Reade 2007 Mater Miscericordiae University Hospital 2011 OLCHC 2012a To provide a route for fluid resuscitation or anti arrhythmic medication should it be required Johnson et al 1993 Beattie 2005 To establish baseline observations for comparison post procedure and detection of changes in patients condition in a timely fashion Lynn McHale et a 1998 Clark 2007 To assess the child for potential arrhythmias or pericardial tamponade Johnson et a 1993 Wollan 1995 O Brien 2008 To create a safe environment and maintain patient safety Wollan 1995 PCNA 2003 Avoid performing the procedure in a child s safe zone to minimise stress of hospitalisation O Brien 2008 To relieve fear anxiety and foster understanding and cooperation of the procedure Information may need to be reinforced if the child is stressed Van Orden Wallace 1998 PCNA 2003 Roschkov and Jensen 2004 O Brien 2008 Mullins et al 2009 Hockenberry and Wilson 2011 Pain Relief Administer analgesia and sedation if required as prescribed by the medical team as per Procedural Analgesia and Sedation Algorithm Appendix VI Sedation will always be given in conjunction with analgesia Assess pain score Positioning The child
26. diac catheterisation i e femoral vein and advanced via a guide wire to right ventricle Transcutaneous Emergency non invasive pacing which may be used for severe symptomatic bradycardia Electrode pads are placed on anterior and posterior chest to deliver stimulus through the chest wall Available on some defibrillators Transoesophageal Paces by impulse transversing tissue between the electrode in the oesophagus and left atrium Usually short term pacing i e atrial pacing without A V block Anderson 2000 Hazinski 2013 Indications for Temporary Pacing 1 Post cardiac surgery e Higher risk of arrhythmias in first 2 3 days post surgery especially left ventricular outflow tract AVSD or VSD surgery e Temporary support to increase cardiac output 2 Asa prelude to permanent pacing 3 To reverse certain types of atrial or ventricular arrhythmias 4 Severe symptomatic bradycardia Hickey and Baas 1991 Hazinski 2013 Types of Cardiac Pacing commonly used Demand To sense the patient s intrinsic activity and deliver an impulse only if intrinsic electrical activity is NOT sensed within a predetermined time Fixed To deliver an impulse at a predetermined rate regardless of intrinsic myocardial electrical activity This type of pacing is less seldom used as it is associated with an increased risk of arrhythmias Sensitivity needs to be turned to lowest level to avoid sensing of patient s own intrinsic activity A V Sequential Du
27. dial pacing wire removal Mullins et a 2009 Mater Misericordiae University Hospital 2011 OLCHC 2012b To ensure correct positioning for removal of epicardial pacing wires Semi upright position is often preferred in children as it is often associated with less anxiety Wollan 1995 Clark 2007 O Brien 2008 Beattie 2008 Procedure only performed by Cardiothoracic Team because of the potential complications that may occur following the procedure Roschkov and Jensen 2004 O Brien 2008 To prevent cross infection universal precautions PCNA 2003 Epicardial pacing wires provide a direct low resistant pathway to the heart and patient may receive micro shocks due to static electricity Wollan 1995 Beattie 2005 To minimise transmission of organisms O Brien 2008 To allow complete visualisation of pacing wire site and holding suture O Brien 2008 Reduces risk of infection O Brien 2008 This allows pacing of the ventricle to restore cardiac output in the event of a symptomatic arrhythmia following removal of atrial pacing wires To reduce the risk of trauma Jerking or pulling against resistance may cause bleeding Wollan 1995 Sheehan et al 2001 PCNA 2003 Clark 2007 Clark 2007 To ensure that the entire wire has been removed and determine the risk of infection migration or haemorrhage Johnson et a 1993 Wollan 1995 Clark 2007 Beattie 2008 Following removal an Opsite occlusive dressin
28. disturbances 3 Under Sensing Sensing is the ability of the pulse generator to see the patients own rhythm Pacing spikes are present and regular but compete with the patients own inherent rhythm This can occur when the sensing amplifier fails to detect the intrinsic activity of the heart the sense threshold has been set too high or when the pacemaker loses the ability for self inhibition fires regardless Mechanical failure of the pacemaker is rare The pacemaker s response to under sensing is to over pace with pacing spikes falling randomly in the cardiac cycle This situation must be corrected as soon as possible because there is a potential for the pacemaker to deliver a stimulus in the refractory period of the cardiac cycle which corresponds with the T wave when the heart is repolarising heart vulnerable It may potentiate lethal arrhythmias i e ventricular tachycardia or ventricular fibrillation Possible causes for under sensing QRS detection e Tissue ischaemia fibrosis e Electrolyte disturbance e Poorly positioned lead e Fibrillation atrial flutter e Lead fracture e Loose connections Reynolds and Apple 2001 Problem Intervention Inadequate QRS signal Contact Cardiothoracic Team medical surgical who may increase sensitivity making the pacemaker more sensitive by decreasing mV to a smaller number Slota 2006 Fracture dislodgement of pacing wire Assess integrity Contact Cardiotho
29. g is applied to the site for a minimum of 24 hours Dispose of used supplies and sharps appropriately Remove gloves and wash hands Post Procedure Bedrest The child will remain on bedrest for 1 2 hour following the procedure Monitoring Monitor and record vital signs immediately following the procedure heart rate rhythm respirations and blood pressure Repeat every 15 minutes x 2 and then every 30 minutes x 2 and then as patients clinical condition dictates Observe patients 5 02 colour perfusion and conscious level Complications The child will be observed for complications e Bleeding bleeding occurs apply direct pressure with gauze for several minutes until ceases Persistent bleeding should be reported immediately to the cardiothoracic surgical team Patients on anticoagulation therapy are at greater risk of bleeding e Arrhythmias i e ventricular ectopic beats due to mechanical irritation of the myocardium Be extra vigilant if the child has a history of heart failure or previous cardiac surgery Report excessive ectopic beats or sustained arrhythmias to the cardio thoracic team e Pericardial Tamponade Rare but serious complication Signs amp symptoms include pallor collapsed child tachycardia tachypnoea dyspnoea reduced capillary refill cool extremities decreased Sa02 sweating decreased conscious level hypotension Report immediately to cardio thoracic surgical team An echocardiogram may be
30. h ms In pacing output used alone usually refers to electrical output of the device while the term cardiac output is used for blood throughput of the heart Maximum 10 volts Wood 2007 Output usually set 3 times output pacing threshold Output Pacing Threshold The minimum electrical stimulus needed to consistently elicit a cardiac depolarisation capture and expressed in millivolts mV Usually 2 mV or less Over Sensing Detection by the pulse generator s sense amplifier of inappropriate electrical stimulus The over sensed signal may or may not be visible on a surface EGG Over sensing can often be corrected by making the pacemaker less sensitive increasing the mV value programming to a triggered mode or by the judicious programming of the refractory period Premature Ventricular Contractures PVCs ventricular contraction initiated by an ectopic focus which occurs earlier than the next expected normal ventricular contraction Also known as ventricular ectopic beats or ventricular premature beats VPBs R Refractory 1 Inability of tissue to respond to a stimulus 2 Inability of a pacemaker to respond to an incoming signal Refractory Period 1 The length of time the myocardium is incapable of responding to a stimulus 2 In pacing an interval or timing cycle following a sensed or paced event during which the sense amplifier will not respond to incoming signals Dual chamber pacemakers have separate refract
31. han K Tometzki A and Tsai Goodman B 2001 National Audit of Temporary Epicardial Wire Removal Unpublished Bristol Royal Children s Hospital Slota M C ed 2006 Core Curriculum for Paediatric Critical Care Nursing 2 Edition Saunders Elsevier St Louis St Jude Medical 2011 Model 3085 Dual Chamber DDD External Pulse Generator User Manual Osypka Medical La Jolla California Trigano A J Azoulay A Rochdi M and Campillo A 1999 Electromagnetic interference of external pacemakers by walkie talkies and digital cellular phones experimental study PACE 22 588 593 Van Orden Wallace C J 1998 Dual chamber pacemakers in the management of severe heart failure Critical Care Nurse 18 2 57 66 Van Orden Wallace C J 2001 Diagnosing and treating pacemaker syndrome Critical Care Nurse 21 1 24 31 35 Wollan D L 1995 Removal of epicardial pacing wires an expanded role for nurses Progress in Cardiovascular Nursing 10 4 21 26 Xia B Thakur M D Shah C P and Hoon V K 1998 Permanent cardiac pacing Emergency Clinics of North America 16 2 419 462 Yorkhill Children s Hospital 2011 Practice Advisory for Temporary Epicardial Pacing after Cardiac Surgery Yorkhill Children s Hospital Glasgow PACEMAKER CONTROLS APPENDIX I Ajuo Ju gN sneg 20 281 Kay sBumag Kauafiuau
32. ing is AAI Atrial Pacing VVI Ventricular Pacing DDD A V Sequential Dual Pacing The Pacing Circuit Pulse Generator Pacing Box This contains the energy source and electrical circuitry to provide an electrical stimulus to maintain the specified rate It also recognises and evaluates the heart s intrinsic rhythm The pacing circuit has terminals for pacemaker wire connection of bi polar leads Bipolar leads measure electrical potential between 2 lead wires in contact with the heart Lead Wire Electrode This transmits the patients rhythm to the pulse generator and also carries an electrical stimulus between the pulse generator and the chamber being paced The electrode needs a negative output pole the tip and positive ground pole the insulator which enables a current to flow between the pulse generator and the heart Epicardial wires may be placed after cardiac surgery on the epicardium or placed transvenously through guided insertion of specialised catheters at cardiac catheter Reynolds and Apple 2001 Hazinski 2013 2 Nursing Care of the Child with a Temporary External Pacemaker Nurses should only care for a child with a temporary external pacemaker having received the necessary theoretical and practical instruction to practice competently within their scope of All nursing care is given with regard to guidance for good practice practice An Bord Altranais 2000 OLCHC 2002 NB All pacemaker settings and
33. itoring The child will have observations taken and recorded prior to removal i e temperature pulse respirations SaO2 and blood pressure The child will be attached to telemetry cardiac monitor for the procedure for minimum of 24 hours Safety The nurse will ensure emergency equipment is working and available at the bedside e Amubag rebreathing circuit and appropriate mask e Oxygen and mask e Suction equipment and suction catheters e Antiarrhythmic drugs and defibrillator available on ward unit Location Plan location of procedure Use treatment room if available Psychological Preparation The child and or family will receive adequate explanation of the procedure at an appropriate level and emotional support prior to wire removal Encourage questions and answers Child should be informed of sensation likely to be experienced during procedure i e mild to moderate pulling sensation as clinically indicated A play therapist may be utilised for preparation and or distraction if clinically indicated To ensure that epicardial pacing wires are removed under safe conditions and observation throughout the day following removal under optimal conditions should emergency intervention be required Johnson et al 1993 PCNA 2003 Beattie 2005 To ensure patient safety PCNA 2003 The presence of coagulopathy requires treatment before removal of pacing wires To minimise the risk of bleeding post removal of wires and
34. l pacing wire There is a potential risk of endocarditis and doctor or dentist may decide to administer prophylactic antibiotics prior to any invasive procedure Johnson et al 1993 References An Bord Altranais 2000 Scope of Nursing and Midwifery Practice Framework An Bord Altranais Dublin An Bord Altranais 2002 Recording Clinical Practice Guidance to Nurses and Midwives An Bord Altranais Dublin Anderson D M 2000 Dorlands Illustrated Medical Dictionary 29 Edition W B Saunders Philadelphia Baas L S Beery T A and Hickey C 1997 Care of pacemaker electrodes in intensive care and telemetry units American Journal of Critical Care 6 4 302 311 Beattie S 2005 Epicardial wires Modern Medicine Available online www modernmedicine com modernmedicine Hands On help Epicardial wires Accessed December 3rd 2012 Beery T A Baas L S and Hickey C S 1996 Infectious precautions with temporary leads a descriptive study Heart and Lung 25 3 182 189 Bernstein A D Daubert J C Fletcher R D Hayes D L Luderitz B Reynolds D W Schoenfeld M H and Sutton R 2002 The revised NAPSE BPEG Generic Code for antibradycardia adaptive rate and multisite pacing Pacing Clinical Physiology 25 260 264 Boyle J and Rost A K 2000 Present status of cardiac pacing a nursing perspective Critical Care Nursing Quarterly 23 1 1 19 Carroll K C Reeves L M Anderson G Ray F M Clopton P L Shivel
35. litator St Theresa s Ward Karen Fitzmaurice Clinical Nurse Facilitator St Bridget s Ward and Tutor CCNE Issue Date January 2014 Review Date January 2017 Contents Page 1 Introduction 2 2 Nursing Care of the Child with a Temporary 3 pacemaker a Monitoring 3 b Documentation 4 C Pacemaker and Wires 5 d Electrical Safety 7 e Insertion Site 8 f Psychological Care 8 3 Trouble Shooting 8 a Potential Complications of Temporary External 11 Pacing 4 Nursing Responsibilities with Assisting with the 11 Removal of Epicardial Pacing Wires 5 References 16 6 Appendices 19 1 Introduction A pacemaker is a device which uses electrical impulses to increase or regulate the heart rate and or rhythm when the patient s own intrinsic function of conduction or impulse generation is impaired A temporary external pacemaker is one which is located outside the body for the purpose of regulating the heart rate and or rhythm for a temporary period of time A pacemaker box is used to regulate and control the function of pacing and pacing wires are used to conduct and sense the heart s intrinsic electrical activity Most often in paediatrics temporary pacing wires are placed on the epicardium or in the myocardium at the conclusion of cardio thoracic surgery or during an emergency thoracotomy in an intensive care setting Other modes of temporary pacing are Transvenous Catheter is Inserted during car
36. llace 1998 Boyce and Rost 2000 Hazinski 2013 Assess tissue perfusion e Peripheral pulses strong or weak Capillary refill brisk or sluggish e Warmth of extremities NB Minimum of 4 hourly or as condition indicates Tissue perfusion depends on adequate cardiac output These are early signs of low cardiac output Boyce and Rost 2000 Hazinski 2013 Assess rate and regularity of respirations Monitor colour and oxygen saturations to establish parameters for same Administer oxygen if ordered and clinically indicated To establish baseline and detect changes in a timely fashion Increased respiratory rate dyspnoea or cough may be indications of increasing heart failure Van Orden Wallace 1998 Hockenberry and Wilson 2011 Maintain strict fluid balance chart Action Monitor serum electrolytes as per medical team Monitor acid base balance as per medical team Inform medical team of changes in patient s condition or laboratory findings Document same To provide information about fluid balance Large positive balance and diminished urine output may indicate worsening heart failure Van Orden Wallace 1998 Hazinski 2013 Rationale and Reference Electrolyte imbalance may interfere with electrical activity of the heart Reiswig Timothy and Rodeman 2004 Hockenberry and Wilson 2011 Pacing thresholds can be affected by acid base balance Hazinski 2013 To allow for timely in
37. of patient care An Bord Altranais 2002 Clark 2007 To ensure patient safety and referral in an appropriate manner PCNA 2003 Retained Wire Lead or Fragments Ensure retained wire lead or fragments are communicated to ward nursing staff on transfer documentation as clinically indicated It should be clearly documented in the patient s medical and nursing notes also Instruct parent to check childs temperature daily until next out patient appointment and report temperature gt 8 Advise parent regarding the long term need to inform doctor regarding any possible signs of infection i e malaise chills fever and signs of infection at epicardial pacing wire exit sites Instruct parent to inform all attending doctors and dentists of retained pacing wire There is increased risk of infection as they create an open wound through the skin which communicates with the pericardial space Complications from retained epicardial wires have been described in the literature i e localised abscess fistula to infective endocarditis Complications have been reported to occur up to many years later Ensure satisfactory communication and continuity of care An Bord Altranais 2002 Yorkhill Children s Hospital 2011 Shaikhrezai et a 2012 Early detection of infected epicardial pacing wire Johnson et al 1993 To ensure prompt and timely treatment of any infection at pacing wire sites or due to retained epicardia
38. ory periods for each chamber atrial and ventricular In most modern pacemakers the refractory periods are programmable values 5 Sensing The ability of the pacemaker to recognise and respond to electrical activity in the heart How the pacemaker responds to sensed signals depends on its programmed mode and parameters Sensitivity A pacemaker parameter which determines the amplitude of signals to which the device s sense amplifiers will respond Sensitivity is stated in millivolts mV Note that the higher the mV value the lower the sensitivity Thus the lower the mV value the more sensitive the device Average setting is 2 lowest 1mV Wood 2007 Sensitivity Threshold The minimum atrial or ventricular intracardiac signal amplitude required to inhibit or trigger a demand pacemaker expressed in millivolts Sensitivity is usually 2 3 times more sensitive than sensitivity threshold i e divide threshold by 3 Spike A small but sharply vertical deflection that appears on the surface ECG indicating that a pacemaker output was delivered It is caused by the brief discharge of electricity produced by the pacemaker to stimulate the heart In some situations a pacemaker spike may not appear clearly on an ECG Telemetry The transmission of signals or data from one electronic unit to another by radiowaves or other means Medtronic 2003 Temporary Lead A pacing lead intended for short term use usually with an external pacemaker Tempor
39. racic Team medical surgical immediately who will replace as necessary NB Remember the skin can be used as a new positive electrode Battery depletion Contact Cardiothoracic Team medical surgical to replace battery 4 Over Sensing Over sensing is when the pacemaker is too sensitive and inappropriately senses internal and external signals and inhibits pacemaker output The pacemaker generator misinterprets an electrical current as a QRS complex inhibits itself and therefore does not fire The Pacemaker may have detected a P wave or T wave rather than the QRS complex or myopotentials i e electrical signals produced by skeletal muscle contraction The sensing amplifier sees too many signals which the pacemaker interprets as the hearts intrinsic rate and therefore does not fire In patients with a pacemaker dependent rhythm this will result in a pause in rhythm and reduction in cardiac output Over sensing may be eliminated by reducing the sensitivity This is performed by the cardiothoracic team Fischer 2008 Problem Intervention P or T wave sensing Contact Cardiothoracic Team medical surgical who may reduce sensitivity making the pacemaker less sensitive by increasing mV to a higher number Slota 2006 Skeletal muscle contractions Contact Cardiothoracic Team medical surgical who may myopotentials or shivering decrease sensitivity Electromagnetic interference Identify and remove source Contac
40. red and ventricular wires on the left Nursing Practice Committee December 2013 N T e N 5 UO UoIsIoep 308115007 UO 108111500 UO UoIsi2ep juejjnsuo J 10 10 10 Od By fiuig 9 wojezepiyy Od 0 G2 0 Od By Buigz 0 Od o Od 0 52 0 gt snid snid J lesseoou a Od g eupiuoo Ood wwuelforiu 91 1 Od eupruoo I 40 Jo peunbe1 Od wejozepiy Od 630 9 0 62 0 Ulejozepii Od sz o Aesseoau j yeeday uesseooujijeede esseoeu yeadey eq jou snid snid J J N uonepes N NI weou N By webosu 9 elsebjeue o 9 ugue J Augu 6 0 Aueque auydio 0 02 auydio 02 0 eutudiow euudio jeuonippv Qa lt gt 1H03WO2 1 2 Aj uo sjueged Aj uo peejje ji sjuened ysod peyeqnixa sjuetjed ion JOU z ei Od 0 erc 3504005 OSN
41. t Cardiothoracic Team medical surgical who may decrease pacemaker sensitivity Reynolds and Apple 2001 POTENTIAL COMPLICATIONS OF TEMPORARY EXTERNAL PACING Contact Cardiothoracic Team medical surgical IMMEDIATELY Problem Cause Arrhythmias e May result from myocardial irritability caused by pacing wires e Ventricular Tachycardia If pacemaker stimulus occurs during QT interval when the heart Fibrillation is repolarising Removal of pacing wires can rarely cause ventricular arrhythmias e g ventricular fibrillation e Asystole If pacing is discontinued abruptly or if batteries fail Electrical Hazards Leads provide a direct low resistance pathway to the heart for an electrical current Haemorrhage Can occur during or after epicardial or endocardial lead placement or removal resulting in cardiac tamponade Pneumothorax or Pheumomediastinum Cardiac perforation or air embolism can occur during transvenous pacemaker insertion Infection Insertion sites should be inspected each shift to detect early signs of infection See c o insertion site Displacement Fracture of leads Lead fracture impairs ability of unit to conduct an impulse Slota 2006 Failure to recognise asystole Monitor may read pacing spikes as a QRS complex even when no QRS follows the pacing spike Asystole may therefore be missed Oslizlok 2007 4 Nursing Responsibilities in Assisting
42. terventions by medical team Van Orden Wallace 1998 An Bord Altranais 2002 Assess bowel function daily Prevent constipation Check pacemaker settings against doctors order and document same in nursing notes Verify pacemaker settings and record the following information on vital signs flow sheet of Clinical Information management System CIMS Appendix NB Minimum once per shift and following all changes to settings To allow timely interventions in preventing constipation Straining on defaecation may reduce cardiac output Van Orden Wallace 1998 Rationale and Reference To ensure correct settings of mode rate sensitivity and output To have baseline settings in case of alterations Documentation provides continuity of care when information is shared Scheider Hickey and Bass 1991 An Bord Altranais 2002 Fischer 2008 Hazinski 2013 To promote and facilitate continuity of care and good communication through effective documentation Schneider Hickey and Baas 1999 An Bord Altranais 2002 Hazinski 2013 Patient s name and hospital number ODate and time mode OAtrial output DAtrial sense OVentricular output OVentricular sense DA V delay change date OBattery voltage OPacing wires Secured to patient Entry site dry Secured to pacemaker OPacing spike s on monitor rate from arterial line or alternative sour
43. tricity To prevent child pulling or interfering with wires To prevent pressure marks to chest Ensure easy accessibility to pacing wires if required Easy identification of wires Lynn Mc Hale et a 1987 Schneider Hickey and Baas 1991 Berry et al 1997 Reynolds and Apple 2001 Overbay and Criddle 2004 Wear non sterile examination gloves at all times when handling pacing wires especially terminal ends Terminal ends are not insulated To prevent micro shocks and static electricity being transmitted via the nurses hands to the patient Lynn Mc Hale et a 1987 Hickey and Baas 1991 Beery et a 1996 Baas et al 1997 Norman 1998 Reynolds and Apple 2001 Overbay and Criddle 2004 Reiswig Timothy and Rodeman 2004 Beattie 2005 Appropriate warnings should be issued against the potential serious risk of using mobile communication devices in the vicinity of a patient with a pacemaker The use of mobile phones walkie talkies is PROHIBITED in close vicinity to the patient There is a potential risk of electromagnetic interference to external pacemakers by mobile phones and walkie talkie s Trigano et al 1999 Medtronic 2001 The Nurse Practice Committee acknowledges the age of this reference However the article is a seminal piece of work which provides a comprehensive overview of the care of a pacemaker and which has been cited extensively by subsequent authors Section 5 INSERTION SITE There are
44. will be positioned supine or alternatively at 30 450 angle if not possible in bed for the procedure Ensure privacy in older child adolescent Procedure Responsility for removal of pacing wires The cardio thoracic team are responsible for removal of the epicardial pacing wires Equipment e Dressing trolley e Dressing pack including sterile gloves and gauze e 0 05 Chlorhexidine solution e Opsite occlusive dressing e Stitch cutter Cardio thoracic Surgeon will wash hands using a Aseptic Non touch Technique ANTT level 2 and put on sterile gloves The nurse will decontaminate hands and assist doctor in laying dressing trolley Nurse will remove dressing around pacing wires to expose pacing wires and then repeat handwashing The doctor will clean around pacing wire sites with Chlorhexidine 0 05 The atrial pacing wires are usually removed first if present and ventricular wires last The holding suture of the pacing wire is released using a stitch cutter Holding the pacing wire near to the chest it will be pulled with a smooth continuous downward pulling motion exerting gentle traction until release from the epicardium is felt The tip of the epicardial pacing wire is inspected for intactness and pieces of myocardial tissue The procedure is repeated by the doctor for each additional pacing wire s To provide comfort and minimise pain Patients have reported mild to moderate pulling sensation on epicar
45. with the Removal Of Epicardial Pacing Wires 5 Epicardial pacing wires atrial x 2 ventricular x 2 are routinely inserted by the cardio thoracic surgeon following open heart surgery i e AVSD repair Fallots Tetralogy repair and VSD repair They are used to diagnosis and treat rhythm disturbances Epicardial pacing wires are traditionally placed atrial wires on right side of chest and ventricular on the left Should pacing be required post operatively these wires allow the heart to be temporarily paced by an external pacemaker Lynn McHale et a 1998 Beattie 2005 Clark 2007 O Brien 2008 ACTION RATIONALE Timing of Wire Removal Epicardial pacing wires are usually removed a minimum of 3 5 days post operatively and at least 24 hours prior to hospital discharge on instruction from cardio thoracic team The child will have a normal heart rate for age and be in sinus rhythm Pre Procedure Investigations The child will have a 12 lead ECG 24 hour Holter ECG and Chest X ray performed and reviewed by the medical team The child will have a coagulation screen and platelet count performed and reviewed by the cardiothoracic team medical surgical NB Therapeutic Heparin infusion is discontinued 4 hours prior to the removal of pacing wires The heparin infusion is then restarted 2 hours post procedure if there is no bleeding IV Access Ensure patient has a patent intravenous cannula in situ prior to the procedure Mon
46. y M and Tarazi R Y 1998 Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery American Journal of Critical Care 7 6 444 9 Clark L 2007 Bedside nurses removing epicardial pacer wires from concept to practice Canadian Journal of Cardiovascular Nursing 17 1 27 30 Cottle S 1997 Temporary transvenous cardiac pacing Nursing Times 93 48 48 51 De Vooght 1999 Pacemaker leads performance and progress American Journal of Cardiology 11 8 187D 191D Dougherty L and Lister S eds 2011 The Royal Marsden Hospital Manual of Clinical Nursing Procedures 8 Edition Wiley Blackwell London Dwyer D 2001 Medical device adverse events and the temporary invasive cardiac pacemaker nternational Journal of Trauma Nursing 7 2 70 73 Dwyer D and Bauer K 2010 Take the lead on safety with temporary cardiac pacing Nursing 40 3 63 64 Fischer M 2008 Transvenous and epicardial pacing monitoring In Verger J T and Lebet R M eds ACCN Procedure Manuel for Pediatric Acute and Critical Care Saunders Elsevier St Louis 375 382 Hart S 2007 Using an aseptic technique to reduce the risk of infection Nursing Standard 21 47 43 48 Hazinski F ed 2013 Nursing Care of the critically Child 3 Edition Elsevier Mosby St Louis Hickey C S and Baas L S 1991 Temporary cardiac pacing AACN Clinical Issues 2 1 107 117 Hockenberry M J and Wilson D eds
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