Section 1.0
Mater Misericordiae University Hospital Ltd.
Eccles Street
Dublin 7
DEPARTMENT OF NURSING
Title: Guidelines for the Care and Removal of Temporary Epicardial Pacing
Wires Post Cardiac Surgery.
To whom does it apply:
Staff nurses caring for and removing Temporary Epicardial Pacing wires within:
The Professor Eoin O’Malley Cardiothoracic Unit, St. Cecilia’s Ward and
Cardiothoracic High Dependency Unit.
Developed by:
Staff Development Facilitator: St. Cecilia’s Ward
Staff Development Facilitator: Cardiothoracic High Dependency Unit.
Signature of Approval:
____________________________
Effective Date:
____________________________
Review Date:
____________________________
Supercedes:
____________________________
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Section 2.0
Title: Guidelines for the Care and Removal of Policy/Guideline/Protocol No:
Temporary Epicardial Pacing Wires Post
Cardiac Surgery.
Effective Date: __________________
Appendices:
a) Temporary Epicardial Pacemaker Care
Approved By: __________________
Plan
Written By: Staff Development FacilitatorsCardiothoracic High Dependency Unit and St
Cecilia’s Ward
Department: Professor Eoin O’Malley
Cardiothoracic Unit, St. Cecilia’s Ward and
Cardiothoracic High Dependency Unit.
Revision: New
Review Status: Annual
Date Reviewed: __________________ Signature: _______________________
Date Reviewed: __________________ Signature: _______________________
Date Reviewed: __________________ Signature: _______________________
Date Reviewed: __________________ Signature: _______________________
Date Reviewed: __________________ Signature: _______________________
Date Reviewed: __________________ Signature: _______________________
Date Reviewed: __________________ Signature: _______________________
Date Reviewed: __________________ Signature: _______________________
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Section 3.0: Index
Section 1.0 ..................................................................................................................... 1
Title: Guidelines for the Care and Removal of Temporary Epicardial Pacing
Wires Post Cardiac Surgery. ...................................................................................... 1
Section 2.0 ..................................................................................................................... 2
Review Status: Annual ............................................................................................ 2
Section 3.0: Index ......................................................................................................... 3
Section 4.0: Terms of Reference: ................................................................................ 4
4.1
Aim of Policy: ............................................................................................... 4
4.2
Clinical areas to which this policy applies: ................................................ 4
4.3
Education and Training: ............................................................................. 4
4.4
This policy must be read in conjunction with the following documents: 4
Section 5.0: Definition of Terms ................................................................................. 5
Section 6.0: Indications for Pacing: ............................................................................ 7
6.1: Temporary Epicardial Pacing in Cardiac Surgical Patients: ...................... 7
6.2: Contraindications: ............................................................................................ 8
6.3: Complications: .................................................................................................. 8
6.4 Most Common Problems Associated with Temporary Epicardial Pacing
Wires: ........................................................................................................................ 8
Section 7.0: Types of Temporary Cardiac Pacing: ................................................. 10
7.1: Insertion and Placement Sites: ...................................................................... 10
Section 8.0: NBG Codes and Modes of Pacing ........................................................ 11
8.1 Modes of Cardiac Pacing: ............................................................................... 13
Section 9.0: Care of the Patient with Temporary Epicardial Leads: .................... 14
9.1: Education: ....................................................................................................... 14
9.2: Microshocks: ................................................................................................... 14
9.3: Dressing: .......................................................................................................... 14
Section 10.0: Removal of Temporary Epicardial Pacing Wires: ........................... 15
10.1: Set up trolley with the following equipment: ............................................. 16
10.2 Removing Temporary Epicardial Pacing Wires:........................................ 16
Section 11.0: References ............................................................................................ 20
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Section 4.0: Terms of Reference:
This policy has been developed for Registered General Nurses working within the Eoin O
Malley Cardiothoracic Unit incorporating St Cecilia’s Ward and the Cardiothoracic High
Dependency Unit, to provide them with a standard of practice to manage patients with
Temporary Epicardial Pacing wires.
4.1
Aim of Policy:
a. To provide nursing guidelines for the management and care of patients with
Temporary Epicardial Pacing Wires.
b. To ensure the safety of patients and provide protection for nurses and employing
authority.
c. To decrease the potential for infection at Temporary Epicardial Pacing Wire sites.
4.2
Clinical areas to which this policy applies:
1. St Cecilia’s Ward
2. Cardiothoracic High Dependency Unit
4.3
4.4
Education and Training:

Nursing staff will receive education and training in the management of Temporary
Epicardial Pacing Wires to enable them to offer a safe and effective service to the
patient.

In determining his/ her Scope of Practice, the nurse or midwife must make a
judgement as to whether he/she is competent to carry out a particular role/ function.
The nurse must take measures to develop and maintain the competence necessary for
professional practice (An Bord Altranais, 2000).

Registered Nurses must complete the relevant competency in relation to the
Management and Removal of Temporary Epicardial Wires.
This policy must be read in conjunction with the following documents:
1. Scope of Nursing and Midwifery Practice Framework (An Bord Altranais April,
2000).
2. Recording Clinical Practice Guidance to Nurses and Midwives (An Bord Altranais,
2002).
3. The Code of Professional Conduct for each Nurse and Midwife (An Bord Altranais,
April, 2000).
4. Mater Misericordiae University Hospital, Procedures for Staff on the Management
and Reporting Incidents (Mater Misericordiae University Hospital, 2006).
5. Mater Misericordiae University Hospital Guidelines and Procedures for the
Prevention and Control of Infection in Hospitalised Patients (November, 2005).
6. Guidance to Nurses and Midwives on the Development of Policies, Guidelines and
Protocols (An Bord Altranais, December, 2006).
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Section 5.0: Definition of Terms
Action Potential: The action potential is brought on by a rapid change in membrane
permeability to certain ions, with unique properties necessary for function of the
electrical conduction system of the heart.
Automaticity: The ability of the cardiac muscles to depolarize spontaneously, i.e
without external electrical stimulation from the nervous system.
Capture: This is both an electrical and a mechanical event. A pacing spike followed
by a corresponding P wave or QRS complex indicates the electrical capture.
Cardiac Tamponade: A compression of the heart that occurs when blood or fluid
builds up in the space between the myocardium (the muscle of the heart) and the
pericardium (the outer covering sac of the heart).
Dysrhythmias: Any of a large and heterogeneous group of conditions in which there
is abnormal electrical activity in the heart. The heart beat may be too fast or too slow,
and may be regular or irregular.
Demand Pacing: A pacing stimulus is delivered to the myocardium if the intrinsic
rate falls below the set rate on the pacemaker.
Epicardial Pacing: Type of temporary pacing where pacing wires are fixed directly
to the myocardium (ventricular and often atrial) and are exposed through the skin on
the chest wall, usually following cardiac surgery.
Epicardium: describes the outer layer of heart tissue.
Fixed Rate Pacing: A pacing stimulus is delivered to the myocardium at a
programmed fixed rate regardless of the underlying rate and rhythm. This is also
known as asynchronous ventricular pacing.
Microshocks: Low voltage electrical current from ungrounded equipment or static
electricity that may pass through to the patient, with as little as 0.1 mA causing
Ventricular Fibrillation. (Beattie, S. 2005)
Myocardium: Composed of specialized cardiac muscle cells with an ability to
contract, and also carry an action potential (i.e. conduct electricity), like the neurons
that constitute nerves. Furthermore, some of the cells have the ability to generate an
action potential, known as cardiac muscle automaticity.The blood supply of the
myocardium is carried by the coronary arteries.
Output: The energy supplied to the heart muscle that is sufficient to stimulate a
contraction.. It is determined by three components:
Rate: the original setting providing a pacing rate to the myocardium.
Amount: level of energy delivered to the pulse generator to the heart
to initiate depolarisation and is measured in millamperes.
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Chamber: The atrial, the ventricle or both chambers can be paced. If
both the atria and ventricles are paced, a separate output setting is
required for each chamber.
Pacing: Electronic pacemakers apply small electrical impulses called stimuli to the
Atrial mass and/ or the Ventricular mass to trigger these muscle masses to depolarise
at the right moments to produce heartbeats at a desired heart rate and sequence.
Pacing Wires:



Atrial Pacing wires are sutured to the right atrial appendage or the body of the
right atrium.
Ventricle pacing wires are placed on the anterior or diaphragmatic surface of
the right ventricle.
Special attention should be paid to the site of lead placement in patients
undergoing Coronary Artery Bypass Grafting, with the leads placed behind ,
rather than in front of the saphenous vein grafts- to avoid the potential
complications relating to graft compression and/or injury.
Temporary Epicardial Pacing: method of stimulating through the use of Tefloncoated unipolar, stainless steel wires that are inserted loosely to the epicardium after
cardiac surgery. The epicardial wires may be attached to the right atrium for atrial
pacing, the right ventricle for ventricular pacing or both for atrioventricular (AV)
pacing. (Paschal and McErlean, 2000). Temporary epicardial pacing may be
especially helpful after Valvular surgery where the incidence of heart block or
arrhythmia is increased.
Threshold: The minimum energy (output) required to maintain consistent capture.
Transvenous Pacing: Type of temporary pacing, where pacing wires are inserted into
the veins via an introducer sheath and passed through the venous system to the heart.
Transthoracic Pacing: Technique of electrically stimulating the heart by use of a set
of pads placed externally on the torso. ECG electrodes are also placed on the patient
to sense ventricular events (spontaneous or paced), and the pulse generator delivers a
wave pulse when a predetermined escape interval has elapsed. (Boehm, 2007)
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Section 6.0: Indications for Pacing:
Table 1: Indications for Pacing
Sick Sinus Syndrome





Symptomatic Sinus Arrest
Suppression of ventricular Ectopy resulting from bradycardia
Atrial Fibrillation
Bradycardia/tachycardia Syndrome
Symptomatic sinus bradycardia
Heart Blocks

Second degree Type I (occasionally) and Type II
Atrioventricular Block
Acute Bifasicular or Trifasicular Block
Complete Atrioventricular Block
Cardiac Arrest with Ventricular Asystole



Drug Refractory Dysrhythmia


Cardiovascular Surgery



Cardiac Transplantation

Overdrive ventricular pacing to suppress or prevent ventricular
ectopic activity
Overdrive pacing to “break” Superventricular Tachycardia or
Atrial Flutter
Prophylactic use during anaesthesia and surgery in patients
with a history of Acute Coronary Syndrome or Cardiac
Dysrhythmias
Treatment for Complete Heart Block developed during or after
surgery
Cardiac Output augmentation post operatively
The incidence of bradyarrhythmias after Cardiothoracic
Transplantation varies between 8-23% (Gregoratos, 2002). In
some patients the need for temporary epicardial pacing may be
transient
6.1: Temporary Epicardial Pacing in Cardiac Surgical Patients:
Epicardial pacing is commonly indicated in cardiac surgical patients using right
ventricle (RV) and /or right atrial (RA) pacing wires. In patients with Sinus rhythm,
two RV and RA epicardial wires are attached, resulting in dual chamber or sequential
atrio-ventricular pacing (DDD) (Flynn, 2005).
In terms of temporary pacing post Cardiac Surgery it is known that less than 10% of
patients may require the post operative use of Temporary Epicardial Pacing Wires
(McClurken, 2006).
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
6.2: Contraindications:
 Anticoagulation status (Abu-Omar, 2006)
 Severe lung disease and positive end expiratory pressure ventilation are
relative contraindications to Internal Jugular and Subclavian entries.
6.3: Complications:













Failure to recognise Ventricular Fibrillation (which is treatable with
defibrillation) due to the size of the artifact on the ECG screen. It is important
to frequently reassess the patient and the rhythm; defibrillation is indicated
immediately if Ventricular Fibrillation occurs.
Induction of other dysrhythmias. Follow ACLS guidelines for arrhythmia
management.
Soft tissue discomfort such as diaphragmatic contractions may result from
pacing. Ensure adequate analgesia and sedation.
There is potential for local cutaneous injury with prolonged Temporary
Pacing. It is important to note that transcutaneous pacing is temporary and it is
important to correct the underlying causes for bradydysrrhythmias and/or
arrange for transvenous pacemaker placement.
Bleeding from Ventricular or Atrial laceration.
Bleeding from the wire exit secondary to laceration of the myocardium or
nearby blood vessels.
Tamponade.
Side branch or graft avulsion- where the graft tears away from the attached
site.
Superior epigastric artery laceration.
Transmigration of Temporary Epicardial Pacing Wires.
Exit site infection.
Infection secondary to retained wire fragments.
Injury to saphenous vein grafts.
(McClurken, 2006)
6.4 Most Common Problems Associated with Temporary Epicardial Pacing
Wires:
Table 2: Most frequent causes for pacing failures in cardiac pacing systems.
(Feurtes, et al 2003)
NO CAPTURE
NO OUTPUT
Lead dislodgement
“Under threshold” programmed output
Increase in pacing threshold
Breach of insulating material
Partial Conductor breach
Perforation
Circuit failure, air in generator pouch, after
defibrillation
Battery depletion
Lead Fracture
Circuit failure
Inhibited pacemaker
Generator to Lead connection failed
Generator screws improperly fixed to the leads
Bipolar programming in unipolar leads
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Table 3: Potential problems with Temporary Epicardial Wire Electrodes.
(Bojar, 2005)
Problem
Competition with the patients own
rhythm
Inadvertent triggering of VT or
VF



Mediastinal Bleeding




Inability to remove the
Temporary Epicardial pacing
Wires

Solution
Suspect that the pacemaker is set at a similar rhythm to
that of the patients intrinsic mechanism. Discuss with the
Cardiothoracic team who may reduce the pacemaker rate
or turn off the pacemaker, leaving it attached for
observation of the patients rhythm.
Can occur through the use of a pacemaker in an
asynchronous mode and competes with the patients own
mechanism.
Pacing wires that are not being used must be
electronically isolated to prevent any AC or DC current
near the wires, that is, covering with tips with gauze and
the wires then covered with Mepore (Beattie, 2005)- See
Section 9.2- Microshocks
Can occur if the pacing wires are placed close to the
Bypass grafts, shearing them by intermittent contact
during ventricular contractions.
Bleeding from the Atrial and Ventricular surfaces can
occur if the wires are sewn too tightly to the heart and
excessive traction is applied for their removal.
Pacing wires should be removed with the patient off
Heparin and before a therapeutic INR is achieved in
patients receiving Warfarin.
Close observation of the patient should be maintained for
several hours post removal of the wires.
The wire may be caught beneath a tight suture on the
heart, or possibly under a sternal wire or subcutaneous
suture. Notify the Cardiothoracic Team immediately,
who will assess the wires and may remove or cut them at
the level of the skin.
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Section 7.0: Types of Temporary Cardiac Pacing:

Percussion: Defined as repeated gentle blows to the middle or lower two
thirds of the patients sternum, percussion pacing is used only in emergency
settings and is indicated in the following situations
 Profound Bradycardia resulting in Clinical Cardiac Arrest
 P-wave asystole (ventricular standstill)
(McNaughton 2006)

External (Transcutaneous): Electrical stimulation of the excitable
myocardial tissue, via adhesive electrodes, which are applied directly to the
chest wall.

Epicardial: Pacing wires are fixed directly to the myocardium (ventricular
and often atrial) and are exposed through the skin on the chest wall. This
specific type of pacing is usually observed following cardiac surgery including
transplantation.

Transvenous: Pacing wires are inserted into the veins via an introducer sheath
and passed through the venous system to the heart. Common insertion sites
include the Internal Jugular, Subclavian and Femoral Veins.

Transthoracic Pacing: Is the technique of electrically stimulating the heart by
the use of pads placed externally on the torso. ECG electrodes are also placed
on the patient to sense ventricular events (spontaneous or paced), and the pulse
generator delivers a wave pulse when a predetermined escape interval has
elapsed. The stimulus is intended to cause cardiac depolarisation and
subsequent myocardial contraction. (Boehm, 2007)
7.1: Insertion and Placement Sites:





Epicardium- post cardiac surgery (coronary artery bypass grafting, valve
repair/replacement/cardiac transplantation)- the wires are paired to each
chamber and passed through the skin in the Subxiphoid region.
Left subclavian
Internal jugular
Femoral Vein
Brachial Vein
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Section 8.0: NBG Codes and Modes of Pacing
These codes are an international identification code universally referred to as the
NBG Code has been produced by the British Pacing and Electrophysiology Group
(BPEG) and the North American Society for Pacing and Electrophysiology,
(NASPE).
Position I:
indicates the chamber (or chambers) paced.
Position II: represents the chamber used for the second function of a pacemaker,
namely, sensing for intrinsic signals.
Position III: the mode of response to sensing. Position III is directly tied into
position II. Without sensing, there can be no mode of response to
sensing.
Position IV: Details the programmable parameters of the device.
Position V: If the pacemaker device has any anti-tachycardia features.
Table 4: Modes of pacing.
I
II
III
IV
V
Chamber Paced
Chamber Sensed
Response to sensing
Programmable
Functions/rate
Modulation
Antitachycardia
Functions
V: Ventricle
V: Ventricle
T: Triggered
P: Pace
A: Atrium
A: Atrium
I: Inhibited
D: Dual (A+V)
D: Dual (A+V)
D: Dual (T+I)
P: Simple
programmable
M: Multiprogrammable
C: Communicating
O: None
O: None
O: None
O: None
S: Single
S: Single
R: Rate
Modulating
O: None
S: Shock
D: Dual
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Table 5: Definition of pacing.
1st Letter
2nd Letter
3rd Letter
Chambers paced
Chambers sensed
Response to Sensing
A= Atrium
A= Atrium
T=Triggered
V=Ventricle
V= Ventricle
I= Inhibit (Demand Mode)
D= Dual (both Atrium and
Ventricle)
D= Dual
D=Dual
O= none
O= none (Asynchrony)
Chamber paced
Chamber sensed
Action or response to a sensed event
I
V
V
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
8.1 Modes of Cardiac Pacing:
Table 6: Modes of pacing:
Mode
Chamber
Paced
Chamber
Sensed
Response of the Atria and Ventricles
None
Action or
Response to a
Sensed Event
None
AOO
Atrium
VOO
Ventricle
None
None
DOO
Dual
None
None
AAI
Atrium
Atrium
Inhibit
VVI
Ventricle
Ventricle
Inhibit
AAT
Atrium
Atrium
Triggered
An asynchronous, fixed rate pacing mode,
whereby the ventricles are paced at a preset
rhythm.
Paces both the atria and the ventricles but
they are not sensed.
Used when the sinus node is damaged and
atrioventricular conduction is unimpaired.
Causes the ventricle to be paced, sensed and
inhibited. The pacer fires if no QRS is
sensed during the preset time interval.
Method of pacing both atria simultaneously
DVI
Dual
Ventricle
Inhibit
VDD
Ventricle
Dual
Dual
VAT
Ventricle
Atrium
Triggered
DDD
Dual
Dual
Dual
The atria are paced but not sensed
Dual mode ventricular Inhibited mode of
pacing, useful in patients with symptomatic
sinus bradycardia or AV Block.
Persistence of sinus rhythm with atrial
asynchronous ventricular pacing
Causes the atria to be sensed but pacing
takes place in the ventricles if no P wave is
seen.
Paces the Atrium and the ventricles, senses
the atrium and ventricles and responds to
sensed events by inhibiting or triggering.
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Section 9.0: Care of the Patient with Temporary Epicardial Leads:
9.1: Education:
For the safe management of patients with Temporary Epicardial Leads, nursing care
and education is essential to ensure your patients safety and minimise the risk of
complications, contributing to a successful outcome.
All wires must be kept separate and wires must not overlap.
9.2: Microshocks:
While epicardial pacing wires are meant to provide a safeguard against
dyssrhythmias, they have the potential to cause a lethal rhythm. Because the
unattached wires provide a direct route for electrical current to flow to the heart, any
stray current poses a threat to the patient, with as little as 0.1mA causing Ventricular
Fibrillation.


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
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

To avoid Microshocks, when handling pacing wires gloves should always be
worn.
It is also necessary to keep the wires insulated by covering each one with
gauze and sterile, non-adherent, adhesive bordered dressing- Mepore (Beattie,
2005).
To avoid stray electrical current, only allow battery operated devices, such as a
radio or shaver at the patients bedside.
A television with an antenna should be avoided at the patients beside as this
can also cause stray electrical current. (Beattie, 2005)
Check that all electrical equipment has a grounding pin (third pin).
Remove any device that doesn’t have a grounding pin on the plug.
If possible carpet should be removed from the room. If this is not possible it
may be treated with a product that eliminates static electricity.
Discourage family and friends from bringing in metallic-coated “get-well”
balloons, as they tend to generate static electricity, therefore posing a risk to
patients.
9.3: Dressing:




The pacing wire sites can be covered with a sterile, non-adherent, adhesive
bordered dressing- Mepore.
The sites must be checked daily for signs of infection, such as redness or
purulent discharge and a swab sent for Culture and Sensitivity with any
change reported to the Cardiothoracic team immediately.
The wires must not be bent or pulled during the daily dressing.
Accidental dislodgement is another concern with Epicardial wires as they are
in a similar position to Chest Drains, which are usually covered with a bulky
sternal dressing. It is important to secure the wires directly to the patients
chest, covering the tip of the wires with gauze and covering with a sterile nonadherent, adhesive bordered dressing, such as Mepore. (Overbay, 2004).
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit




If the Temporary Epicardial Pacing Wires become frayed or break, notify the
Cardiothoracic Team immediately.
If the pacing wires are attached to the Pulse generator (Pacing Box) this
should be securely hung on an Intravenous Drip stand to prevent it from
accidentally dropping to the floor, pulling on the cables or pulling out the
wires.
Educate the patient, ensuring they understand the importance of not interfering
with the wires and the pulse generator (Pacing Box).
Ensure that the Pacing box remains in the locked position unless changes in
settings are required.
9.4 Battery:


The pulse generator (Pacing box) takes its power from batteries (Duracell
Procell 9 volt). The battery life is approximately 7 days. It is essential to have
a spare battery attached to the pulse generator particularly if the patient has
NO underlying rhythm.
To identify a reduction in the battery life an L will appear on the screen.
Section 10.0: Removal of Temporary Epicardial Pacing Wires:

The patient must be hemodynamically stable and the procedure should be
completed at least 24 hours prior to the patient being discharged.

Epicardial pacing wires are usually removed in accordance with Surgeons
preference, aiming for Day 5 postoperative if patient has stable heart rhythms
(This is assessed on an individual patient basis daily).
NOTE: PATIENTS POST-CARDIAC TRANSPLANTATION AWAIT THEIR FIRST CARDIAC
BIOPSY PRIOR TO REMOVAL OF TEMPORARY EPICARDIAL PACING WIRES.

Temporary epicardial pacing wires should be removed on instruction from
Consultant Cardiothoracic Surgeon or Cardiothoracic Registrar.

Continue Cardiac monitoring and assess the patients electrolyte and
coagulation status prior to pacing wire removal.

Prior to the removal of Temporary Epicardial Pacing Wires, if the patient is on
Intravenous Heparin, it should be discontinued temporarily for 4 hours.

When the APPT/ACT is normal, the pacing wires can then be removed and
Intravenous Heparin commenced 4 hours later.

INR must be checked prior to removal of wires if patient is receiving anticoagulant therapy. INR should be < or equal to 2.0 as per all Consultants.

If the platelet count is below 150,000 the removal of Temporary pacing wires
should be discussed with the Cardiothoracic Team.
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
10.1: Set up trolley with the following equipment:





Dressing pack.
Sterile gloves in pack for performing the dressing.
0.9% Normal Saline sachet – wound cleaning.
Stitch cutter – remove tube stitch.
Sterile small non-adherent, adhesive border, occlusive dressing, mepore.
10.2 Removing Temporary Epicardial Pacing Wires:
1)
2)
3)
4)
Explain the procedure to the patient.
Assess patients’ pain score and offer oral analgesia.
Attach patient to cardiac monitor.
Record baseline vital signs – Blood pressure and heart rate, respirations,
oxygen saturations.
5) Remove dressing that is securing the temporary epicardial pacing wires.
6) Wash hands as per MMUH Hand Hygiene and put on gloves provided in
dressing pack.
7) Clean puncture site/s with 0.9% NaCL.
8) Remove skin suture if the temporary epicardial pacing wire is sutured in place.
9) Unthread wire until it exits from the skin in one site only. The wires attached
to the atrium exit the chest on the right side of the sternum, whilst those
attached to the ventricle exit the chest on the left.
10) Gently pull each wire individually, applying steady, slow motion, observing
the monitor for dsyrhythmais during procedure. If a lethal arrhythmia
develops, stop the procedure and intervene according to Cardiac Arrest
management. (Beattie, 2005).
11) If resistance is met during removal, leave the wire insitu and inform the
Cardiothoracic team.
NOTE: If undue “cardiac tugging” is encountered whilst trying to remove the pacing wire, contact the
Cardiothoracic Team.
12) After removal, inspect each wire tip to ensure that it has been removed
completely and send tips for Culture and Sensitivity.
13) If bleeding occurs at the site, apply direct pressure until it stops. However, if it
continues notify the Cardiothoracic Team.
14) When the procedure is complete, place sterile small non-adherent, adhesive
border, and sterile occlusive dressing.
15) Dispose of sharps as per standard precautions.
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
16) The patient must rest in bed for one hour following procedure.
17) Record observations at 15-minute intervals for the first hour, then hourly for
the next two hours. This is to detect signs of Cardiac Tamponade. (Beattie,
2005)
18) Document date and time of removal of Temporary Epicardial Pacing Wires in
nursing care plan.
NOTE: Avoid Temporary pacing wire removal after 16.00hrs as per local practice within the Professor
Eoin O’Malley Cardiothoracic Unit. For any serious concerns, rapid patient assessment, evaluation and
treatment and notification of the Cardiothoracic Team must occur.
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National
Cardio Thoracic Unit
Appendix I: Temporary Pacemaker Core Care Plan
Patient Name:
Date of Temporary Pacemaker insertion:
Medical Record Number:
Reason for Temporary Pacemaker Insertion:
Date
Problem
Goal(s)
Maintaining a safe environment:
Patient attached to Temporary
Pacemaker
1. Safe management
of patients with a
Temporary
pacemaker
No:
2. Minimise the risk
of complications.
Wound:
Pacing Wire Insertion Site
1. There will be no
signs of infection at
Epicardial pacing
wire insertion site.
Action/Interventions


Continuous cardiac monitoring with monitor alarm on at all times.
Check that prescribed pacemaker parameters are maintained and
document any changes in parameters by the Cardiothoracic team.
 Observe the cardiac monitor for appropriate pacemaker function, i.e.:
sensing, capturing and pacing.
 Ensure that the pulse generator (pacing box) is in the locked position at
all times unless changes in the settings are required.
 Ensure that the battery life is regularly checked- a small “L” will
appear on the screen when there is reduction in battery life.
 Ensure that spare batteries are readily available-9 volt Duracell Procell.
 Ensure pacing wires are secure at all times.
Safe guard and Prevention of Microshocks- Pacing wires are covered at all
times when not in use with a sterile, non-adherent, adhesive bordered dressingMepore.
 When handling pacing wires gloves should always be worn.
 Check all electronic devices have a grounding pin (third pin).
 To avoid stray current, only battery operated devices, such as a radio or
shaver should be kept at the patients bedside. Also Televisions with
Antenna should be discouraged from use at the bedside.
 Discourage visitors from bringing in metallic-coated “get well”
balloons, as they can generate static electricity.
 The pacing wires must be dressed daily as per Local guidelines.
 The sites must be checked daily for signs of infection, such as redness
or purulent discharge and a swab sent for Culture and Sensitivity and
report changes to the Cardiothoracic team.
 Monitor and record the patients temperature 4 hourly and notify the
Cardiothoracic team of any changes.
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National Cardio Thoracic Unit
Review care
plan each
shift
Sign
Patient Name:
Date of Temporary Pacemaker insertion:
Medical Record Number:
Reason for Temporary Pacemaker Insertion:
Date
Problem
Goal(s)
Mobilisation:
Restricted mobility due to
Temporary Epicardial
Pacemaker and leads
The patient is able to
engage in activities at
the bedside whilst
understanding the
importance of caring
for their pacing box
and leads.


1.The patient will
exhibit a reduction in
their level of anxiety.

No:
Communication:
Patient is anxious regarding the
temporary Epicardial
Pacemaker
2. The patient will
demonstrate an
awareness of the pulse
generator (pacing
box).
Action/interventions






Provide supervision and assistance for the patient as required.
Check that the epicardial pacing wires are secure at all times, using a
safety pin to secure the pulse generator (pacing box) to the patients
pyjamas or hanging safely on an Intravenous pole at the bedside.
Encourage full mobility as soon as the patient is able.
Educate the patient and encourage active limb exercises whilst
mobility is restricted.
Educate the patient in awareness of their pulse generator (pacing
box) and leads.
Provide instruction on the function of the pacemaker.
Educate the patient about the importance of performing their
activities of daily living whilst the pulse generator (pacing box) is
attached.
Provide reassurance for the patient and encourage the patient to
voice any fears and anxieties in relation to their pulse generator
(pacing box) and wires.
Provide support, education and encourage questioning for the family
in relation to the pulse generator (pacing box),
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National Cardio Thoracic Unit
Review care
plan each
shift
Sign
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© Mater Misericordiae University Hospital- Professor Eoin O’Malley National Cardio
Thoracic Unit