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IN PRE-OP
Is Patient pacemaker dependent?
Check with Rep
YES
TO OR
PIV, A-line, GA, ETT
CVL for temp pacer wire*
TEE - look for clots or effusion
TO OR
PIV, A-line, GA, ETT
TEE
NO
Preparation
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Set up your OR (including Pacemaker) as for heart case less TXA and DEX drip
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Check if pacemaker rep is present
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Perfusionist ready for stand-by
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Laser person present
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X-ray person present
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Heparin Syringe 60ml READY TO GO
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2-4U RBC
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if low EF, low H&H consider 2U RBC on ice in OR
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Sequence:
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Pt. goes off to sleep, ETT
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If pt. is pacemaker dependent, temporary needs to be inserted,
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*Right IJ is cannulated with 7F peel off introducer from surgical field by anesthesia. Leave the sterile drape on the field, since surgeon will float in temporary. At this time Rep usually turns the pacemaker off and connect the temp pacer to the machine (WEAR LEAD UNDER STERILE GOWN).
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If Rep is not present, hook up to our pacemaker, dial A output to zero and V-pace the only wire.
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If intra-op decision made by surgeon is to use LASER, then the surgeon places femoral venous line. Spike of the sterile tubing is handed to anesthesia from sterile field (already part of OR setup), who prepares 1000ml of crystaloid for spiking.
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If cardiologist did not extract coronary sinus lead, that would be first to go, laser is used only up to but not inside the coronary ostium. Atrial lead usually goes smoothly, but ventricular lead can be cemented in. Laser sheath takes parts of myocardium, so you can see and be ready for PVCs, VT, and VF. The last 10 cm of laser lead extraction surgeon may ask for vent off for better X-Ray visualization.
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Laser hurts, so Dilaudid works well, plan is to extubate at the end and go MONITORED to PACU
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FOR epicardial lead insertion, pt is rolled 45 degrees to the right, and arm is tucked posteriorly with gel strip (no pink foam)
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GA, PIV, a-line, CVL
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TEE tech marks pt externally before prep with sharpie
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IF lung function is LOW consider double lumen tube otherwise expect long lung down periods
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TEE. Watch for VF when Bovie on a heart.
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Epicardial lead is often tunneled all the way across the chest to right subclavicular pocket.
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Watch for chest tube output from the epicardial site