Temporary epicardial pacing wire removal for patients on Ward 1E, RHC

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Objectives

To provide a consistent and safe approach to temporary epicardial pacing wire removal within 1E.

Scope

Applies to removal of all temporary epicardial pacing wires within 1E at RHC.

Audience

The multidisciplinary team managing epicardial pacing wires on the cardiology ward at RHC.

Introduction

Children are at risk of developing arrhythmias in the early post-operative period. Therefore, epicardial pacing wires are placed onto the epicardial surface of the heart during cardiac surgery which can then be promptly connected to an external pacemaker aiding rapid treatment of an abnormal rhythm.

Epicardial wires are passed out through the skin before the child’s chest is closed. Complications related to temporary pacemaker wire removal are uncommon.

Epicardial pacing wires can be removed between 0900-1600 Monday –Friday and between 09.00-12.00 at weekends and public holidays with the consultant cardiologists approval.

Guideline

a) Ensure that a 12 lead ECG has been obtained prior to removal and that patient is in sinus rhythm and no longer requires temporary pacing wires. Pacing wires should not be removed within 24 hours of disconnecting the pacemaker unless there is a significant contraindication such as entry site infection, or sepsis potentially related to retaining wires.

b) Pacing wires can be removed from day 1 post op

c) Review the most recent full blood count and coagulation profile. The platelet count should be above 50.

d) If patient is on warfarin, INR should be < 2 prior to removal.

e) Obtain baseline observations and monitor patient on cardiac monitor during wire removal.

f) Pacing wires should be removed one at a time by the application of firm, steady traction.

g) If the pacing wires do not remove easily, then a cardiac surgeon should be informed.

h) Repeat observations immediately after wire removal, then 1 and 2 hourly post removal. Clinical symptoms of cardiac tamponade in children include : onset of pallor, tachycardia and tachypnea. Compensatory mechanisms in the paediatric patient will maintain the blood pressure initially. Tachycardia with cool and mottled extremeties will be apparent. Hypotension is a late sign, it is not until blood loss reaches 30ml/kg, almost half the total blood volume, that blood pressure will fall.  

i) Patient must remain on a cardiac monitor and bed rest for 1 hour post wire removal

j) Routine echo is NOT required following wire removal

k) Children should not be discharged until at least 6 hours following wire removal and should have a set of observations within normal limits prior to discharge home. 

References

British Committee for standards in haematology, Blood transfusion task force (2003) Guidelines for the use of platelet transfusionsBritish journal of haematology, Vol. 122, p10-13.

Carroll K,  L M Reeves, Anderson G, Ray F, Clopton P, Shively M & Tarazi RY (1995) Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery, American Journal of Critical Care, vol 7, no 6 pp 444-449

Elsayed, E, et al  (2016) Clinical and mechanical factors associated with the removal of temporary epicardial pacemaker wires after cardiac surgery. Journal of Cardiothoracic Surgery, vol. 11(8).

Johnston, L.J and McKinley, D.F. (2000) Cardiac tamponade after removal of atrial intracardiac monitoring catheters in pediatric patient: case report. Heart &Lung, Vol. 29 (4)

Jowett V, Hayes N, Skridharan S, Rees P & Macrae D (2007) Timing of removal of pacing wires following paediatric cardiac surgery. Cardiology in the Young, vol 17 pp 512-516

Miller O (2010) Removal of Pacing Wires Guideline, Evelina Children’s Hospital

McKee L & Reeve B, (2009) Removing Pacing Wires Guideline, Golden Jubilee National Hospital

Mahon, L, et al (2012) Cardiac tamponade after removal of temporary pacer wires. American journal of critical care, Vol. 21, pp. 432-440

McNaughton A (2006) Postoperative epicardial pacing : indications and care, British Journal of Cardiac Nursing, vol 1, no 8 pp 366-368

Reade MC (2007) Temporary epicardial pacing after cardiac surgery : a practical review. Part 1 : General considerations in the management of epicardial pacing. Anaesthesia Vol 62 pp 264-271

Editorial Information

Last reviewed: 01 October 2016

Next review: 01 October 2019

Author(s): N Robertson

Approved By: Clincal Effectiveness

Reviewer Name(s): B Smith