Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Minimizing Complications from Temporary Epicardial Pacing Wires after Cardiac Surgery James B. McClurken, M.D., F.A.C.C., F.C.C.P., F.A.C.S. to certain details involved in both technical aspects Professor and Vice-Chair of Surgery, Surgical Subspecialties Director of Perioperative Services, Cardiothoracic Surgery of placement of wires and in considerations for re- Temple University Hospital moval. These considerations are presented in list form. PA-PSRS has received reports of complications from the place- ment of temporary epicardial pacing wires during open heart Placement of TEPW: surgery. One report was of bleeding from the insertion site, leading to pericardial tamponade post-operatively. The tampo- 1. Keep electrodes at least 1.5 – 2.0 cm apart nade was treated with pericardiocentesis, and the patient was on the epicardium to maximize efficacy. returned to the OR for correction of the underlying leak. The other report was of a fatal, exsanguinating hemorrhage into the a) Electively, test and record threshold chest upon post-operative removal of an atrial pacing wire, be- function for wires. cause the removal of the wire tore the child’s atrium. These two reports represent the Scylla and Charybdis of temporary epicar- b) Secure the TEPW at the exit site with a dial pacing wire placement, leaking and binding. PA-PSRS suture. asked Dr. James McClurken, a cardio-thoracic surgeon with expertise on this topic, to comment. John R. Clarke, M.D., Editor 2. Carefully select locations. a) Avoid arterioles/venules on the right F or years, virtually all patients at most cardiac surgical centers received temporary epicardial pacing wires (TEPW). Although the incidence of ventricle. b) Pick ‘thicker’ spots on the right atrium on complications from placement or removal of TEPW the mid and lower right atrial wall; con- has been low, the adverse events can cause major sider Waterston’s groove, left atrium. morbidity and even mortality. In addition to inade- quate lead function, the majority of serious morbidity c) If right atrial appendage used, be certain reported relates to lead removal. Complications bare wire does not inadvertently also reported have included bleeding from ventricular or contact right ventricle, as simultaneous atrial laceration, tamponade, side branch or graft atrial and ventricular contraction could avulsion, superior epigastric artery laceration and or occur with resultant hemodynamic com- retention.1,2 Transmigration of a retained TEPW en- promise. dobronchially has also been reported.3 d) Be ever mindful of the exit course of the Recently, the evolution of indications has shown a wire and its relationship to nearby graft more defined pathway for TEPW use in coronary (s) – avoid “clotheslining.” artery bypass grafting (CABG) patients.4,5 In fact, e) Keep exit direction of pacing wire from less than 10% of CABG patients may require post- epicardium in as straight a line as possi- operative use of TEPW. Predictors of necessity for ble to epigastric exit site, to avoid Gigli TEPW on multivariate analysis of CABG patients saw effect or tearing upon removal. include diabetes, preoperative arrhythmia, and pac- ing required to separate from bypass.4 Added to that 3. If repair suture for bleeding required, use list on univariate analysis were advanced age, cardi- smallest suture possible (e.g. 4-0, 5-0, or omegaly, preoperative antiarrhythmic therapy, and even 6-0). inotropic agents upon leaving the operating room. The need for TEPW may be greater for complex This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 3, No. and valvular cardiac surgery,6 especially where de- 1—March 2006. The Advisory is a publication of the Pennsylvania Patient calcification of the aortic annulus may risk dysfunc- Safety Authority, produced by ECRI & ISMP under contract to the Authority as tion of proximate conduction system fibers. Key but part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). subtle features of the dynamics of myocardial func- Copyright 2006 by the Patient Safety Authority. This publication may be re- tional recovery after cardiac surgery frequently are printed and distributed without restriction, provided it is printed or distributed in the indications also cited by many surgeons for use its entirety and without alteration. Individual articles may be reprinted in their of TEPW. entirety and without alteration provided the source is clearly attributed. Complications of TEPW can be reduced by attention To see other articles or issues of the Advisory, visit our web site at www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2006 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) Minimizing Complications from Temporary Epicardial Pacing Wires after Cardiac Surgery (Continued) a) Consider mattress suture with or without a) If undue ‘cardiac tugging’ is encoun- pledgets rather than figure-of-8 sutures, tered while trying to remove, consider in order to facilitate removal. transecting the wire after sterile prep- b) Don’t over tighten/strangulate the hemo- ping of skin and external wire. Then, static suture, as the TEPW needs to be with as much gentle traction as possible removed. cut with sterile scissors flush with skin level. Notify the patient and family that 4. Avoid long, redundant loops of wire; prevent some TEPW necessarily remains. Sub- conduit ensnaring or lassoing which could sequent removal of remnant wire is in- occur at removal. frequently required. a) Be especially cognizant of conduit side 4. Keep the patient in hospital ~ 24 hours after branch clips and their relationship to the TEPW removal to watch for signs of delayed TEPW course to avoid avulsion of clip at tamponade or rhythm disturbances with one removal. hour of bed rest immediately after removal. b) Be certain both ventricular and/or both a) Keep on telemetry. atrial wires are on the same side of a graft to prevent constriction at removal. b) Periodic vital signs. 5. Keep epigastric exit sites near the midline on c) Consider ECG, CXR to assess voltage each side with intra-institutional standardiza- and mediastinal silhouette stability prior tion for ventricular wires to the left of midline to discharge. and atrial to the right. This avoids confusion d) For any serious concerns, rapid patient for critical care/nursing staffs. evaluation and treatment must occur with a) Check intrathoracic epigastric exit site possible emergent return to the OR. carefully to avoid exit of the needle 5. Avoid TEPW removal late in day or if there is through the colon, stomach, liver or concern about coverage team. lung. Considerations should be given to having emer- b) Check for epigastric artery and rectus gency sternotomy trays stored on the unit where muscle bleeding after TEPW needles pacing wires are removed. passage. These considerations are indicative of a strategy for 6. Keep electrode ends of TEPW electrically safety as regards TEPW. There are many ways to isolated in some fashion. achieve similar results, and these considerations Removal of TEPW: are by no means immutable. 1. Be certain TEPW is no longer needed Notes (especially if removal is driven by a clinical 1. Del Nido P, Goldman BS. Temporary epicardial pacing after open heart surgery: complications and prevention. J Card Surg. pathway protocol.) 1989 Mar;4(1):99-103. 2. Be aware of coagulation status and medica- 2. Gal TJ, Chaet MS, Novitzky D. Laceration of a saphenous vein tions. graft by an epicardial pacemaker wire. J Cardiovasc Surg (Torino), 1998 Apr;39(2):221-2. a) If the patient is on intravenous heparin, 3. Gentry, WH, Hassan AA. Complications of retained epicardial discontinue temporarily. pacing Wires: an unusual bronchial foreign body. Ann Thorac Surg. 1993 Dec;56(6):1391-3. b) If the patient is on warfarin, allow INR to 4. Bethea BT, Salazar JD, Grega MA, et al. Determining the drift down to <1.5. utility of temporary pacing wires after coronary artery bypass surgery. Ann Thorac Surg. 2005 Jan;79(1):104-7. c) If the platelet count is low, understand 5. Puskas JD, Sharoni E, Williams WH, et al. Is routine use of the reason and correct if necessary. temporary epicardial pacing wires necessary after either OPCAB d) It is probably acceptable to continue or conventional CABG/CPB? Heart Surg Forum. 2003;6(6):E103- 6. aspirin and clopidrogel as long as no 6. Rho RW, Bridges CR, Kocovic D. Management of postopera- subcutaneous heparin is being given tive arrhythmias. Semin Thorac Cardiovasc Surg. 2000 Oct;12 and there is no abnormal aPTT, INR, or (4):349-61 platelet count. 3. Pull one wire out at a time, using gentle trac- tion. Page 2 ©2006 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) Minimizing Complications from Temporary Epicardial Pacing Wires after Cardiac Surgery (Continued) Figure 1. Correct Placement of Pacing Wires (Heart Only) ©2006 Pennsylvania Patient Safety Authority Page 3 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) Minimizing Complications from Temporary Epicardial Pacing Wires after Cardiac Surgery (Continued) Figure 2. Correct Placement of Pacing Wires (In Situ) Page 4 ©2006 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) Minimizing Complications from Temporary Epicardial Pacing Wires after Cardiac Surgery (Continued) Figure 3. Potential Failure Modes—Incorrect Placement of Pacing Wires ©2006 Pennsylvania Patient Safety Authority Page 5 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) Minimizing Complications from Temporary Epicardial Pacing Wires after Cardiac Surgery (Continued) You can obtain a free 17” x 24” laminated poster based on this article while supplies last. Call PA-PSRS at 866-316-1070. You may also download an 11” x 17” version in PDF format from the Patient Safety Authority website at: www.psa.state.pa.us. Page 6 ©2006 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. ©2006 Pennsylvania Patient Safety Authority Page 7