Temporary pacemaker leads are routinely placed on the epicardium—the outer layer of heart muscle—during cardiac surgery. The
wires extending from the leads provide quick access to a temporary pacemaker's pulse generator in case something goes wrong
in the early postop period.
That's critical when you consider that dysrhythmias are common after heart surgery and can occur for any number of reasons,
including electrolyte imbalances, hypothermia, and injury or edema from the procedure itself.
Typically, the surgeon places four wires, attaching one positive and one negative electrode to both the right atrium and the
right ventricle before the chest is closed. The physician loosely sutures the leads onto the epicardium and threads the wires
through to the outside of the chest via small, stab-like incisions.
The wires attached to the atrium exit the chest on the right side of the sternum; those attached to the ventricle exit the
chest on the left. That way, either the atrium or ventricle or both may be paced as needed. And while the wires attach to
the same pulse generator as transvenous pacemakers, there's one crucial difference: The epicardial pacing wires are usually
not attached to the pulse generator unless pacemaker therapy is indicated.
In caring for a patient with these pacing wires—which remain in place anywhere from 24 hours to several days postop—you'll
need to ensure that the wires are properly managed and ready for action. You'll also need to monitor the exit sites for signs
of infection.
Vigilance is needed to avoid trouble
While epicardial pacing wires are meant to provide a safeguard against dysrhythmias, 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. Microshocks—low-voltage electrical current from ungrounded equipment or static electricity—can
pass right through you and into your patient. As little as 0.1 mA can cause ventricular fibrillation.
Preventing microshocks is your No. 1 priority in managing epicardial pacing wires. To avoid them, you should always wear gloves
when handling the wires. It's also necessary to keep the wires insulated by covering each one with a finger cot or the snipped-off
finger of a disposable glove.
To avoid stray electrical current, allow only battery-operated devices, such as a radio or shaver, at the patient's bedside.
In addition, check to see that any electrical equipment in use is grounded. Remove any device that doesn't have a grounding
pin on the plug. If the patient's bed doesn't have a grounding pin or the grounding pin is broken, unplug the bed and leave
it unplugged until the pacing wires are removed.
If possible, have carpet removed from the room. If not, request that it be treated with a product that eliminates static electricity,
such as Static Guard. Since static electricity increases in winter months, make sure the patient's room is properly humidified
in cold weather.
Finally, discourage friends and family from bringing the patient metallic-coated "get well" balloons. These balloons tend
to generate static electricity and could pose a risk to the patient.
Other ways you can protect your patient
Stray electrical current is not the only thing that has a direct route to the heart of a patient with epicardial wires. Bacteria
do, too. Therefore, scrupulous daily site care is key.
The sites can be left open to air or covered with a light, sterile dressing, depending upon your facility's protocol. In either
case, be sure to check for signs of infection, such as redness or purulent drainage, and report any abnormal findings immediately.
Accidental dislodgement is another concern. For 24 – 48 hours postop, epicardial pacing wires, along with the mediastinal
chest tube, are usually covered with a bulky sternal dressing. However, once the dressing and chest tube are removed, the
pacing wires can easily become dislodged.
To prevent this, keep the wires securely taped to the skin. You can accomplish this by taping the insulated wires directly
to the patient's chest or covering them with a 4 x 4 gauze dressing and taping the gauze to the chest.
If the pacing wires are attached to the pulse generator, pin the generator in its pouch to the patient's gown. That will prevent
it from accidentally dropping to the floor, yanking on the connecting cables, and pulling out the wires. Make sure that your
patient understands the importance of leaving the wires and pulse generator alone.
The road to recovery, and wire removal
Once your patient is hemodynamically stable, the epicardial pacing wires can be removed. This procedure takes only a few minutes,
but it should be done at least 24 hours before your patient is discharged so you have time to observe him for complications.
Removing the wires is often done by an advanced practice nurse, a doctor, or a physician assistant. At many hospitals, however,
critical care nurses can perform this procedure. (You'll find a review of the wire removal process in the box.)
If you're not removing the wires, you'll still have an important role in the process. You'll need to prepare the patient,
monitor his EKG, assist with the procedure, and observe for complications once the wires are out.
Start by explaining that the wires will be removed through the skin. Tell the patient he may feel a light, slow and steady
pulling sensation. Some patients experience minor discomfort, so you may want to give him pain medication, as ordered, about
30 minutes prior to wire removal.
Continue cardiac monitoring and assess your patient's coagulation and electrolyte panels prior to wire removal. Make sure
he's not taking an anticoagulant and that his electrolytes are within normal limits. In addition, verify that his IV lines
are patent in case emergency medication or fluids are needed. Then, place the patient in the supine position for wire removal.
When the wires are removed, bleeding may occur from the sites on the epicardium where the leads were placed—putting the patient
at risk for a buildup of blood in the pericardial sac. Cardiac tamponade is a rare but serious complication that you'll need
to watch for.
Signs and symptoms of cardiac tamponade include anxiety, jugular vein distention, tachycardia, hypotension, muffled heart
tones, decreased peripheral pulses, and dyspnea. Anticipate the need for pericardiocentesis before tamponade occurs and have
emergency equipment on standby.
If no immediate intervention is needed, place a sterile occlusive dressing over the exit sites. Keep the patient on bed rest
for at least five hours and continue to monitor for dysrhythmias. Take and record vital signs every 15 minutes for the first
hour, every 30 minutes for the next two hours, then hourly for the next two hours.
Document your ongoing assessments, how well your patient tolerated the procedure, and any complications and interventions
associated with wire removal. Include his EKG strips in his chart. In addition, record the name of the clinician who removed
the wires and the date and time of the procedure. Document the patient education you provided, as well.
Vigilant nursing care is the key to safe management of temporary epicardial pacemaker wires. The requisite knowledge and skill
will enable you to ensure your patient's safety, minimize the risk of complications, and contribute to a successful outcome.
SOURCES
1. Jackson, M., & Woods, S. S. (2005). Temporary transvenous and epicardial pacing. In D. J. Lynn-McHale Wiegand, & K. K.
Carlson (Eds.), AACN procedure manual for critical care (5th ed.), (pp. 349 – 361). St. Louis: Elsevier Saunders.
2. Shamloo, C. (2005). Epicardial pacing wire removal. In D. J. Lynn-McHale Wiegand, & K. K. Carlson (Eds.), AACN procedure manual for critical care (5th ed.), (pp. 311 – 313). St. Louis: Elsevier Saunders.
3. Jong, M. D., Coombs, V., et al. (2005). Patient management: Cardiovascular system. In P. G. Morton, D. K. Fontaine, et
al. (Eds.), Critical care nursing, A holistic approach (8th ed.), (pp. 350 – 359). Philadelphia: Lippincott Williams & Wilkins.
4. Overbay, D., & Criddle, L. (2004). Mastering temporary invasive cardiac pacing. Crit Care Nurs, 24(3), 25.
Here's how to remove epicardial pacing wires
After washing your hands, don goggles, mask, and gown to reduce the transmission of microorganisms and maintain standard precautions.
Have the patient assume a supine position, which provides the best access during and after the procedure.
Put on non-sterile gloves to minimize the possibility of microshock when handling the wires. Remove any dressings and tape
to expose the exit sites. Then, use a suture removal kit to untie or cut the suture or first knot of each of the wires at
the skin. You're now ready to remove them.
One at a time, gently pull each wire, applying steady, slow tension. This movement will uncoil the pacing leads on the surface
of the heart. At the same time, watch the cardiac monitor for dysrhythmias. If a lethal rhythm develops, stop the procedure
and intervene according to ACLS protocol.
If the patient remains stable, pull each wire all the way out. (If you find that you're unable to remove the wires, stop and
notify the physician at once.)
After removal, inspect each wire to ensure that it has been extracted completely. You may see a tiny bit of tissue on the
end of each lead. If bleeding occurs at the exit site, apply direct pressure until it stops. Again, notify the physician if
bleeding or oozing continues.
When the procedure is completed, place a sterile, occlusive dressing over the exit sites and discard the used supplies.
Source: Shamloo, C. (2005). Epicardial pacing wire removal. In D. J. Lynn-McHale Wiegand, & K. K. Carlson (Eds.), AACN procedure
manual for critical care (5th ed.), ( pp. 311 – 313). St. Louis: Elsevier Saunders.
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