Lawrence Obendorf, RN
Nursing care during pacemaker implantation
Although pacemaker implantation has become a well-established procedure during the past decade, the nature of the surgery demands some special consideration for intraoperative nursing care. Pacemaker patients need reassurance. They realize that their hearts are diseased and are frightened by the thought of a heart operation and of reliance on a mechanical device. This fear is managed best by skillful communication and reassurance. Communication is particularly important in pacemaker implantation because local anesthesia is the recommended procedure. An effective way to allay apprehension about the needle delivering the anesthetic is to tell the patient, “There will be a small needle stick and some burning when the medication is injected. After that, you won’t feel anything in that area,” and “If you do feel anything at all, let the doctor know and he will put in more medication.”
Lawrence Obendorf, RN, is in the cardiovascular-thoracic surgical unit at Cedars-Sinai Medical Center in Los Angeles. He received his BSN from Southern Illinois University, Edwardsville, Ill.
Because the patient is awake, attending to his physical needs is especially important. He should be kept out of drafts, with blankets handy if he should become cold. Modesty should be respected, and unnecessary exposure avoided. Discussion of his condition should be well out of the patient’s hearing range. Patient safety. After the patient is placed on the operating table, knee straps should be applied loosely to prevent circulatory impairment. The patient is usually supine and should be in as comfortable a position as possible. The operative field must be adequately exposed. Circulation must not be obstructed by an awkward position or undue pressure on any part. There should be no interference with the patient’s respiration as a result of pressure of arms on the chest or from constriction of a gown about the neck or chest. Nerves must be protected from undue pressure. Improper position of arms, hands, legs, or feet may cause serious injury or paralysis. Concern for the patient as an individual includes special consideration for the very thin, the elderly, or the obese. The patient should be properly grounded with a conducting plate in contact with skin if electrocautery is to be used. However, electrocautery
d-. AORN Journal, October 1977,Vol26, No 4
771
0
R personnel should wear radiation film badges.
should never be used within 6 inches of an implanted pacer or lead. Instruments or devices that produce strong electromagnetic fields should be used with care. When instruments capable of causing interference are used near or on a patient receiving a pacer, defibrillation and resuscitation equipment should be, available for immediate use. All electrical equipment should be checked to make sure it is in safe working order. OR personnel safety. During pacemaker implantations, OR personnel should wear radiation film badges. The rays emitted from fluoroscopy during the operation should routinely be monitored in this way, although studies show that significant radiation exposure to OR personnel is unlikely.' However, rays emitted during fluoroscopy do remain for a longer period than do those fiom diagnostic x-rays or gamma rays. Anesthetic. Although local anesthesia is preferred, it may be contraindicated in highly nervous, apprehensive patients. The emotional trauma experienced by a frightened patient under local anesthesia may be more harmful than any physiological problem following general anesthesia. The most frequently used anesthetic in pacemaker implantations is lidocaine, either with or without epinephrine. The drug penetrates to nervous tissue and diffuses rapidly, thus proI14
ducing prompt loss of pain perception. However, it may be accompanied by a variety of adverse reactions. Excessive dosage, too rapid absorption, inadvertent intravenous injection, or allergic reaction may cause high plasma levels. These reactions are systemic and involve the central nervous system and the cardiovascular system. Excitatory andlor depressant reactions may occur. Excitatory reactions in the central nervous system may be nervousness, dizziness, blurred vision, and tremors. Depressant reactions may be characterized by drowsiness, convulsions, unconsciousness, and possibly respiratory arrest. Excitatory reactions may be brief or absent. In this case, however, the first manifestation of any reaction may be unconsciousness or respiratory arrest. Adverse cardiovascular reactions to lidocaine are depressant, occurring as hypotension, myocardial depression, bradycardia, or possibly cardiac arrest. Treatment may demand an airway, oxygen, and assisted or controlled respiration. If circulatory depression occurs, treatment would include intravenous therapy and vasopressors. Resuscitative equipment and drugs should be available. The addition of epinephrine to lidocaine creates an ischemic action, which reduces the rate of absorption of the local anesthetic. Epinephrine prolongs the pain-preventing effect, re-
AORN Journal, October 1977,Vol26, No 4
d u e s the danger of systemic toxic reaction, and has a vasoconstrictive action, which reduces bleeding in the area of injection. However, if epinephrine enters the systemic circulation, side effects may include pallor, hypertension, cardiac arrhythmia, chest pain, and headache. If not treated, cerebral vascular accident, ventricular fibrillation, or cardiac dilation with pulmonary edema could lead to death. By knowing the effects and side effects of lidocaine, the nurse is aware of the problems that may arise. By monitoring the patient’s vital signs closely, one can detect any deviation early and possibly prevent progression to a dangerous condition. Pacing leads. There are two types of pacing leads, epicardial and endocardial. Skin preparation and operative procedure differ according to the kind of lead used. For implantation of an epicardial pacing lead, the skin should be scrubbed for five to ten minutes covering the area for a left anterior thoracotomy and a left upper quadrant transverse incision. A left thoracotomy through the fourth or fifth intercostal space is performed, and the pericardium is incised. A left upper quadrant transverse incision is made and a subcutaneous pocket for the pacemaker is created. A subcutaneous tunnel is made between the thoracic and abdominal incision, and the pulse generator is put in the pouch and the leads passed through the tunnel. The electrode tips are inserted into the myocardium via a small stab wound and are sutured in place. A chest tube is inserted, and the two incisions are closed. For implantation of an endocardia1 pacing lead, the skin should be scrubbed for five to ten minutes covering the upper outer chest wall and neck on whichever side the surgeon 776
has chosen. The pulse generator is placed in a subcutaneous pouch, usually on the right upper chest wall. The veins on the right are preferable because they are a direct line to the heart. The neck area is incised, and a vein is exposed. A small hole is made in the vein; under fluoroscopy, the lead is threaded through the superior vena cava and tricuspid valve. It then curves gently to the apex of the right ventricle, where the electrode tip is lodged under one or more trabeculae. The lead is introduced slowly and cautiously to avoid perforating the relatively thin wall of the right ventricle. Monitoring is important when the pacing leads are being inserted. An electrocardiographic (ECG) monitor is needed to watch for premature ventricular contraction, which frequently occurs when the leads enter the right ventricle and are being positioned. ECG monitoring is also needed to indicate whether or not the pacemaker impulse is being captured and transmitted through the ventricle. Although pacemaker implantation may be considered a minor procedure, to the patient who needs psychological support and physiological assessment, it is a stressful event. Proper intraoperative nursing care helps to assure a successful and uneventful postoperative period. 0 Notes 1. John L Day, David A Lightfoot, “OR radiation hazards,“ AORN Journal 20 (August 1974) 24% 256.
AORN Journal, October 1977,Vol26, No 4
Nursing care during pacemaker implantation
Although pacemaker implantation has become a well-established procedure during the past decade, the nature of the surgery demands some special consideration for intraoperative nursing care. Pacemaker patients need reassurance. They realize that their hearts are diseased and are frightened by the thought of a heart operation and of reliance on a mechanical device. This fear is managed best by skillful communication and reassurance. Communication is particularly important in pacemaker implantation because local anesthesia is the recommended procedure. An effective way to allay apprehension about the needle delivering the anesthetic is to tell the patient, “There will be a small needle stick and some burning when the medication is injected. After that, you won’t feel anything in that area,” and “If you do feel anything at all, let the doctor know and he will put in more medication.”
Lawrence Obendorf, RN, is in the cardiovascular-thoracic surgical unit at Cedars-Sinai Medical Center in Los Angeles. He received his BSN from Southern Illinois University, Edwardsville, Ill.
Because the patient is awake, attending to his physical needs is especially important. He should be kept out of drafts, with blankets handy if he should become cold. Modesty should be respected, and unnecessary exposure avoided. Discussion of his condition should be well out of the patient’s hearing range. Patient safety. After the patient is placed on the operating table, knee straps should be applied loosely to prevent circulatory impairment. The patient is usually supine and should be in as comfortable a position as possible. The operative field must be adequately exposed. Circulation must not be obstructed by an awkward position or undue pressure on any part. There should be no interference with the patient’s respiration as a result of pressure of arms on the chest or from constriction of a gown about the neck or chest. Nerves must be protected from undue pressure. Improper position of arms, hands, legs, or feet may cause serious injury or paralysis. Concern for the patient as an individual includes special consideration for the very thin, the elderly, or the obese. The patient should be properly grounded with a conducting plate in contact with skin if electrocautery is to be used. However, electrocautery
d-. AORN Journal, October 1977,Vol26, No 4
771
0
R personnel should wear radiation film badges.
should never be used within 6 inches of an implanted pacer or lead. Instruments or devices that produce strong electromagnetic fields should be used with care. When instruments capable of causing interference are used near or on a patient receiving a pacer, defibrillation and resuscitation equipment should be, available for immediate use. All electrical equipment should be checked to make sure it is in safe working order. OR personnel safety. During pacemaker implantations, OR personnel should wear radiation film badges. The rays emitted from fluoroscopy during the operation should routinely be monitored in this way, although studies show that significant radiation exposure to OR personnel is unlikely.' However, rays emitted during fluoroscopy do remain for a longer period than do those fiom diagnostic x-rays or gamma rays. Anesthetic. Although local anesthesia is preferred, it may be contraindicated in highly nervous, apprehensive patients. The emotional trauma experienced by a frightened patient under local anesthesia may be more harmful than any physiological problem following general anesthesia. The most frequently used anesthetic in pacemaker implantations is lidocaine, either with or without epinephrine. The drug penetrates to nervous tissue and diffuses rapidly, thus proI14
ducing prompt loss of pain perception. However, it may be accompanied by a variety of adverse reactions. Excessive dosage, too rapid absorption, inadvertent intravenous injection, or allergic reaction may cause high plasma levels. These reactions are systemic and involve the central nervous system and the cardiovascular system. Excitatory andlor depressant reactions may occur. Excitatory reactions in the central nervous system may be nervousness, dizziness, blurred vision, and tremors. Depressant reactions may be characterized by drowsiness, convulsions, unconsciousness, and possibly respiratory arrest. Excitatory reactions may be brief or absent. In this case, however, the first manifestation of any reaction may be unconsciousness or respiratory arrest. Adverse cardiovascular reactions to lidocaine are depressant, occurring as hypotension, myocardial depression, bradycardia, or possibly cardiac arrest. Treatment may demand an airway, oxygen, and assisted or controlled respiration. If circulatory depression occurs, treatment would include intravenous therapy and vasopressors. Resuscitative equipment and drugs should be available. The addition of epinephrine to lidocaine creates an ischemic action, which reduces the rate of absorption of the local anesthetic. Epinephrine prolongs the pain-preventing effect, re-
AORN Journal, October 1977,Vol26, No 4
d u e s the danger of systemic toxic reaction, and has a vasoconstrictive action, which reduces bleeding in the area of injection. However, if epinephrine enters the systemic circulation, side effects may include pallor, hypertension, cardiac arrhythmia, chest pain, and headache. If not treated, cerebral vascular accident, ventricular fibrillation, or cardiac dilation with pulmonary edema could lead to death. By knowing the effects and side effects of lidocaine, the nurse is aware of the problems that may arise. By monitoring the patient’s vital signs closely, one can detect any deviation early and possibly prevent progression to a dangerous condition. Pacing leads. There are two types of pacing leads, epicardial and endocardial. Skin preparation and operative procedure differ according to the kind of lead used. For implantation of an epicardial pacing lead, the skin should be scrubbed for five to ten minutes covering the area for a left anterior thoracotomy and a left upper quadrant transverse incision. A left thoracotomy through the fourth or fifth intercostal space is performed, and the pericardium is incised. A left upper quadrant transverse incision is made and a subcutaneous pocket for the pacemaker is created. A subcutaneous tunnel is made between the thoracic and abdominal incision, and the pulse generator is put in the pouch and the leads passed through the tunnel. The electrode tips are inserted into the myocardium via a small stab wound and are sutured in place. A chest tube is inserted, and the two incisions are closed. For implantation of an endocardia1 pacing lead, the skin should be scrubbed for five to ten minutes covering the upper outer chest wall and neck on whichever side the surgeon 776
has chosen. The pulse generator is placed in a subcutaneous pouch, usually on the right upper chest wall. The veins on the right are preferable because they are a direct line to the heart. The neck area is incised, and a vein is exposed. A small hole is made in the vein; under fluoroscopy, the lead is threaded through the superior vena cava and tricuspid valve. It then curves gently to the apex of the right ventricle, where the electrode tip is lodged under one or more trabeculae. The lead is introduced slowly and cautiously to avoid perforating the relatively thin wall of the right ventricle. Monitoring is important when the pacing leads are being inserted. An electrocardiographic (ECG) monitor is needed to watch for premature ventricular contraction, which frequently occurs when the leads enter the right ventricle and are being positioned. ECG monitoring is also needed to indicate whether or not the pacemaker impulse is being captured and transmitted through the ventricle. Although pacemaker implantation may be considered a minor procedure, to the patient who needs psychological support and physiological assessment, it is a stressful event. Proper intraoperative nursing care helps to assure a successful and uneventful postoperative period. 0 Notes 1. John L Day, David A Lightfoot, “OR radiation hazards,“ AORN Journal 20 (August 1974) 24% 256.
AORN Journal, October 1977,Vol26, No 4
