Removal of Pacing Wires

  1. 0
    Hi, I'm curious to know what others hospital policies are regarding removal of epicardial pacing wires post cardiac surgery
    Our policy requires baseline obs, remove wires, obs x2 30 minutes apart, pt to remain in bed 1 hour, watch for signs of tamponade (dec BP, tachy, SOB, pain)
    We aim to remove wires during 'office' hours (plenty of staff around), on day 4-5 post-op and while INR is <2.5. Ofcourse this is all with Dr's orders on pt assessment.
    Had pt last night: INR 3.4, day 6, due to be D/C next day, surgeon did round at 1900 hours & ordered wires to be removed now. Reminded Dr of policy & voiced concerns, Dr said to do it while he was on the ward.. this is fine but what about later if she tamponades? Made sure documentation was in order, & removed wires. No problems as far as I know (I am on a pm shift so hopefully she has gone home safely)
    Some nurse feel the policy is over-kill as nobody has seen a pt tamponade post wire removal.
    Thoughts please & what are others doing with this procedure?
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  5. 0
    Doesn't anyone take out pacing wires???
    Maybe they are called something different in the states??
    Help??
  6. 0
    Following my wife's open heart the pacer wires were pulled by the PA who is in the group for the surgeons. Her's came out on
    Day 7 post-op. Of course, she had some major work done (when isn't open heart). She had rings place on her tricuspid and mitral valves, a patch for a ASD and a MAZE done. The MAZE fixed the A-FIB but she has remained in a junctional rhythm. Her post-op period would have been a great time to be ignorant about medical procedures and such!
    As far as I can recall, there was no special observation period, other than on telementry, and definately no one from the floor taking vitals. She was not told to stay in bed either. Sometimes you wonder if many of the tried and true methods are done away with because nothing ever happens...and we are setting ourselves up for some major grief.

    bob
  7. 0
    Thanks for your reply Bob, hope your wife has fully recovered from her surgery, she sure had some major work done.

    Maybe the extra precautions (vitals & RIB) are because we are over precautious if an incident occurs & the threat of legal action if duty of care is not maintained is always there?

    Maybe the extra precautions are because someone suggested it was done from the start & no one has proven, via research, that it is unneccessary? "We've always done it that way....."

    Or maybe, like you said, the precautions have slackened off because no incident has occured, on what best practice evidence though?

    Anyone with evidence of an event post wire removal & best practice based on research? Sounds like a project coming up!

    cheers, Lee
  8. 0
    Dear Dyno
    I know this is a really late reply - did you get any interesting information relating to this subject.
    At our hospital we are currently looking at developing a guideline in relation to epicardial wire removal. The literature is minimal and no one appears to have policies in place.We currently have a policy where by only those nurses whp have undergone specific training can removal wires and they follow strict observational guidelines on removal. I unfortunately have seen 'tamponade' following wire removal and don't see the observations required as over-kill! :stone
    Any more information required let me know
    Cheers
    Sharron68

    Quote from Dyno
    Hi, I'm curious to know what others hospital policies are regarding removal of epicardial pacing wires post cardiac surgery
    Our policy requires baseline obs, remove wires, obs x2 30 minutes apart, pt to remain in bed 1 hour, watch for signs of tamponade (dec BP, tachy, SOB, pain)
    We aim to remove wires during 'office' hours (plenty of staff around), on day 4-5 post-op and while INR is <2.5. Ofcourse this is all with Dr's orders on pt assessment.
    Had pt last night: INR 3.4, day 6, due to be D/C next day, surgeon did round at 1900 hours & ordered wires to be removed now. Reminded Dr of policy & voiced concerns, Dr said to do it while he was on the ward.. this is fine but what about later if she tamponades? Made sure documentation was in order, & removed wires. No problems as far as I know (I am on a pm shift so hopefully she has gone home safely)
    Some nurse feel the policy is over-kill as nobody has seen a pt tamponade post wire removal.
    Thoughts please & what are others doing with this procedure?
  9. 0
    Quote from sharron68
    Dear Dyno
    I know this is a really late reply - did you get any interesting information relating to this subject.
    At our hospital we are currently looking at developing a guideline in relation to epicardial wire removal. The literature is minimal and no one appears to have policies in place.We currently have a policy where by only those nurses whp have undergone specific training can removal wires and they follow strict observational guidelines on removal. I unfortunately have seen 'tamponade' following wire removal and don't see the observations required as over-kill! :stone
    Any more information required let me know
    Cheers
    Sharron68
    Hi Sharron, thankyou for your reply, only 4 years later but who's counting LOL. I am no longer in cardiac surgical now, transferred to cardiac investigations but the policy is still the same for pacing wire removals in our hospital. I never found any other info but best practice seems to be to contunue what we are doing. I am glad you also don't think it is over-kill, I think sometimes we are guilty of minimising risks for patients when we see the same procedure day-in-day-out but the potential is always there for tamponade, etc with removal of these wires. Same thing for CV line removal, patients up & out after 2 hour obs post biopsy (heart transplant patients). I always make sure they have our number close by but often they are independant & drive themselves home. Anyway, thanks again for your reply. cheers Dyno.
  10. 0
    don't ya just hate the ignorance or doctors..pulling wires with a inr of 3.4..duh what an [language edited by moderator]
    Last edit by RNPATL on Jan 22, '05
  11. 0
    I too have found little written about nurses removing epicardial pacing wires and am in need of a policy. Other nearby facilities are doing this with a checklist and no policy. Currently we will be removing them post openheart 24 hours prior to discharge to allow time for monitoring. Complications are not only tamponade (from coring the ventrical) but also electrically irritating the ventrical resulting in some mean dysrhythmias, as well as fragmentation and migration of the wire parts. (oops)
    At this point I have found that the INR should be less than 2.4, the patient should be on bedrest for 30 minutes, VS X2 30 min apart, observing for SXS tamponade and monitoring X 24 hours. If pacer wire is sutured internally, pull the wire and cut off at the skin with sterile scissors. We are considering having only the APN or CNS doing this procedure. I'll be watching for more on this.....there's not much!
  12. 0
    No, the protocol your hospital requires is not overkill. I am a RN who witnessed her mother go into cardiac tamponade 1 1/2 hours following the resident pulling her epicardial wires in the room. She died as a result of a tear of the right atrium. It does happen and I would not wish it on anyone. By the time she was rushed to surgery it was too late. She had been doing great following her procedure was expecting to go home the next morning. I watched her suffer until she went unconscious on the floor. As a result I am trying to find written protocols and information regarding the removal and care of a patient following the removal of the epicardial wires? Are all of the patients usually on a telemetry unit? I would appreciate any info that I can acquire regarding this procedure.

    Thanks,

    Emmynurse
  13. 0
    Where I work as an RN patients wires are removed any day after day 4 post surgery only patients with irregular heart rhythms such as af are on telemetry. an ecg is performed and as long as there are P waves it is ok to either remove or cut the wires. However, one SHO after i gave him an ecg was concerned tht a patient was in af he said if he is a known af then it would b ok but if it was a new onset of af then he wouldnt b happy, however wen spking to another RN they said af isnt an indication for keepin wires in as the pacing wires are usually used to treat bradycardia post op via pacing box. so i asked the consultant who identified P waves on the ecg and said it was fine to remove the 2 RA wires and cut the 2 RV as the two RV were stitched to the heart whilst the RA were just resting on the surface. if patient on warfarin they require an INR of ethier < 2.5 or <2.0 depending on surgeon preference before removal. baseline obs are required proir to removal in order to identify cardiac tamponade in any changes post removal with 2 x 15 min obs post removal, patients are required to lie flat or reasonably flat for 30 mins post removal and require to remain in hosp overnight post removal. wires are only removed during theatre hours incase of cardiac tamponade which may mean tht chests would have to b opened on the ward if it was to happen. if a wire tht is meant to be pulled is resistant then dont force it, spk to dr if they wanna pull it fine, i have seen some RNs cut the wire cos it is not budging.


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