This month, we are including some of the recent responses to our questions under discussion. In addition, please review last month’s question still under discussion. Readers, it is not too late to send in your responses to questions from past issues. If you have information or tips that might be helpful, email us at eplabdigest@hotmail.com or go to www.eplabdigest.com and click on the email discussion group link. Our website is constantly being updated with new responses, so check back often!

Bretylium
Is anyone else having trouble getting Bretylium? My pharmacy department is telling us they can't find any. If anyone has a supplier and/or ishaving the same problem, please respond.
— G. Cusworth, RN

Having been a paramedic for 22 years, we noticed that Bretylol (Bretylium Tosylate) became hard to get around 1999–2000 or so. Bretylium resources were apparently scarce, and the manufacturers were not able to get the supplies necessary to make the drug. It is my understanding that this is still the case. This was about the same time that amiodarone came on strong (coincidence?), so Cordarone replaced Bretylol, and that change is evidenced in the changes in ACLS. Ditch the Bretylol...you don't need it.
— T. Ginapp, RCIS

ICDs
For patients receiving a prophylactic ICD, (Madit II) how many physicians are doing an EPS prior to the ICD implant?
— C. Jennerjohn

Our EP physician does a study on each patient before an ICD implant, unless the patient has a documented 30-beat run of VT captured on paper. In those cases, the EPS study is waived and the implant is done immediately.
— T. Ginapp, RCIS

National Standards
We are sharing a new EP lab with the cath lab. We are in the process of converting the device implants from the OR to our lab. Some EP/cath labs are very strict regarding sterile technique practices. Others are less rigid. Is there a national standard regarding sterile technique practices and proper cleaning of an EP lab/cath lab that performs device implants?
— L. Payne, RN, Dallas, Texas

I am not able to refer to any literature regarding standards, but I do know that your EP lab should be terminally cleaned just like an OR room. You need to be as strict as possible regarding sterile technique. Infection problems can occur up to one year after implant and be considered implant related. A patient who gets an infection may very likely have to have the entire system removed, and reimplanted on the right, days later after a course of antibiotics. The cost and the risk to the patient are both high.
— C. Jennerjohn

EP Protocol
Does anyone have a current magnet protocol for ICDs? Our anesthesiology department would benefit from one, and I am finding it confusing to combine the different companies to come up with a generic standard. If anyone has a pacemaker one as well, that would be helpful.
— K. Kaczmarek

We have a policy regarding shutting off the ICD in the OR, because we turn detection off via the programmer, and connect the patient to a monitor/defibrillator. A magnet placed over an ICD should close a reed switch and inhibit detection, no matter what brand it is. One exception is that there are some older Guidant devices that can become programmed to "off" when in contact with a magnet for a short period of time. Magnet application to an ICD should not affect the pacing therapies like it would a pacemaker.
— C. Jennerjohn