There are an additional two new questions this month. Readers, do you have any questions that you would like to ask our discussion group? Perhaps about how a difficult case should have been handled or about the upcoming ICD registry? In the email discussion group, feel free to be listed as “name withheld” or “anonymous”. Our members are located all over the country, so you can share your questions with a wide range of professionals and see how other labs handle similar issues.

If you would like to respond, please email us at eplabdigest@hotmail.com. Remember, when posting or responding to the discussion group, please let me know if you would like your name, location, and/or email address listed as well — that way you will get more instant results! You can also go to www.eplabdigest.com and click on the email discussion group link. The website is always being updated, so please check back often. We look forward to hearing from you!

New Questions Under Discussion:

Pacemaker Lead Removal
Requesting any information you have on guidelines and protocols. Thank you!
— name withheld by request
(Readers, to reply to this question, please type “Pacemaker Lead Removal” in your subject line.)

Regarding lead extraction, we recently went looking for standards and found there was very little consensus. We finally created our own based on our experience and a literature review. We perform 50–60 extractions per year, so our physicians are comfortable with the procedure. We use the Spectranetics laser routinely. We have three labs and four ORs in which the laser can be used. Our protocol will designate anyone with epicardial leads, leads more than 6 years old (if multiple) to 8 years old (if single), and fragile patients (physician discretion) as high-risk. These patients will be done in the OR, but are started by a cardiologist and are using the laser. 
All other patients can be done in the EP lab, but with OR stand-by. All of our patients have CBC, Chem 7 and 2–4 units of blood cross-matched and in the room before starting. We get both a procedure consent and consent for Mediastinal Exploration for urgent surgery before starting. We typically put in a femoral arterial line and a large (8F) femoral venous line. We prime a blood tubing with saline and run it KVO to the femoral sheath. If a temporary pacemaker is needed, we usually put in a second venous sheath for it. We confirm OR availability and forewarn respiratory therapy that if we page, just come before we prep for the extraction. We have at least three staff in the room, including two RNs (one for sedation, one to circulate) and one person to document and serve as a runner. We usually also provide a scrub unless there is a fellow assigned to the case. (We have both private practice and academic groups working in our lab.) After all leads are removed, we watch the patient intensely for 10–15 minutes before notifying OR and respiratory that we are clear. If the physician feels we may have a problem, we contact the surgeon to come evaluate the situation before we proceed. He usually waits for 5–10 minutes until we get past that point. Not everyone is overjoyed with the process yet, but it works.
—Howard Mattingly, RN, Team Leader, EP Lab, Methodist Hospital, Indianapolis, IN


Bispectral Index (BIS) Monitoring During Pacer Insertion
What credentials, if any, are necessary to use this during a pacemaker procedure? I am a nurse new to the cath lab and am concerned that this is getting into the “anesthesia arena” and that I may not be licensed for BIS monitoring.
— name withheld by request
(Readers, to reply to this question, please type “BIS Monitoring” in your subject line.)

Regarding BIS monitoring, we used the monitors to evaluate the level of sedation during procedures. In our hospital, they are not restricted to anesthesia, and using it was not a licensing issue. What we found was the monitors worked sometimes and didn’t others. One of anesthesiologists told us the BIS monitor works best on patients under general anesthesia, and they didn’t use them for sedation cases. We eventually gave ours to anesthesia because they weren’t reliable for us.
—Howard Mattingly, RN, Team Leader, EP Lab, Methodist Hospital, Indianapolis, IN