essential checks before procedure
Pre-operative Check List
All operators should for zero mortality and near zero acute morbidity for elective pacemaker implantation. A preoperative check list is the first step to achieve that goal
General Points
The fundamental basis of safety is sticking to the WHO surgical safety protocol – which includes a written safety protocol based on facilities available at the institution and a checklist for operators to adhere. The staff should actually follow the protocol rather than keep it on paper. The elements consists of a team briefing before cases and an individualized checklist for each. I am not going into details of, but the operator should be aware and practice according to local rules.
For elective implants, the patient should have a shower the previous night. Clothing policy prior to arrival in the theatre depends on the hospital. Some hospitals prep-up in wards and change over to sterilized gowns, in our institution, patients wear a clean white cotton dress prior to arrival in the theatre. Shaving is done just before the patient is dispatched to the theatre and the rest of the skin prep occurs in theatre.
The assisting nurse personally speaks to the patient, verifies the name and procedure, and concurs with the implanting physician. She also re-confirms allergies specifically for povidone iodine, contrast media and antibiotics and if any concerns, communicates with the implanter. She also briefly explains the procedure and immediate aftercare to the patient and what to expect – from a nursing point of view.
Specific Pointers
The implanter himself does an independent check on the following issues which have a direct bearing on the safe performance of the case:
The indication for pacing is reviewed and hardware is selected upon the pacing strategy. In our setup where economics of pacing are prohibitively expensive, we try to optimize our hardware use to minimize wastage. For example, if the patient is of small stature, we will use a 52 cm lead for the ventricle if they are in excess stock. Another critical decision is DDD vs AAI for sinus node dysfunction. Depending on pathological need and availability of resources we will make a decision on dual chamber versus single chamber pacing
Usually most of these factors are planned ahead in the ward or clinic but as a routine we re-assess while in the theatre. The implanter checks what the patient knows and gives a brief explanation of what to expect during the implantation and concurs with the patient. The written consent for implantation and anesthesia which was taken in the ward is confirmed in the theatre.