PROCEDURE D e fi brillation (Internal) Perform 37 Marion E. McRae PURPOSE: The purpose of internal defi brillation is to deliver electrical current directly to the epicardial surface of the heart via sterile internal defi brillation paddles when a shockable rhythm is present.

PREREQUISITE NURSING • Large sterile suction catheter (Yankauer), sterile tubing, KNOWLEDGE suction canisters, suction regulator, and suction source • Sterile internal paddles (ensure compatibility with the • Cardiac arrest after cardiac surgery, which occurs in about defi brillator). Adult internal paddles are usually 5 to 0.7% to 2.9% of patients, is the most common scenario in 7.5 cm in diameter. which internal defi brillation is needed.3,11 • D e fi brillator • Understanding is needed of cardiovascular anatomy and Additional equipment, to have available as needed, includes physiology, principles of cardiac conduction, dysrhythmia the following: interpretation, and electrical safety. • Intubation equipment • Advanced cardiac life support knowledge and skills are • Flow meter for oxygen administration needed. • Bag-valve device with mask capable of delivering 100% • If open-chest resuscitation with internal defi brillation oxygen and at least 500-mL volumes is attempted in cardiac arrest, it should be performed • Intravenous (IV) fl uids (e.g., 500 mL of normal saline) within the fi rst 5 minutes after cardiac arrest for the best • Emergency medications outcomes.11 • Temporary pacemaker equipment • Clinical and technical competence in the use of the defi - • Antiseptic skin prep solution (e.g., 2% chlorhexidene- brillator is needed. based preparation) • Knowledge of aseptic and sterile technique is necessary. • Emergent sternotomy or thoracotomy precedes internal PATIENT AND FAMILY EDUCATION defi brillation (see Procedure 39 ). • Knowledge of internal paddle placement and energy • Teaching may need to be performed after the procedure. requirements for internal defi brillation is needed. Rationale: Internal defi brillation usually is performed in • Internal paddle placement should ensure that the axis of the face of sudden hemodynamic collapse. the heart is situated between the sources of current. • Explain to the family the need for internal defi brillation. • Energy requirements for internal defi brillation usually Rationale: This information keeps the family informed. range from 5 to 20 J for biphasic shocks and 10 to 40 J for monophasic shocks.11 It has been suggested that bipha- sic shocks for ventricular fi brillation and pulseless ven- PATIENT ASSESSMENT AND tricular tachycardia should start at 10 to 20 J 10 or at 20 J.1 PREPARATION Biphasic shocks are more effective than monophasic shocks at the same energy level in internal defi brilla- Patient Assessment tion.10,12 The amount of myocardial damage from internal • Assess for dysrhythmias, especially ventricular ectopy. defi brillation does not differ between monophasic and Rationale: Ventricular dysrhythmias may precede ven- biphasic shocks.12 tricular tachycardia and ventricular fi brillation. • Assess vital signs when dysrhythmias occur. Rationale: EQUIPMENT This assessment provides data about the patient ’ s response to dysrhythmias. • Surgical head covers, masks, eye protection, sterile gowns, • Assess for pulseless ventricular tachycardia or ventricular sterile gloves, large sterile drape fi brillation. Rationale: Assessment determines the need • Open sternotomy or thoracotomy tray for resuscitation, which includes internal cardiac defi bril- lation. If immediate intervention is not initiated, return of circulation may not be possible. This procedure should be performed only by physicians, advanced Patient Preparation practice nurses, and other healthcare professionals (including critical care nurses) with additional knowledge, skills, and demonstrated competence per • Verify correct patient with two identifi ers. Rationale: professional licensure or institutional standard. Before performing a procedure, the nurse should ensure

310 37 Defi brillation (Internal) Perform 311

the correct identifi cation of the patient for the intended • Prepare for this procedure by opening the chest and intervention. draping the patient in a sterile fashion (refer to Procedure • Ensure the patient has a patent airway and ventilation 39 ). Rationale: Allows the internal paddles to be inserted before the initiation of the procedure. Assign responsibil- into the patient ’ s chest. ity to this task to another qualifi ed provider. Rationale: • Remove all metallic objects from the patient ’ s skin. Ratio- The patient ’ s airway is protected and maintained, and a nale: Metallic objects are conductors of electrical current means for adequate ventilation and oxygenation is and may cause burns. provided. • Order sedation and analgesia as needed. Rationale: Pro- • Place the patient in a fl at supine position. Rationale: This motes patient comfort. position provides the best access during the procedure and during intervention for management of adverse effects.

Procedure for Internal Defi brillation Steps Rationale Special Considerations 1 . HH 2 . PE 3. Confi rm that the patient is in Reconfi rms that defi brillation is External defi brillation should be ventricular fi brillation or pulseless needed. attempted fi rst whenever possible (see ventricular tachycardia. Procedure 36 ) unless the chest is already open and there is rapid access for internal defi brillation. Follow institution ’ s standard. 4. Initiate basic and advanced cardiac Life-saving interventions are It is controversial whether external life support.11 (Level D * ) necessary. cardiac compressions (because of potential damage to the postoperative cardiac patient) should be started if rapid defi brillation can be accomplished.2,8 External cardiac compressions should be delivered while awaiting a defi brillator.6 The American Heart Association ’ s 2010 advanced cardiovascular life support guidelines recommend external chest compressions if emergency resternotomy is not immediately available.11 Deformation of transcatheter aortic valves with external chest compressions has been reported.5,9 Left hemithorax compressions may be safer with transcatheter than compressions over the sternum.9 Follow institution ’ s standards regarding initiation of external cardiac compressions.

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

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Procedure for Internal Defi brillation—Continued Steps Rationale Special Considerations 5. Don sterile equipment. Prepares for sterile procedure. The physician, advanced practice nurse, or other healthcare professional(s) performing the procedure should perform hand antisepsis and hand scrub if possible.1,4 However, if a closed sleeve technique for gowning and gloving technique is used, handwashing is not necessary in cardiac arrest as it delays resuscitation. Increased time to defi brillation decreases the likelihood of successful resuscitation.1 6. If there is blood/fl uid in the Fluid/blood may need to be mediastinum, connect a sterile evacuated from the Yankauer suction to a sterile mediastinum before suction tubing and suction the defi brillation. mediastinum before defi brillation. 7. Ask for internal paddles ( Fig. Prepares the equipment. 37-1 ) to be opened and placed on the sterile fi eld and hand off the connection cable for the defi brillator to an unsterile assistant to connect to the defi brillator.

Figure 37-1 Internal paddles. (Courtesy Marion E. McRae.)

8. If the internal paddles are two-part Prepares the equipment. paddles, connect the defi brillation paddles to the handles (usually via screw mechanism). 9. Identify the number of joules the The lowest energy level that Biphasic shocks of 5–20 J usually are defi brillator is to be charged to will convert the rhythm and suffi cient to convert pulseless (usually 5–20 J for biphasic minimize damage to the rhythms.10–12 shocks, 10–40 J for monophasic myocardium is used. Refer to the defi brillator manufacturer ’ s shocks).11,12 (Level D * ) operation guidelines for specifi c recommendations and follow institution guidelines.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. 37 Defi brillation (Internal) Perform 313

Procedure for Internal Defi brillation—Continued Steps Rationale Special Considerations 10. Position one paddle over the right This will aid in depolarizing the atrium or right ventricle; the other entire myocardium. paddle is placed over the apex of the heart ( Fig. 37-2 ).

Figure 37-2 Paddle placement for internal defi brillation. (From Kinkade S, Lohrman JE: Critical care nursing procedures: a team approach , Phila- delphia, 1990, BC Decker.)

11. State “all clear” three times and Electrical current can be Use a mnemonic such as “I ’ m clear, visually verify that all personnel conducted from the patient to you ’ re clear, we ’ re all clear,” and look are clear of contact with the another person if contact at the patient while talking to ensure patient, bed, and equipment. occurs. that no one is touching or is in contact with the patient. 12. Simultaneously depress and hold In the defi brillation mode, an Follow manufacturer ’ s the buttons on each paddle until immediate release of the recommendations. the defi brillator discharges if the electrical charge depolarizes paddles are equipped with cardiac muscle. defi brillation buttons. If the Simultaneous depolarization of paddles are not equipped with the myocardial muscle cells defi brillation buttons, ask for the may result in simultaneous defi brillation button on the repolarization of enough defi brillator to be activated. myocardial cells to reestablish (Level M * ) a single cardiac impulse. 13. Assess the patient ’ s response to Determines whether additional defi brillation (heart rate and interventions may be needed. rhythm, blood pressure, level of consciousness).

* Level M: Manufacturer ’ s recommendations only

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Procedure for Internal Defi brillation—Continued Steps Rationale Special Considerations A. If the fi rst defi brillation is not Continues emergency treatment. successful, perform additional defi brillations as needed.11 ( Level D * ) B. Open chest cardiac Open-chest cardiac compression Do not press your fi ngers into the compressions may be initiated may be initiated if internal epicardial surface as tears can occur in if needed: defi brillation is not thinner or weak areas of tissue. i. Place one hand around the successful. Do not lift the apex of the heart as surface of the apex of the Internal cardiac massage is posterior ventricular rupture can heart toward the posterior superior to external cardiac occur,4 especially if there are aspect of the heart with the massage.4 prosthetic atrioventricular valve palm up and fi ngers straight. prostheses in situ. ii. Avoid lifting the apex of the heart. iii. Avoid any grafts or other structures on the heart such as epicardial pacemaker leads. iv. Place the palm of the other hand on the anterior surface of the heart keeping the fi ngers straight. v. Squeeze the heart between your two hands at 100/min. 4 ( Level E * ) C . I f d e fi brillation is successful, Aids in determining whether Provide additional supportive therapies obtain vital signs and assess additional interventions are as needed. Epicardial pacing and the patient. needed. vasoactive agents may be needed. 14. Prepare the patient for transfer to Prepares for chest closure. Follow institution standard for closing the operating room to close the the chest in the unit or in the chest; cover the patient ’ s chest operating room. with a sterile drape or sterile The chest may be left open with a sterile occlusive dressing before occlusive dressing in place particularly transporting the patient to the if the patient remains unstable. operating room. 15. Remove sharps from the open Reduces risk for injury. chest tray and discard in a sharp container. 16. Place the internal paddles in the Prepares for sterilization of Follow manufacturer and institutional appropriate bag or container and equipment. guidelines for cleansing the ensure that it is sent for defi brillator and internal paddles. decontamination, disinfection, and Discard disposable internal paddles if sterilization. used. 17. Remove PE and sterile equipment Reduces the transmission of and discard used supplies in microorganisms; Standard appropriate receptacles. Precautions. 18. HH 19. Request that sterile internal Prepares for another emergency. paddles and an open chest tray are immediately restocked.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. * Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations. 37 Defi brillation (Internal) Perform 315

Expected Outcomes Unexpected Outcomes • Reestablishment of a single origin of the cardiac • Inability to resuscitate; death impulse • Cerebral anoxia, brain impairment • Hemodynamic stability • Infection • Myocardial injury (e.g., from hypoxia, defi brillation, sternotomy/thoracotomy, internal compressions) • Pain

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Continue to monitor the Dysrhythmias may develop. • Dysrhythmias patient ’ s cardiac rate and rhythm after defi brillation. 2. Assess the patient ’ s Determines patient ’ s neurological • Change in level of consciousness neurological status after status after arrest and defi brillation. defi brillation. Order the The benefi t of therapeutic frequency of neurological hypothermia in cardiac arrest after assessments. If resuscitation is cardiac surgery is unknown. successful but the patient However, due to the strength of remains unresponsive after the evidence in other populations it resuscitation, consideration should be considered. Hypothermia should be given to therapeutic can impair coagulation which is a hypothermia at 32–34°C for at concern if a patient is bleeding. least 12–24 hours. 7 ( Level E * in this population ) 3. Order arterial blood gases and Determines oxygenation and acid- • Abnormal respirations ventilator settings for ongoing base balance after arrest and • Abnormal oxygen saturation patient care. defi brillation and provides for • Abnormal arterial blood gas results ongoing respiratory support. 4. Order vital sign monitoring Determines the patient ’ s • Abnormal vital signs immediately after hemodynamic stability. defi brillation and at least every 15 minutes until stable. 5. Prescribe intravenous Antidysrhythmic medications may be • Dysrhythmias antidysrhythmic medications prescribed to prevent or control as needed. dysrhythmias. 6. Order hemoglobin/hematocrit Ensures suffi cient hemoglobin for • Abnormal hemoglobin and levels if blood loss occurred oxygen transport. hematocrit results during the procedure. 7. Order blood replacement Replaces blood loss that occurred products if needed. during the procedure. 8. Order electrolyte levels and Abnormal electrolyte levels may • Abnormal electrolyte results replace electrolytes if low. contribute to the development of ventricular dysrhythmias. 9. Order and interpret a 12-lead Assesses for myocardial ischemia. • ECG abnormalities electrocardiogram (ECG). 10. Order analgesia and sedation Ensures patient comfort. • Continued pain or agitation despite as needed. pain and sedation interventions

* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations

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Documentation Documentation should include the following: • Orders given during the resuscitation • Any unexpected outcomes and interventions taken • A procedure note describing the procedure performed, • Amount of chest drainage/blood loss the sequential events occurring, patient assessment • Time chest was covered with a sterile occlusive before and after defi brillation, and complications of the dressing or when the chest was closed. procedure • Laboratory values obtained immediately before and • Printout of ECG tracings with cardiac events before, after defi brillation. during, and after each defi brillation • Family notifi cation of the event. • Patient response to defi brillation • Patient (if applicable) and family education about the • Pain assessment, interventions, and effectiveness event • Medications and IV fl uids given during the resuscitation

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .