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. Procedure continues on following page 312 Unit II Cardiovascular System 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