Temporary epicardial pacing after cardiac surgery

This advisory will cover the peri-operative management, ie from pre operative checking of batteries, intra-operative instillation of pacing wires to the postoperative period on the PICU or cardiology ward of a paediatric patient having temporary epicardial pacing in Yorkhill. The advisory is a continuum of care and is not limited to the postoperative patient on the PICU. It does not cover transvenous pacing, trans-oesophageal pacing or permanent pacemakers. It is a synthesis of expert opinion, open commentary, manufacturer’s data and in house biomedical engineering studies.

It is intended for use by nursing and medical staff that are responsible for looking after the aforementioned patients. Its contents are regarded by the faculty as best practice.

The NBG code will be used to classify temporary pacing modes within our advisory. *

The Medtronic 5388 (dual chamber) is accepted as the pacemaker to be used for temporary cardiac pacing after cardiac surgery within our hospital (here after referred to as pacemaker).

A temporary pacemaker system consists of a pacemaker, temporary myocardial lead(s) and patient connecting lead(s) to connect the myocardial lead to the pulse generator.

(*Permanent pacemakers are classified using the North American Society of Pacing and Electrophysiology (now the Heart Rhythm Society)/British Pacing and Electrophysiology Generic Code, the NBG code. This was revised in 2002. Of the 5 positions, the first 3 are relevant to temporary pacemakers)

• Temporary myocardial leads placed by cardiothoracic surgeons will be connected to the pacemaker by patient connecting cables (Medtronic 5433A {atrial-blue} Medtronic 5433V {ventricular-white}).
• The patient connecting cables should be connected to the connector block at the top of the pacemaker. The receptacles are clearly marked “A” for Atrium (colour coded blue) and “V” for ventricle (colour code white). It is possible to connect the myocardial leads directly to the pacemaker. This should only be done in an emergency if connecting cables are not available or if there is a specific problem with a connecting cable and a spare is not immediately available.
• 9V Lithium batteries are to be used as the energy source for the pacemakers. (Ultralife Lithium Cell, 9volt; Part No 9VL-FP). (1)
• All batteries, ie those to be inserted and spares should be tested for charge, using the Battery Tester (model MW333) and should be accepted only if they rate as GOOD. Batteries rating as WEAK or POOR should be removed from service and disposed off as per hospital policy.
• Batteries should not be stored in the pacemaker.
• A new battery should be used for every patient.
• A pacemaker will be regarded as “in use” once it has left PICU. An “in use” pacemaker should have a new battery placed in the pacemaker on leaving PICU. A new spare battery should be attached to the pacemaker. The securing tape should not be placed over the display screen or control buttons.
• The spare battery will remain in its packet, and will be tested before insertion into the pacemaker, by competent staff in theatres, cath lab, PICU or on the cardiology ward.
• Used batteries should be tested once pacemaker is no longer required. If the test rating is “GOOD” then transfer them to the general battery store. This store should be distinct from the pacemaker battery pool which should only contain new unused batteries. No battery once used should be returned to this pool. If they rate as WEAK or POOR then dispose of them as per hospital policy. A used battery should not be returned to the pacemaker battery pool even if it is rating as GOOD. The pacemaker will continue to operate for a maximum of 15 seconds after battery removal at paediatric appropriate settings: Rate 150, A and V output 20mA, provided the back light is off and the lower screen is inactive. (2)
• A battery will last for 24 hours in the pacemaker after the low battery warning light first appears. Specific testing at paediatric values was not undertaken by our biomedical engineering department as we had already decided that we would check for a low battery warning every 12 hourly.
• The connection of an external cable to the pacemaker to output signals to our computer information system is prohibited. This means that the pacemakers cannot be interfaced with the CIS.(3)
• Pacemakers will be tested six monthly according to manufacturers specification. (4)
• Bioengineering staff will identify pacemakers by their serial number and “Y” number, which will be traceable via the OPTIM database. This will highlight to bioengineering when a service is due.
• Device specifications can not be changed, this means that the default settings are adult appropriate. (5)

(1) Bench testing on lithium and alkaline manganese batteries performed by G Dobson: Medtronic 5388, rate 150bpm, current 20mA, atrial and ventricular connected to test load 510 ohm: Lithium batteries 14 days 18 hours before low battery icon warning, manganese 6 days before low battery icon (2) Testing by G Dobson. Model 5388 Technical manual states 15 seconds, but this is at settings: rate ≤ 70, A and V output ≤10mA. G Dobson informs us that the efficiency of the capacitor is extremely unlikely to alter with age of the pacemaker, and is more likely to fail completely than degrade, hence age of capacitor will not impact on the duration of operation after battery removal. (3) G Dobson confirmed that external leads, including electrically screened cables will conduct high levels of electrical interference to the pacemaker, causing problems with sensing and capture thresholds. In addition the pacemaker may be inhibited to revert to asynchronous operation when subjected to interference. (4) G Dobson has obtained a test protocol from colleagues in the cardiovascular department at the Royal Infirmary, and programmed his equipment management database to create maintenance jobs. A total of 24 different tests will be performed. (5) K.M, J.S, D.E regarded this as acceptable in the short term, but age and diagnosis appropriate settings should be established as a matter of urgency.

• All patients who have cardiopulmonary bypass, with the exception of Atrial Septal Defects should have pacing wires routinely sited by the cardiac surgeon.
• Patients with ongoing rhythms requiring pacing should be paced.
• Patients who have had heart block or bradycardia intra-operatively may be connected to a pacemaker, with a back up rate programmed, after agreement between the cardiac surgeon and anaesthetist.
• Patients who required pacing to come off CPB, even if they subsequently revert to sinus rhythm, should be connected to the pacemaker and programmed to VVI back up.
• Patients requiring pacing should be identified and the pacing mode should be agreed between the cardiac surgeon and the cardiac anaesthetist. (The consultant cardiologist should be consulted if the arrhythmia is difficult to control).
• De-novo arrhythmias arising on the PICU that warrant pacing should be discussed between cardiac surgeon, cardiology and intensive care staff, and the mode selected should be appropriate for the underlying diagnosis.

• Two wires should be sited in each chamber that is to be paced, to allow for bipolar pacing.
• Atrial wires should exit to the right of the sternum, ventricular wires to the left. This convention should be maintained irrespective of underlying diagnoses. Indications for internal crossing of wires should be clearly documented on the Patient Handover Form.
• Knots should be tied in the wires after they exit the skin to minimise potential for entanglement by reducing redundant loops.
• In patients who do not require pacing the temporary myocardial leads should be wound round swabs/dental roll and securely attached to the patient’s skin. If not used then the ends of the pacing wires should be covered (insulated)
• All temporary myocardial leads (and if the wires are connected to the pacemaker, connecting cables) should be clearly labelled as Atrial and Ventricular with descriptive labels before leaving theatre. These labels should be stored in theatres and in PICU (along side pacemakers and connecting cables).
• Blue patient connecting cables should be to be connected to atrial pacing wires, and white patient connecting cables should be connected to ventricular pacing wires (this adheres to convention but will not alter functionality). If there is a reason why this cannot be done then this should be clearly stated on the Patient Handover Form, and conventional arrangement adopted at the earliest safe opportunity.
• All pacemakers whether attached to the patient or transferred with the patient should have had the in situ battery tested, prior to use and the test results recorded on the Patient Handover Form, by the cardiac physiologist delivering the pacemaker. A spare battery should be available.
• The cardiac physiologist should sign that the battery has been checked on the Patient Handover Form.
• In those patients requiring pacing, ability of the pacemaker to work effectively should be confirmed before departure from cardiac theatres (or the location, where the procedure has been performed if not cardiac theatres). If a problem is identified it should be rectified. Circumstances may preclude this happening, but an agreement must be reached between the cardiac surgeon, cardiac anaesthetist and cardiologist and if on PICU the paediatric intensivist that a compromise is to be tolerated. This should be clearly documented on the Patient handover Form ( or if on PICU on CIS pacemaker section)
• Pacemaker settings should be completed on the Patient Handover Form
• Any changes made after these initial settings should be documented on the Patient Handover Form ( ie each episode of pacing should have these details on the form) with indications/explanations prior to arrival on PICU
• The following details should be entered on the Patient Handover Form for any period of pacing completed or ongoing:
• Indication for pacing o Mode o Base rate
• Atrial output
• Ventricular output
• Atrial tracking o Upper rate
• PVARP
• A-V interval
• Confirmation batteries have been checked-(cardiac physiologist to sign)
• YNumber, Pacemaker Serial Number
• Number of wires per chamber
• Confirmation connecting leads are colour appropriate: Atrial-Blue; Ventricular White
• Confirmation connecting leads clearly labelled
• Testing thresholds and sensitivities in theatre on a child established on pacing may compromise their condition, at a time of stability. As such the initial testing should be deferred until the next day on PICU.

• The pacemaker should be locked prior to moving patient to prevent inadvertent changing of settings.(1)
• All patients being paced should have continuous electrocardiography and peripheral pulse oximetry monitoring.
• Check that the spare battery is still attached.
• The patient should have a Patient Handover Form completed prior to transfer. The cardiac anaesthetic consultant is responsible for ensuring that the Patient Handover Form is completed.
• Any changes to settings that occur after the Patient Handover Form has been sent to PICU should be communicated by the anaesthetist or cardiac physiology staff as part of the verbal patient handover on the PICU.
• The pacing details should be transferred into CIS by the PICU doctor admitting the patient.
• If there is an enforced change between the patient arriving and this information being entered due to a change in the patient’s condition then the values on the Patient Handover Form should still be entered on CIS as admission values. The reason for changing these and the existing settings at the time the staff are able to enter data should also be entered on CIS.

(1) Medtronic 5388 Technical Manual: - If the lock key is not pressed, the device automatically locks the parameters on the upper screen 60 seconds after the last device adjustment.

• Pacemaker mode should be selected on the ECG settings on the bedside Phillips Intellivue monitor.
• ECG rate alarm settings to be set 10pm below the set pacemaker HR to detect failure to capture.
• Patients attached to a pacemaker should have continuous pulse oximetry, and ECG monitoring, to identify cardiac rate and rhythm.
• Back up pacing capability, an ECG machine capable of performing a 12 lead ECG and atrial electrocardiogram and defibrillation equipment should be available at all times.
• Nursing staff nursing patients being temporarily paced by an epicardial system should have passed Nursing Cardiac Competency No 19. *
• A connection check, checking that the temporary myocardial pacing wires are securely attached to the connecting leads ( or pacing box ) and that the connecting leads are securely inserted in the pacemaker, should be performed
• At the beginning of each shift
• After any procedure that could cause disconnection of the wires eg
• Lifting for CXR , transfer to another bed
• Before and after chest closure
• Before transfer of a patient
• After any manipulation of wires/leads

• As soon as possible after the beginning of a shift and mid shift ( CIS prompt) the bedside nurse will undertake a pacemaker check, which will include o A connection check
• Checking that the settings on the pacemaker are the same as those on the CIS pacemaker form. If not the nurse in charge and senior physician on duty must be informed.
• That the pacemaker is sensing and capturing appropriately, if not senior nurse and medic should be informed. (ie. Sensing lights on/ pacing spikes present and HR as set)
• That the low battery light is not on
• That the background lights are not illuminated.
• That the wires are not entangled and that there are not excessive redundant loops on the pacing wires or the cables.
• That the wires and patient connecting cables are labelled.
• That there is no obvious wear/or damage to the wires, connection cables.
• That the entry site is not infected
• That a spare battery is attached.
• Abnormal pacemaker checks should be discussed with the senior nurse and Consultant Intensivist on duty IMMEDIATELY
• Any concerns with pacing that may indicate an underlying arrhythmia, or a problem with patient pacemaker interaction should immediately be discussed with the senior nurse and physician
• In addition to the above scenarios the bedside nurse should be at liberty at any time to raise concern with the senior nurse, physician.

* Competency No. 19 will be part of the training process for implementation of advisory. In future it will be included at induction.

• At the earliest possible opportunity after returning from theatre the details on the Patient Handover Form should be transferred into CIS by the admitting PICU doctor.
• Daily pacemaker checks should be entered onto CIS by the Electrophysiology staff.
• Electrophysiology staff will be allocated limited access passwords for CIS.
• Any assessment, adjustment should be entered on CIS. It is the responsibility of the individual making adjustments to inform the nursing staff of any changes made and the reason for making changes. If the staff member does not have CIS access then the PICU trainee should enter the details and these should be checked and confirmed as accurate by the individual making the changes prior to being saved.
• Change of battery or pacemaker should be documented (dated) on CIS.
• CIS will provide a prompt to notify staff that a pacemaker check has to be done each shift and to remain active until completed.
• CIS to provide a prompt after 12 days that a battery change is due.
• Retention of pacing wires
• Patient Pacemaker Form if still paced when discharged
• CIS admission page to have options for all pacing episodes prior to as well as on admission
• Summary of outcomes of discussions relating to replacement of wires, or changing to an alternative pacing modality. 

• It will be assumed that patients being paced should have a pacemaker check performed daily by the cardiac electrophysiology staff. It should be decided before the morning ward round which patients should NOT have a pacemaker check performed.  
• A spare pacemaker must be immediately available, with battery power checked and settings as per the current patients settings prior to undertaking any diagnostic assessment.
• A defibrillator and resuscitation drugs should be available
• The patient must have continuous ECG and pulse oximetry monitoring
• Pacemaker checks should be routinely assessed in the mornings by cardiac electrophysiology staff.
• These checks will only be performed after the duty intensivist has confirmed that it is safe to do so.
• The senior nurse for the unit must be informed of the intent to do a pacemaker check.
• A physician should be available when checks are carried out, and be aware that a check is about to be performed.
• The bedside nurse must be in attendance and informed of the intent to do a pacemaker check
• The patient pacemaker form must be completed on CIS by the person performing the pacemaker check.
• The pacemaker check should include a rhythm strip which should be clearly identified with patient name, hospital number/chi number DOB, date and time of investigation and placed in patients paper notes.
• The outputs should be set to 2x the capture threshold (MINIMUM 10mA), and the sensitivities set at the discretion of the Cardiac Physiologists.
• If problems are diagnosed then where possible the Cardiac Physiologist will rectify these. Identified problems, solutions and changes to the pacemaker settings should be contemporaneously entered into CIS. The duty intensivist must be informed. 

• Outwith these routine checks, pacemaker assessment should occur
• in response to perceived failure to capture, pace or sense o when there is patient competition with the pacemaker
• at the discretion of staff competent in making assessments adjusting pacemakers to determine underlying rhythm
• at the discretion of staff competent in making assessments adjusting pacemakers to assess ongoing requirement for pacing.
• Any individual making changes to pacemaker settings should inform the bedside nurse of any changes which must be contemporaneously entered into CIS.
• The pacemaker should be locked after any assessment or settings change.
• The bedside nurse should check that the lower screen has become inactive and that the back light is off 5 minutes after a pacemaker has been unlocked.
• If a patient still requires pacing at the time of discharge from PICU then a CIS Patient Pacemaker Form must be completed as part of their discharge pack.

• Batteries should be electively changed every 12 days.
• Once the battery light is illuminated the battery should be changed
• A battery should be changed by a competent member of staff
• Only 9V Lithium batteries are to be used as the energy source for the pacemakers. (Ultralife Lithium Cell, 9volt; Part No 9VL-FP).
• In case there is a fault with the pacemaker during a battery change a spare pacemaker should be available and set to the patients existing settings. This pacemaker should have had its battery checked prior to insertion.
• The spare battery to be inserted should have its charge checked prior to insertion into the pacemaker using the Battery Tester (model mw333).
• A defibrillator must be accessible
• Resuscitation drugs to be available
• ECG, and pulse oximetry must be continuously monitored.
• To replace a battery:
• For an elective change the spare battery should be rechecked to ensure that it still has adequate charge before insertion, if not it should not be used and an alternative appropriately charged battery should be sourced and inserted. The back light should be off (occurs 60 seconds after a change of settings) and the lower screen should be inactive prior to a battery change.(1)
• Make sure that the pacemaker is locked o Press the button at the lower end of the pacemaker to open draw
• Insert battery (make sure the polarities are correct and that any protective cap has been removed from the battery)
• Close the battery drawer making sure it clicks into position.
• If the process takes too long the pacemaker will turn off. On turning on again it will default to factory “adult” settings. Reset to patient settings. (2)
• Do not press any buttons during the 4 second self test period which starts after the pacemaker is turned on. (3)
• If the self test fails again then the pacemaker should be removed from service and forwarded to bioengineering with a “Medical Device Fault Report Label” attached, and cardiac physiology must be informed.
• If the patient’s condition deteriorates due to a time delay in reestablishing the patient settings on the existing pacemaker then connect the patient connecting leads to the standby pacemaker which has been set to patient settings.
• After the battery is replaced, ensure that another appropriately charged battery is attached as the spare.

(1) The backlight should not illuminate when the battery warning light is on. The Medtronic 5388 Technical Manual states that you have 15 seconds to change a battery. This is at RATE ≤ 70, A output and V output ≤ 10mA, back light off and lower screen off. Bench testing performed by G Dobson at Rate 150, A and V output 20mA illustrated that this decreased to 13 seconds. If the battery is removed while the backlight is on or the lower screen is active, the device may shut down immediately depending upon the battery level. The back light will go off when the pacemaker is locked or 60 seconds after the last adjustment. The upper screen parameters do not lock, and the lower screen does not blank until five minutes after the last adjustment or rapid atrial pacing delivery.

(2) If there is a problem with the self test on turning on again then immediately change the patient leads onto the spare pacemaker. Don’t press a button during the self test, this will produce an error code which can only be resolved by taking the battery out and putting it back again, increasing the time during which the patient is not being paced.

(3) When the pacemaker is turned on it does a self test which takes about 4 seconds. Pressing a key while the selftest is in process can cause the Model 5388 to fail the self-test, and display error code, “0004.” The device may interpret the pressed key as being “stuck” and, therefore, malfunctioning. If a key is pressed during the self-test, remove and re-insert the battery to clear the error code.

• Elective termination of pacing is to be discussed on the morning ward round.
• The pacemaker should not be disconnected until the patient has been in sinus rhythm at a rate capable of sustaining an adequate cardiac output for 48 hours.
• There should be a formal assessment of the patients underlying rhythm prior to termination of pacing and a rhythm strip should be obtained and placed in the patients notes.
• Pacing wires should remain in situ for at least 24 hours after termination of pacing, unless there is a significant contraindication such as entry site infection, or sepsis potentially related to retaining wires.

• Pacing wires should be removed after day 3 if no criteria remain for pacing wires to remain in situ (including ongoing pacing requirement, haemodynamic instability that could require pacing)
• Pacing wires should not be removed within 24 hours of disconnecting the pacemaker unless there is a significant contraindication such as entry site infection, or sepsis potentially related to retaining wires.
• A cardiac surgeon should be informed that wire removal is occurring.
• The decision to remove pacing wires should be made on the morning ward round.
• A rhythm strip should be obtained prior to wire removal, to confirm that the patient remains in a rhythm that does not require ongoing pacing. This rhythm strip should be placed in the patients notes. If there are any concerns regarding the patient’s rhythm then these should be discussed with the consultant cardiologist prior to wire removal.
• Wires should not be removed after 16.00 hours during the week and not at weekends unless a surgeon is informed.
• A group and save specimen from the patient should have been sent to the blood bank prior to wire removal.
  (Fresh O-ve blood is always available in theatres, cardiology cath lab and blood bank)
• Platelet count and coagulation profile should be reviewed and where necessary acted on prior to wire removal.
• Platelets should be ≥ 80 ( ≥100 for high risk patients). The coagulation profile should be normal.
• Heparin should be stopped for 2 hours prior to wire removal, and a coagulation screen performed to confirm normal values before the wires are taken out. (In patients on treatment as opposed to prophylactic heparinisation this period may have to be shorter).
• Recommence Heparin 1 hour after wire removal, but do not administer a bolus.
• If a mediastinal drain is in situ at the time of intended wire removal then it should stay there until 1 hour after the wires are removed.
• Appropriately trained staff should remove pacing wires one at a time by the application of gentle traction.
• If the pacing wires do not remove easily then a cardiac surgeon should be informed. The decision should be made to either cut the wires at the skin or to have further attempts at wire removal.
• If wires are retained then a clinical incident form should be completed and the parents/guardians, patients cardiologist and surgeon should be informed. Retention of pacing wires should be entered on CIS.
• In the event of suspected tamponade an echo must be ordered urgently, and the consultant Intensivists and surgeon informed.
• Signs suggestive of tamponade
• Elevated CVP, LA
• Elevated HR
• Decreased BP
• Decreased peripheral pulses
• Decreased oxygen saturation
• If tamponade is suspected then 2 units of blood should be cross matched.
• Patients should have continuous HR ECG monitoring during wire removal and for 4 hours afterwards.
• Removal of pacing wires does not preclude discharge of patients from critical care to the cardiology ward, but mandates informing staff on the receiving ward that wires have been removed.
• It is not necessary to perform an echocardiogram routinely after wire removal.
• The cardiology ward staff are to be notified if wires remain in situ at time of discharge.

The following conditions should generate a discussion between cardiology, cardiac surgery and intensive care consultants, for consideration of wire replacement, alternative pacing. The outcome of the discussion should be entered on CIS

• Output threshold levels >1/2 maximal output
• Daily increment in output threshold , decrement in sensitivity threshold
• Failure to capture/pace not remedied by adjusting pacemaker settings

(1) NB: Oesophageal pacing is only suitable for atrial pacing.

• Only Lithium batteries (9VL –FP) are to be used for pacemakers. These are to be stored separately from Alkaline Manganese batteries.
• Batteries should be stored in a common location with the Uniross battery tester, Pacemaker, Pacemaker connecting leads (and temporary myocardial wires in PICU and Theatres).
• Battery testers to be stored in the same location as the batteries and pacemakers in Cardiology and PICU, and the temporary myocardial wires in theatres.
• 2 Battery Testers in cardiology , 1 in thetatres, 2 in PICU. (Glen Dobson, bioengineer will keep a spare in his room)
• On PICU the battery tester, batteries, pacemaker and pacemaker connection cables, are to be stored in the clean utility (drugs room).
• Atrial and Ventricular adhesive identification labels to be kept in theatres and PICU
• Spare pacing equipment will be located in other areas:
• 5A: 1 Pacemaker, 1 blue and 1 white connection lead
• Cath Lab: 1 Pacemaker 1 blue and 1 white connection lead
• Cardiac Theatres: 2 Pacemaker 4 blue and 4 white connection leads
• Cardiology: 1 Pacemakers 2 blue and 2 white leads.
• PICU: all other available stock.
• If connection leads or pacing boxes are used from these other areas then the PICU must be in formed in order to replace them.

• The senior nurse for the unit must be informed of the intent to do an AEG
• The bedside nurse must be in attendance and informed of the intent to do an AEG
• AEG’s are to be performed by appropriately trained staff. A laminate indicating the convention for wire studies is attached to the ECG machine on PICU.
• Staffing levels should be such that immediate resuscitation could be provided if necessary.
• The AEG should be performed according to the standard convention for the unit
• Patient should have continuous ECG and pulse oximetry.

• The Medtronic pacemaker is incompatible with MRI
• The bipolar pacing wires are incompatible with MRI. (Theoretically MRI could induce a current in a pacing wire and precipitate an arrhythmia, the wire will heat up, the wire can dislodge due to the magnetic field).
• If the patient has pacing wires but is not dependant on pacing and there are no other contraindications to an MRI scan then a discussion must take place between radiology staff and cardiac surgery, cardiology and intensive care staff as to whether the scan needs doing. If so and there are no other contraindications then the pacing wires should be removed.

The manufacturers recommend disconnecting the pacemaker from the lead system before cardioversion /defibrillation where possible. If cardioversion is deemed necessary then place the paddles as far away from the pacemaker and leads as possible. (manufacturers manual recommends that paddles be placed at least 15 cm away from the Model 5388 or the lead system.)

• If the patient has pacing wires but they are not attached to the pacing box
• The pacemaker should be attached to the patient leads and be accessible to the anaesthetist/intensivist during such procedures
• The connecting leads should be connected to the myocardial wires o The patient connecting leads should be accessible
• Prior to such procedures the thresholds and sensitivities should be checked.
• If the battery needs changing it should be changed before the procedure.
• The spare battery charge should be checked before a procedure, and if necessary the spare battery should be changed for one with suitable charge.
• If the patient is being paced then the patient connecting leads and pacemaker should be easily accessible. The spare battery charge should be checked before a procedure, and if necessary the spare battery should be changed for one with suitable charge.
• A spare pacemaker set to the patients current settings should be available
• The pacemaker does not need to be set to an asynchronous mode during diathermy.
• If new pacing wires are placed then they should have thresholds etc formally assessed by cardiac physiology staff unless the patient has just commenced pacing, in which case 24 hours should elapse prior to testing
• Details on new wires should be entered on CIS

• Rapid atrial pacing should only be performed after discussion with the duty cardiology consultant.
• Other than under exceptional circumstances RAP should only be performed by consultant cardiology staff, consultant cardiac surgery or cardiac electrophysiology staff.
• Emergency drugs and defibrillator to be available (RAP may result in tachycardia, acceleration of existing tachycardia, or fibrillation.)
• Patient to have continuous ECG and pulse oximetry
• If invasive arterial line is unavailable then set non-invasive BP to “stat” (remember to rest timings of NIBP at end of procedure)
• Ensure wires are connected to the atrium and not the ventricle

This tester may be used to test 12 different types of batteries including the 9V Lithium battery that we intend to use. The tester is powered by a 1.5 Volt (AAA) battery.

1. The battery is tested by placing the battery terminals of battery under test against the two silver studs (top right hand corner) of the tester. The LCD display will then display black vertical lines along the horizontal axis with the legends “Poor” , “Weak” and “Good” annotated along its length. The “Poor” range is positioned at the extreme left of the horizontal axis and “Good” at the extreme right hand of the axis. A weak battery will normally display 1-5 black vertical lines and a Good battery 11-18 black vertical lines.
2. Only batteries displaying within the “Good” range should be used. Batteries displaying outwith this range MUST be rejected.