Techniques of Programmed Stimulation and Entrainment Periprocedural Care

Updated: Jan 27, 2015
  • Author: Ethan Levine, DO; Chief Editor: Jeffrey N Rottman, MD  more...
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Periprocedural Care

Patient Education & Consent

Patients should be familiarized with the procedure and the possible complications, including those related to sedation given for the procedure.

Patient Instructions

Patients should be made aware of the requirement for bedrest after the procedure is performed when vascular access is required, Written home care instructions should be provided to the patient, as well.

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Equipment

The equipment required for these techniques differs depending on the particular issue being investigated. In 2003, the North American Society of Pacing and Electrophysiology (NASPE), now known as the Heart Rhythm Society (HRS), provided a position statement addressing this issue. [9]

As a rule, because of the potential to induce hemodynamically unstable arrhythmias, resuscitation equipment must be readily available. In addition, when performed invasively, a recording system and electroanatomical mapping system are typically used, as is a fluoroscopic imaging system. As with any procedure that involves sedation, supplemental oxygen, wall suction, and equipment to monitor heart rate, blood pressure, and oximetry are mandatory.

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Patient Preparation

Patients should be kept on NPO status for the procedure.

Anesthesia

As a rule, these procedures are safely performed with conscious sedation. Agents such as midazolam and fentanyl are commonly used for sedation, with adjunctive lidocaine for local anesthesia; 1% lidocaine is preferred, as it has been demonstrated that with higher concentrations and overly liberal infiltration, patients can achieve blood lidocaine levels high enough to alter the electrophysiologic properties of the heart. [10]

In some cases, general anesthesia or deep sedation may be preferred. When the expected procedural time is extensive, the rhythm being investigated is hemodynamically unstable, or the patient is unable to lie still, deeper levels of sedation make for a safer procedure. For small children and younger adolescents, general anesthesia is preferable.

When using deeper levels of sedation, the addition of beta agonists such as isoproterenol may be required to counteract the sympatholysis induced from deep sedation. Mechanical support, such as intra-aortic balloon pumps, may also be required in these cases.

Positioning

In most cases, these procedures are performed in an electrophysiology laboratory under fluoroscopic guidance with the patient in a supine position. Positioning is typically with the arms at the sides to allow for free movement of the imaging camera. When these techniques are performed via an existing pacemaker or implanted defibrillator, the patient is typically supine on a stretcher or bed, although, because no venous sheathes are involved, they may be in a reclining rather than supine position. In all cases, it is imperative that the positioning is such that loss of consciousness will not result in injury.

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Monitoring & Follow-up

In the immediate postprocedural period, frequent monitoring of vital signs is mandatory. Typically, vital signs postprocedure are assessed every 15 minutes for the first hour and then every 30 minutes for the subsequent hour. With each assessment of the vital signs, the vascular access sites are checked for signs of bleeding, hematoma, or other vascular complications.

Patients who undergo a diagnostic electrophysiologic study without ablation or insertion of a cardiac rhythm management device afterward are typically discharged to home the same day after 4-6 hours of observation. When an ablation is performed or a device other than a loop recorder is inserted after an electrophysiologic study, the standard of care in most of the United States is overnight observation in a telemetry ward.

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