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Pacing wires, chest drain, LA and PA Line removal

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Sedation / pain relief

  • Neonates (< 3 months old) to have oral sucrose (link to sucrose analgesia guideline)
  • Infants may have Paracetamol +/- Morphine. 
  • Children may benefit from Midazolam (0.5 mg/kg, no more than 15 mg) plus above. 
  • Involve play therapist during procedure; for anxious children, play-therapists can help by discussing procedure with the child beforehand

LA/PA line, pacing wire and direct central line removal

LA/PA lines and pacing wires

  • Aim for early removal at 0830 - 0900hrs. Preparation and decisions regarding removal done the day before (ECG, blood work, IV access - see Table 1 below).
  • Lines and wires NOT routinely removed after 1PM, unless specified otherwise by the surgeon. This ensures presence of surgeon if complications arise. 
  • Most LA/PA lines are removed in PICU. 
  • Pacing wires are removed day 3 - 5 post-op if the child is clinically stable. Unless specified otherwise by the surgeon.
  • If LA/PA lines are left in, should be removed at same time as wires.
  • Lines or pacing wires left in longer than 5 days are a risk factor for sternotomy infection. 
  • When LA/PA lines and wires are removed there is a small risk of bleeding or of tamponade. Pulmonary hypertensive crises can also be precipitated by removal. Small infants are most at risk. These serious events will usually occur in the first hour after removal but occasionally slow blood loss can occur over a few hours.


Table 1: LA / PA line and pacing wire removal

  Withdrawal 
day
IV line 
needed prior 
Group & Hold
required 
Weekend withdrawal 
<4kg or < 6 weeks old  4 or 5  Yes  Yes  Not permitted unless discussed with surgeon prior 
4-10kg   3 - 4  No Yes  Yes 
Greater than 10kg 3 No  No Yes 

Direct Central Lines

Central line that is direct to the right atrium or left atrium. These lines are rare and usually only required in a small infant with poor IV access. Removal is usually done 5 days post operation. These lines carry the highest risk of bleeding because they are widest in calibre

  • One surgeon must be on site and not in theatre when these are removed. 
  • Monitored in IOA or in PICU post removal for 2 hours 
  • Group and Hold mandatory 
  • IV access is preferable if infant < 4kg, or ≤ 28 days of age (but is not always achievable).

Prior to removal

  1. Check post-operative bloods: 
    1. Platelet count >100 and PR < than 1.8 
    2. If platelet count is under 100, repeat FBC on day 2 or 3. Discuss with surgeon if platelets remain low after day 4.
  2. Patients on Warfarin: ensure INR < 3.0
  3. Patients on Heparin: ensure heparin infusion off for 30 minutes prior to removal. 
    1. Where heparin infusion needs to be restarted again (e.g. infant ≤ 5 kg with CVL to remain insitu) ensure heparin infusion is off for a minimum of 2 hours after removal of LA/PA lines or pacing wires 
  4. Record baseline observations
  5. Ensure Group & Hold is available if < 10 kg (see table 1). 
    1. If < 4 months age the initial crossmatch will be valid.
    2. If > 4 months needs a new group and hold sent. 
  6. 12 lead ECG done and checked by medical team. If not in sinus rhythm confirm with cardiologist prior to removal of pacing wires.
  7. IV access if ≤ 4kg or ≤ 28 days age

Removal

  1. Cut stitch
  2. Remove LA /PA lines first then pacing wires (both ventricular and atrial wires together)
  3. Calm infant / child as quickly as possible afterward e.g. feed / cuddle. Easier to monitor changes when quiet or sleeping.

Following removal

  1.  Keep patient in the same place for 2 hours following removal (i.e. do not move child from PICU to 23b during this time).
  2. Cardiac monitoring: 30 minute observations for 2 hours (pulse, BP, oximetry, capillary refill time, level of consciousness).
  3. Remove IV access 4 hours after removal of lines/wires if clinically stable and no change in baseline parameters.
  4. Notify medical staff if cardiac condition changes (e.g.≥ 10 % change in usual parameters)
  5. No Post-wires echocardiogram needed unless clinical concerns or baseline parameters change by >10%. 
  6. PLEASE don't forget the post-op echo prior to discharge, suggest book for post-op day 5
  7. Chest X-Ray (portable) only if pleural effusion is suspected (sometimes the blood drains directly to the pleural cavity).

Signs of bleeding or tamponade

  1. Tachycardia
  2. Tachypnoea, dyspnoea and respiratory distress.
  3. Pallor
  4. Cooling or mottling of peripheries
  5. Restlessness or agitation
  6. Prominence of neck veins and liver enlargement (late signs).

In the event of patient deterioration

  1. Call CODE as per usual criteria. 
  2. Call the on-call Cardiologist and on-call Surgeon
  3. Order RBC from Blood Bank (ext 24014)
  4. Obtain IV access / check IV access is still patent (intraosseous access may be needed)
  5. Give volume - 10mls/kg 0.9% Normal saline or Plasmalyte 
  6. Prepare for rapid transfer to PICU
  7. Urgent echocardiogram once transferred to PICU in consultation with on-call cardiologist. Don't delay transfer from Ward 23B for echocardiogram. 
  8. A decision to open the chest in PICU is made based on clinical status.

Chest drain removal

  • Decision is made on morning round (drainage < 5ml/kg/day and no bubbling). Chest drains may be removed in afternoon, follow-up CXR done and reviewed before 5 pm.
  • Chest drain removal is more painful than wires/ line removal and requires more analgesia (see procedural pain guideline )
  • Involve play therapist during procedure; for anxious children, play-therapists can help by discussing procedure with the child beforehand
  • IV lines & Group and Hold are not necessary, coagulation does not need to be checked prior

Procedure for removal

It is a two person procedure:

  1. Have dressing pad and airtight dressing ready
  2. Remove tape
  3. Cut holding stitch and get purse string stitch ready to tie down.
  4. If child old enough get them to hold their breath (i.e. take in a big breath and hold - then pull drain)
  5. First person pulls drain out with steady pull (time removal for when child is breathing out)
  6. Second person uses finger or gauze pad to press onto the drain site or pinch drain site as drain comes out.
  7. First person puts drain down and then picks up purse string stitch and ties it. Second person is to keep finger or gauze over insertion site until the purse string stitch is tied.
  8. First person puts airtight dressing over tied drain site. If edges of wound gape use the tegaderm or opsite (clear / transparent dressing) to approximate the edges.
  9. Post removal
    1. Listen for air entry especially L) and R) apices.
    2. Ensure CXR done within 2 hours of removal.
    3. Can go to X-ray department depending on patient status.
    4. Monitor status for 1 hour post removal (pulse, BP, oximetry, capillary refill time, level of consciousness especially where altered level of consciousness following Analgesia/Sedation)
    5. Any change ≥ 10% from baseline recordings warrants a review by the medical team.

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Document Control

  • Date last published: 11 March 2019
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Cardiology
  • Owner: Kirsten Finucane
  • Editor: Marion Hamer
  • Review frequency: 2 years