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JGM DBS / BNS Replacements (chest)

Last modified by XWikiGuest on 2024/10/09 03:50

DBS / VNS Battery Replacements

Supplies

Ask for all of the following to be in room to speed up the case. 

For each battery incision:

  1. 10 cc bupivicaine
  2. silk stitch tie x 1 
  3. Ancef irrigation large bulb x 3 
  4. Vanc powder
  5. poly 3-0s or 2-0s x 1 
  6. biosyn x 1 (subQ closure) 
  7. Skin glue x 1 
  8. Telfa x 1 
  9. Tegaderm medium x 1 

Prep

  1. Chloroprep x 1 over incision
  2. inject 
  3. Chloroprep x 1 over incision again
  4. Drape 

Operation

1. Score skin with knife 

2. Bovie down to the device. Do not hurt the leads! Theoretically they should be under the device if the last person did it correctly, but be careful around the corners.  

3. Remove the device from scarred pocket. If you're fighting it, need to bovie more around the corners.

4. Get a clean raytek and gently wipe the lead tips. Ask for mineral oil and gently rub over leads. Suction out any blood from lead holes on the device. 

5. Insert leads into new device, tighten until you hear clicks x 2.  

6. Consider expanding your pocket on the corners at this point with the device out of the pocket. 

7. Insert device into pocket

8. Test impedance with the device rep.  

9. Ancef irrigation x 3. Do not insert the tip of bulb into the wound and be aggressive, that actually can introduce bacteria. Just irrigate over open wound directly. Try not to use suction directly over wound at this point. 

10. Dump vanc powder into wound. 

11. Use an empty bulb to spread the powder.  

12. Use a clean raytek to clean out the surrounding skin. 

13. Use 3-0 polys to close scarred pocket layer with buried stitches if possible (note this is not possible in a new pocket since there is no scarred tissue - in that case you just do deep dermals and skin) 

14. If needed (the patient is fat), bring together dead space with horizontal U stitches

15. Close deep dermal layer 

16. Close subQ layer with a single biosyn stitch 

17. Wet/dry. Do not be sloppy with the drying, it will make your tegaderm fall out and your skin glue useless. 

18. Place light layer of skin glue over whole wound.  

19. Place telfa over wound AFTER glue dries. You don't want it to stick then tear off the glue layer when patient removes it. 

19. Drapes down

20. Double check everything is dry. 

21. Place tegaderm over a dried area. 

Error

2 ways these simple cases can become a disaster

1. You use a bovie after implanting the new device. This can destroy the device. If you're going to expand your pocket, do not do it with the device in there. If absolutely needed, indirectly bovie by making contact with an instrument.

2. You destroy the leads with sharp instruments / electrocautery. You can also bend them by being too aggressive with pulling out the device from the scarred pocket. You should not be struggling to pull it out, if you are you have either not released the prior silk stitch or you need to extend your incision. 

Discharge Instructions

1. Prescriptions:

  • 24 hours of Keflex: 500 q12 hours x 2  
  • Zofran x 3 days
  • 500 APAP for 1 week
  • silver sulfadiazene 

3. Wound instructions

  • Can run water over the tegaderm/telfa on post-op day 1
  • Take telfa/tegaderm off on post-op day 3
  • Gently shower over wound  

 

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