Pacemaker/ICD Implant Procedure Note (Pediatric)

Procedure Date: [Date; start time - stop time] (If unavailable, write "Not documented")

Location: [EP lab / OR / hybrid room] (If unavailable, write "Not documented")

Primary Operator: [Name, credentials] (If unavailable, write "Not documented")

Assistant(s): [Name(s) and role(s)] (If unavailable, write "Not documented")

Anesthesia: [Type; airway] (If unavailable, write "Not documented")

Patient Age: [Age] (If unavailable, write "Not documented")

Weight: [kg] (If unavailable, write "Not documented")

BSA: [m²] (Include if used for device selection; otherwise write "Not applicable" or "Not documented")

Clinical Context: [inpatient / outpatient]; [urgent / elective] (If unavailable, write "Not documented")

Procedure(s) Performed

• [Device class and configuration: pacemaker / ICD / CRT-P / CRT-D / subcutaneous ICD; single / dual / biventricular chamber]
• [Approach: transvenous / epicardial / mixed]
• [Pocket site and laterality: left / right; pre-pectoral / subpectoral / abdominal / preperitoneal]
• [Procedure type: new implant / generator change / lead revision / lead addition / system upgrade]

Indication / Pre-procedure Diagnosis

[Rhythm diagnosis or condition prompting implant, symptom or risk context, and relevant pediatric anatomic or congenital heart disease considerations affecting approach] (2–5 sentences. For ICDs, document that shared decision-making occurred or that emergent circumstances limited discussion. If indication documented elsewhere, state "See [source] for details.")

Consent and Universal Protocol

• [Informed consent obtained from parent/guardian] (Note interpreter use if applicable; if on separate form, state "Consent on file")
• [Patient assent] (Include when appropriate by age)
• [Pre-procedure verification and time-out completed confirming correct patient, procedure, and site]
• [Exception process documentation] (Only include if emergent and usual consent could not be obtained; document reason)

Antibiotics / Infection Prevention

• [Pre-incision antibiotic(s): name, route, dose, timing relative to incision] (Include re-dosing if applicable; if not given, document reason)
• [Pocket adjuncts: antibacterial envelope / irrigation solution with product name] (Only include if used)

Procedure Details

Access and Preparation

[Patient positioning and sterile preparation]

[Transvenous: venous access site(s), method, and imaging guidance] (Only include if transvenous approach used)

[Epicardial: surgical approach and exposure] (Only include if epicardial approach used)

[Relevant anatomic/CHD constraints and workarounds] (Document vascular anomalies, shunts, conduits, prior surgeries as applicable)

Pocket Creation

[Pocket location: laterality and plane] [Hemostasis technique] [Drain placement] (If nonstandard location chosen due to patient size or growth considerations, state rationale)

Lead Implantation

[Brief narrative of lead placement and fixation for each lead, including venous or epicardial pathway and confirmation of stability. Explicitly document whether slack was left for growth and where it was positioned. If any lead was abandoned or capped, document details.]

Lead #	Chamber/Target	Manufacturer/Model/Serial	Fixation Type	Final Position	Slack for Growth
[1]	[RA / RV / LV / His-bundle / LBB area / epicardial atrial / epicardial ventricular / S-ICD]	[Manufacturer / Model / Serial] (Or "See implant log")	[active / passive / epicardial screw-in / suture-on]	[Final anatomic position]	[Yes – location of loop / No]
[2]	[Chamber/Target]	[Manufacturer / Model / Serial]	[Fixation type]	[Position]	[Slack details]
[3]	[Chamber/Target]	[Manufacturer / Model / Serial]	[Fixation type]	[Position]	[Slack details]

(Add or remove rows as needed)

Generator Implantation

[Generator manufacturer, model, serial number, and orientation in pocket] (If serial recorded elsewhere, write "See implant log")

[Generator tie-down and pocket hemostasis]

System MRI Status: [MRI-conditional / Non-conditional / Mixed components] (State explicitly; critical for pediatric patients especially with epicardial leads)

Intraoperative Testing

Lead #	Capture Threshold (V @ ms)	Sensing Amplitude (mV)	Impedance (Ω)	Phrenic Stimulation
[1]	[Value]	[Value]	[Value]	[Present / Absent / Not tested]
[2]	[Value]	[Value]	[Value]	[Present / Absent / Not tested]

(If any thresholds could not be obtained, document reason)

ICD High-Voltage Impedance: [Ω] (Include for ICD or CRT-D systems)

Defibrillation Testing (DFT): [DFT performed / DFT not performed] (If performed: document arrhythmia induced, energy delivered, success, number of shocks, and complications. If not performed: document rationale)

Final Programming

• Pacemaker settings: [Mode; lower rate; upper tracking/sensor rates; output settings; AV/VV delays; safety margin approach] (May reference full programming report)
• ICD settings: [Brady mode and lower rate; detection zones with rate criteria; ATP schemes; shock therapies with max energy] (May reference full programming report)

Closure

[Layered closure technique and materials] [Dressing type] [Immobilization if ordered] [Sponge/needle/instrument counts]

EBL, Specimens, Complications

Estimated Blood Loss (EBL): [Numeric mL] (Always state; use "0 mL" if none)

Specimens: [None / List specimens sent] (Always state)

Complications: [No complications / Describe event, timing, and management] (Always state)

Post-procedure Status

• [Patient condition: stable / unstable; extubated / intubated]
• [Destination: PACU / ICU / ward]
• [Immediate orders: device interrogation timing, chest X-ray, echocardiogram if indicated, telemetry plan, anticoagulation plan]

Follow-up Plan

• [Wound check timing]
• [Device clinic interrogation timing]
• [EP/cardiology follow-up appointment]
• [Remote monitoring: enrolled and equipment provided / enrollment to be arranged]
• [Caregiver education provided to: parent / guardian / patient]
• [If system non-MRI-conditional: family advised to consult EP/cardiology before any MRI]
• [If patient remains inpatient: discharge planning deferred to inpatient team]

Implants / Explants

• Implanted Components:
  • [Component type]: [Manufacturer / Model / Serial / UDI] (Or "See implant log")
  • [Additional component]: [Details]
• Explanted Components: (Include if applicable)
  • [Component type and identifier]: [Reason for removal] – [Disposition]

Operator Attestation

[Operator name, credentials]

[Date/Time]