What we set up and why
EP cases are long, instrument-heavy, and involve direct intravascular access — usually multiple sheaths in both groins, sometimes a subclavian or jugular. The sterile setup has to protect against infection while staying organized enough that we can find the right catheter on the right side at the right moment in a 4-hour case.
The goal is a field that’s clean, organized, and predictable — so the operator’s hands know where things are without looking.
Prep
Patient prep
- Both groins, chest to mid-thigh, even if we only plan one side — backup access happens
- Chlorhexidine-alcohol per institutional protocol, allowed to dry fully before drape
- Hair clipped (not shaved) at the access sites if needed
- Foley placed before prep for long cases
- Defib pads, mapping reference patches, and ECG leads on before the sterile drape goes down — moving them later means breaking the field
Team prep
- Scrub roles: operator, first assistant, scrub tech
- Gown and double-glove standard
- Lead under the gown
- Eye protection — splash shields or glasses
Draping
- Standard EP angio drape with bilateral groin fenestrations and an upper-body drape extending to the head
- Anesthesia divider attached so anesthesia stays sterile-side-out at the head
- Drape edges clipped or tucked so they stay put when the C-arm moves
- Light handles draped if they’ll be touched
- Cable covers for ICE, ablation, and mapping cables routed under the drape and out the foot of bed
Sterile corridor
Once the drape is down, we operate with a defined sterile zone:
- From the operator’s hands to the back table to the mayo
- No one walks between the table and the mayo
- The rep, mapping tech, and circulator stay outside that lane
- If someone needs to cross, they go behind the operator, not in front
Catheter and equipment layout
Think left-to-right in the order we use them:
- Mayo stand: active catheters (mapping, ablation, ICE), connected and flushed
- Back table: sheaths, dilators, guidewires, transseptal needle and sheath system, spare catheters, suture
- Foot table: RF/cryo generator cables, irrigation tubing, ICE controller hand piece
Catheters out of their packaging go in the same place every time — your hands shouldn’t have to search.
Flushes and labels
- Every basin and syringe labeled
- Heparinized saline for sheath flushes per institutional concentration
- RF irrigation primed and the flow zeroed at the generator before insertion
- ICE catheter pre-flushed and checked
- Contrast in a clearly labeled syringe, separate from saline
Common omissions to catch on the pre-case timeout
These are the small misses that cause big problems downstream:
- Reference patches not yet on the patient — adds a sterile break to fix
- Defib pads not connected to the defibrillator (on the patient but not plugged in)
- ICE catheter not on the field when it’s a transseptal case
- Transseptal kit not opened or wrong sheath length
- RF irrigation bag not spiked, or set to wrong flow at start
- Saline bags warmed if planned, available if not
- Antibiotic for device cases not yet given
- Heparin drawn up and labeled
Sterile discipline during the case
- Counts — needle, sharp, and sponge counts at start and end
- Sharps stay on the operator’s side — no transverse passes over the patient
- One break, one call — if you see a contamination, you say so out loud. Don’t hope nobody noticed
- Long cases get re-gloved every 2 hours or any time the operator’s gloves contact anything questionable
- Door discipline — every door open is an air exchange that breaks our pressure differential. Plan supply trips, don’t run them
- Talk volume — for awake or moderately sedated patients, the room voice level is calm and low
End of case
- Sheaths pulled per the access plan (manual pressure, figure-of-eight, or closure device)
- All catheters accounted for in the count
- Cables disconnected before we move the patient
- Drapes removed with attention to the access site — don’t yank dressings off
- Specimens (if any from ICE or biopsy) labeled before leaving the room