Temporary Cardiac Transvenous Pacing

1. Temporary Cardiac Transvenous Pacing Presented by: JonnaBobeck BSN, RN, CEN

2. Introduction • Restore cardiac depolarization and myocardial contraction • Usually considered after less invasive treatment have been exhausted • Establish central venous access • Introduce the electrode through the venous system into the right ventricle

3. Indications • Heart block • Sinus node dysfunction • Dysrhythmias complicating acute MI • Long QT syndrome with ventricular dysrhythmias, • Chronotropic incompetence in the setting of cardiogenic shock. • Bradyarrhythmias of atrial fibrillation with slow ventricular response or malignant ventricular escape rhythms, • Drug induced bradycardias, • Ventricular standstill /cardiac arrest, • Permanent pacemaker failure.

4. Equipment • Temporary pulse generator • Connecting cables. • Pacing catheter • Introducer • Cardiac monitor with defibrillator and external pacer capacity • Local anesthetic • 3mL syringe with 31-25g needle • Normal Saline 10mL for injection, • Heparin 10u/ml. • 10mL syringe with needless adaptor. • Sterile 4 X 4’s • Sterile towels, drapes, gloves, masks, caps • Scrub solution • Crash cart with emergency supplies. • Possibly fluoroscopy. • Possibly 12 lead EKG equipment during insertion.

5. Procedure • Notify radiology of procedure • Explain procedure to patient (if possible). • Obtain informed consent (if possible). • Review patient’s lab work, insure physician is notified of abnormal electrolytes. Ensure that potassium and magnesium levels are with in normal limits. • Gather necessary equipment, • Ensure IV access two sites preferably.

6. Procedure • Notify Imaging Services to be alert for possibility of fluoroscopic guidance. Inform Respiratory Care Services for EKG on call for procedure. • Perform battery check of generator. • Attach the connecting cable to the pulse generator. • Clip hair of insertion site if needed, prep site with appropriate antiseptic. • Assist with insertion of percutaneous sheath introducer kit (or cutdown tray if brachial site is being utilized). • Use rubber gloves when handling exposed terminal wires

7. Assisting physician: 3 Standard Methods • Emergency blind placement • Urgent placement using EKG monitoring • Fluoroscopic insertion

8. Procedure Post Insertion • Connect wire to generator • Program per physician order • Assist physician with suturing wire to the skin • Secure generator to IV pole • Place sterile dressing over insertion site • Obtain chest X-ray

9. Basic Pacing • Demand (synchronous) mode • Asynchronous mode • Determine pacing mode • Sensitivity • Demand between 0.5 and 20 mV • Asynchronous turn the sensitivity fully counterclockwise to ASYNC • Pacing parameters • Rate • Output • sensitivity

10. Determining Sensing Potentials • To ensure the pacer will sense in the Demand mode • Set the rate • Set the output • Set the sensitivity • Slowly decrease the sensitivity • Slowly increase the sensitivity • The millivolt at which the pacer resumes sensing is the “threshold” • Set the sensitivity twice as sensitive as the threshold • Turn the RATE and OUTPUT to their original values

11. Determine Stimulation Threshold • Verify 1:1 capture by slowly increasing the RATE then gradually decrease the output • Slowly increase the output until 1:1 capture is regained • The value of where the recapture is regained is the stimulation threshold • Set the OUTPUT to a value that is at least twice the threshold value • Reset the Rate

12. Precautions/Troubleshooting • R wave sensing • EXTREME care must be taken to ensure all electrical equipment near patient is grounded • lead fracture may lead to loss of capture or sensing • During insertion myocardial irritability could lead to fibrillation • Perforation and tamponade may occur at time of implant • Additional risks

13. Documentation • Education • Baseline Ekg • Pre insertion assessment • Insertion site • Medications • Patient tolerance • Pacer rate, threshold, mA setting, mode of pacing • Dressing • Post insertion assessment • Catheter insertion in centimeters

15. Key Points • Do not manipulate the pacer wire • For loss of capture: • Have patient cough • Place patient supine • Increase sensitivity • Assess insertion site • Monitor electrolytes • Maintain strict caution against current leakage to protect the patient from electrical shock.

16. Key Points • Extracardiac electrical signals • Reassess threshold • Have transcutaneous pacing always available • Pace light and sensing indicator light • External generators can be damaged by defibrillation • Do not touch patient, electronic equipment and pacing system simultaneously • Symptomatic bradycarida • Electrolyte abnormalities

17. General Information: Terms • Sensing • Capture • Milliamperes • Threshold • Demand pacing • Asynchronous pacing

18. General Information: Controls • Output • Rate • Sensitivity • On/Off control

19. Evaluation • Pacer sensing and capturing appropriately. Patient demonstrates adequate tissue perfusion and cardiac output with mean arterial pressure of >60, alert and is oriented, no dizziness, shortness of breath, nausea or vomiting, or chest pain.

20. References • Medtronic. (2003). Medtronic technical manual. In Minneapolis, MN: Medtronic Inc. Retrieved from http://manuals.medtronic.com/wcm/groups/mdtcom_sg/@emanuals/@era/@crdm/documents/documents /198137001_cont_20080311.pdf • Pullman Regional Hospital. (2012). Temporary cardiac transvenous pacing protocol Retrieved from \\prhs5\groups\Policies and Procedures\Patient Care