Temporary Transvenous Cardiac Pacing

Reviewed and revised 20 August 2014

OVERVIEW

  • emergency pacing via an intravenous device

USES

  • life-threatening or unstable bradyarrhythmia

DESCRIPTION

3 types of pacing equipment:

(1) semi-rigid, bipolar pacing lead (under II guidance)
(2) paceport PA catheter
(3) balloon flotation leads (ECG or pressure guided)

METHOD OF INSERTION AND/OR USE

  • supine and head down
  • U/S guided or landmarks (apex of sternomastoid sternal and clavicular heads)
  • insert sheath

(1) Flotation Catheter – can be inserted by ECG guidance as follows:

  • connect pacing wire to pacing box (black to negative, red to positive)
  • set to demand
  • check box and batteries are OK
  • turn rate to 30 bpm greater than intrinsic rate
  • set output to 4mA
  • insert wire to 15-20cm
  • inflate balloon
  • advance observing ECG for changes in ECG morphology and capture of pacing rate (if using II direct wire to RV apex)
  • approximate depth 35-40cm
  • once pacing captured deflate balloon and decrease mA to find threshold and double.
  • get patient to cough to check that wire doesn’t dislodge.
  • tape wire securely so it doesn’t move

(2) Semi-rigid wire

  • insert under II guidance until leads up against right ventricular wall
  • connect to control box
  • set output and sense to minimum and to an appropriate rate
  • gradually increase output until capture takes place (ideal capture @ 2mA)

(3) Paceport on PA

  • insert PAC
  • attach pressure transducer to RV port to ensure in RV
  • attach adaptor to TV port and insert probe to the reference mark
  • attach ECG monitoring and advance until ST elevation indicates contact with epicardium
  • secure and connect side port to a saline flush
  • commence pacing

OTHER INFORMATION

  • dress to ensure wires are not exposed
  • suture
  • perform CXR

COMPLICATIONS

  • arrhythmia
  • microshock
  • CVL insertion complications
  • myocardial perforation
  • infection

VIDEO

Al Sachetti on transvenous pacing
Chris Davis on transvenous pacing
Jason Nomura on emergent pacing

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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