Transvenous Pacing
Usually inserted in an emergency, a temporary pacemaker consists of an external, battery-powered pulse generator and a lead or electrode system. The purpose of a transvenous pacemaker is to maintain circulatory integrity by providing for standby pacing should sudden complete heart block ensue, to increase the heart rate during periods of symptomatic bradycardia and, occasionally, to control sustained supraventricular or ventricular tachycardia.
In addition to being more comfortable for the patient, a transvenous pacemaker is more reliable than a transcutaneous pacemaker. Transvenous pacing involves threading an electrode catheter through a vein into the patient’s right atrium or right ventricle. Veins used for insertion include the subclavian, brachial, internal jugular, and femoral.1 The femoral site should be used as a last resort because it’s associated with an increased risk of infection. The electrode then attaches to an external pulse generator. As a result, the pulse generator can provide an electrical stimulus directly to the endocardium.
Indications for transvenous pacing include management of symptomatic bradycardia, tachyarrhythmias, and other conduction system disturbances; it may also help diagnose conduction abnormalities.
According to the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, pacing isn’t recommended in cardiac arrest.2
Equipment
Temporary pacemaker generator with new battery ▪ guide wire or introducer ▪ electrode catheter ▪ gloves ▪ sterile gloves ▪ sterile dressings ▪ adhesive tape ▪ antiseptic solution (preferably a chlorhexidine-based solution) ▪ nonconducting tape or rubber surgical glove ▪ pouch for external pulse generator ▪ emergency cardiac drugs ▪ intubation equipment ▪ defibrillator ▪ cardiac monitor with strip-chart recorder ▪ equipment to start a peripheral IV line, if appropriate ▪ IV fluids ▪ sedative ▪ bridging cable ▪ percutaneous introducer tray or venous cutdown tray ▪ sterile gowns ▪ mask, head cover, and goggles or face shield ▪ linen-saver pad ▪ antimicrobial soap ▪ alcohol pads ▪ vial of 1% lidocaine ▪ 5-mL syringe ▪ fluoroscopy equipment, if necessary ▪ fenestrated drape ▪ sutures ▪ dextrose 5% in water ▪ Optional: elastic bandage or gauze strips, restraints, clippers.
Implementation
Gather the appropriate equipment.
Make sure that informed consent has been obtained and that it’s documented in the patient’s medical record.3,4
Conduct a preprocedure verification to make sure that all relevant documentation, related information, and equipment are available and correctly identified to the patient’s identifiers.5
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.9
If applicable, explain the procedure to the patient.
Check the patient’s history for hypersensitivity to local anesthetics. Then attach the cardiac monitor to the patient and obtain a baseline assessment, including the patient’s vital signs, skin color, level of consciousness (LOC), heart rate and rhythm, and emotional state. Next, if ordered, insert a peripheral IV catheter (see “IV catheter insertion and removal,” page 421) and initiate the ordered IV infusion at the ordered rate.
Insert a new battery into the external pacemaker generator, and test it to make sure it has a strong charge. Connect the bridging cable to the generator, and align the positive and negative poles. This cable allows slack between the electrode catheter and the generator, reducing the risk of accidental catheter displacement.
Place the patient in the supine position. If necessary, clip the hair around the insertion site.
Open the supply tray while maintaining a sterile field. Label all medications, medication containers, and other solutions on and off the sterile field.10
If assisting with the insertion, put on a mask, head cover, goggles or face shield, sterile gown, and sterile gloves.11,12
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