Transvenous Pacing

DOCUMENTATION

EQUIPMENT

  • Transvenous pacer kit
  • Pacemaker generator w/ battery
  • ECG machine/cardiac monitor
  • Ultrasound machine w/ sterile cover
  • Sterile Drape
  • Sterile Gloves
  • Sterile Gown
  • Faceshield

PROCEDURE

  • Place central venous access (Right IJ and left subclavian are preferred access routes as they have the straightest route to the heart, however left subclavian many times used for permanent pacemaker so try to stay away from)
  • Confirm correct central line placement
  • Connect negative pacemaker lead to EKG V1 lead
  • Ensure that catheter balloon is working
  • Inflate balloon to 0.75ml after enters superior vena cava (approximately 10-12cm in), lock inflation port, leave syringe attached
  • Advance pacing catheter quickly and smoothly
  • When catheter tip is above the atrium, both P and QRS waves will be negative (downward deflection)
  • When tip enters the atrium, large P waves will be seen (often larger than corresponding QRS) and P waves will start first to be isometric and then positive as continue to advance
  • As the catheter passes through the tricuspid valve, P waves become smaller and QRS complex becomes larger

If it goes too far (into IVC, QRS and P waves amplitude decreases, into pulmonary artery, P wave turns negative again and QRS complex becomes smaller)

  • When in desired position, should see ST elevations
  • Deflate balloon (do not draw back on syringe, let is deflate by self else can rupture balloon) and advance 1-2 CM more to seat in endocardium
  • Set rate to 80 or 10 higher than intrinsic ventricular heart rate(easy rule of thumb, everything in the middle, adjust sensitivity and threshold as needed, i.e. keep lowest setting while still having capture)
  • Check for capture (pacer spike followed by QRS complex), also check for mechanical capture (palpable pulse with pacer spikes and QRS complexes)

PROCEDURE NOTE

Date:

Indication: Therapeutic placement of transvenous pacemaker for symptomatic bradycardia

Resident:

Attending:

Consent was obtained and a time-out was completed verifying correct patient, procedure, site, and positioning. The patient’s right(?)left neck was prepped and draped in sterile fashion. 1% Lidocaine was(?)was not used to anesthetize the surrounding skin area. Ultrasound was(?)was not used to identify Internal Jugular (Subclavian Vein). A needle was used to access the vein. A guide wire was threaded over this and a Cordis was placed with proper technique. A Chest x-ray (or Ultrasound) was used to confirm proper line placement. A transvenous pacemaker was floated and placed into the right ventricle with capture. The patient tolerated the procedure well and there were no complications. Blood loss was minimal.