1. Temporary Transvenous pacemaker insertion
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2. Temporary Transvenous Pacing
Contacts and Ownership
Preparation
Equipment Checklist
Quick Reference
Patient and Family Education
Management Protocol
Assessment
Procedure
Patient Monitoring
References

3. Individuals to contact for questions regarding Temporary Transvenous Pacemaker Insertion
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Donna Reeves (CICU) Owner
CICU supervisor on duty
Cardiac Cath Lab (07:00 – 17:00)
Cardiac Fellow on call,
contact Hospital operator

4. Steps to prepare for Temporary Transvenous Pacing
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During hours 07:00 – 17:00
Attending Physician notification by Resident
During hours 17:00 – 07:00
Attending physician notification by Resident
Contact Cardiac Fellow on call to obtain supplies from Cath Lab, CICU may have their own supplies.

5. Bedside placement of Temporay Transvenous Pacemaker check list.
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Verify need for emergent bedside vs cath lab procedure of Temporary Transvenous Pacemaker.
Resident to notify Attending Physician
Pt must be in an ICU or ER setting with continuous ECG monitoring.
Informed consent obtained by Physician
Time-out procedure
Discuss Educational Material ( may be given to pt and family)
Properly trained individuals notified and assembled
          1.  Primary service resident
          2.  Cardiology fellow  (Call Hospital operator at and ask to have Cardiology fellow paged
          3.  Procedure Nurse (gather equipment) and (prep patient)
          4. Radiology Tech if Fluoro is needed at
          5. Ultrasound Tech if ultrasound is used  at or        

6. Patient Preparation 1. Connect patient to 5-lead monitoring system
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1. Connect patient to 5-lead monitoring system
or 12-lead ECG machine.
Facilitates the placement of balloon-tipped catheter by indicating position of catheter during placement.
Allows for monitoring of patient’s cardiac rhythm during procedure.
2. Begin patient/family teaching if not already done.
Time-out procedure
4. Ensure pain medication or sedation is
administered
May not be possible if hemodynamically unstable
Return to checklist

7. Equipment Checklist Supplies assembled
      1. Balloon-tipped pacing catheter (Located in CICU utility room or cath lab)       
2. Generic procedure insertion tray
        3.  Chlorahexidine-based solution
         4. Pulse generator (Located  in CICU)            
5.  9-volt battery
      6. Local anesthetic
7. Sterile drapes, towels, masks, goggles or
face shields, gowns and gloves     
Return to  placement

8. 10. Introducer sheath with dilator (steri sleeve - if don't use kit)
           
8.   Connecting cable (Located in CICU, or Cath Lab)
9.  Percutaneous introducer needle comes in percutaneous sheath introducer set or can do individually
10.  Introducer sheath with dilator (steri sleeve - if don't use kit) 
     11.  Guide wire
        12.  Alligator clips or wire with connecting pins
(Located in CICU or Cath Lab)
         13.  Suture with needle 2.0 silk, syringes, needles
          14.  ECG monitor and recorder
         15.  Dressing supplies
           16.  Pain Medication / Sedation if ordered

9. Additional Equipment that may be needed
Emergency equipment (Crash Cart)
Fluoroscopy
Lead aprons or sheets
12-lead ECG machine
Transcutaneous ultrasound
Place a new battery in the pulse generator
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10. Quick Reference Guide for Nurses
Main Menu
Once temporary pacemaker inserted
check its threshold parameters and assure proper functioning
Mode of pacing set on:
Demand
Pacemaker senses heart’s impluses, paces when patient needs it.
Asynchronous (Red button)
Pacemaker fires at fixed rate.
Return

11. Quick Reference Guide Set rate as prescribed.
Set the stimulation threshold
Set the sensitivity after determining the sensitivity threshold
Pt should be transferred to an Adult ICU if not already there.
Chart all of the above procedure and initiate the Temporary Transvenous pacemaker management protocol

12. Quick Reference Guide
Once temporary pacemaker is inserted, insert new battery into generator box

13. Quick Reference Guide Turn pacer on Select mode of pacing. Demand or
asynchronous
Return

14. Quick Reference Guide Adjust rate Adjust Atrial Adjust Ventricular
Output (mA) Output (mA)

15. Quick Reference Guide for Nurses
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Quick Reference Guide for Nurses
Once setting are made and no need for changes, push key button to lock settings.

16. Quick Reference Guide Achieving Capture
mA = voltage delivered to myocardium.
Threshold = lowest amount of mA needed for capture.
Successful capture is “spike” followed by P wave (atrial pacing) or by R wave (ventricular pacing)

17. Quick Reference Guide Stimulation Threshold Set in demand mode
Set rate 10 bpm above patient’s rate.
or as high as needed to see 100% capture.
(spike with each beat)
Slowly turn down mA until 1:1 capture is lost
(EKG will show spikes without complexes following)
Slowly turn up mA until capture is regained.

18. Quick Reference Guide
Sensing = ability of pacemaker to detect the heart’s own electrical activity and deliver paced beats only when needed.
Set the rate 10 beats below patient’s inherent rate
Contraindicated if patient has no intrinsic rate or symptomatic bradycardia
Reduce mA to lowest level (threshold)
Turn sensitivity dial counterclockwise toward higher numerical setting (Sensing light, which flashes when sensing, will stop.) Pacemaker is now less sensitive to patient’s heartbeat.

19. Quick Reference Guide
Turn sensitivity dial clockwise until the sensing light starts flashing again. Sensitivity threshold.
Set the sensitivity,(mV = millivolts) at half the sensitivity threshold value obtained. (If sensitivity threshold is 4 you set dial on 2 mV
Restore mA and rate to proper settings.

20. Quick Reference Guide Troubleshooting
Check stimulation and sensitivity thresholds done daily if in demand mode.
Failure to pace: No pacer spikes shown on ECG or telemetry strip
Check batteries and replace if necessary (change every 2 – 3 days)
Check to make sure all connections are tight
If still no spikes, pacer may be oversensing
Lower mV on sensitivity dial

21. Quick Reference Guide
Oversensing may be caused by electromechanical interference such as electric devices or muscle movement and artifact
Undersensing : can be dangerous
Pacer fails to sense the patient’s intrinsic beats
Pacer spikes fire indiscriminately throughout cardiac cycle, can trigger lethal dysrhythmia if spike falls on T-wave.
Lower pacemaker’s sensitivity to the heart by turning up the dial to higher mV

22. Educational Material Temporary Transvenous Pacemaker
Main Menu
Normal heartbeats begin in the top right chamber of the heart. A cluster of heart cells start an electrical signal that travels through both of the upper chambers of the heart. This signal is delayed in cells called the AV node while the top chamber squeezes blood to the bottom chambers. The signal then goes to both lower chambers causing them to squeeze and pump blood to the body through the arteries. As the blood moves out of the heart into the arteries, you can feel it as a pulse in your wrist. Return

23. Educational Material
Normally the heart speeds up and slows down all the time as your activity changes. You need a faster heart beat when you are exercising to pump the blood faster through your body. When you are resting or sleeping, your heart rate slows. Unusually slow heartbeats can cause symptoms of weakness, shortness of breath, dizziness or even blackouts. Some of the time, a very slow heart beat is temporary. It may be caused from a side effect of a drug, blockage in one of the arteries of the heart or from another cause. A temporary pacemaker may be necessary to treat slow heart rates. A pacemaker is often the only way to get a steady, reliable heart rhythm.

24. Educational Material
When a patient develops a slow heart beat, sometimes a temporary pacemaker may be necessary until the cause is identified. For the patients who are too unstable to go to the cath lab and transvenous pacing is chosen, the procedure is done at the bedside with a local anesthetic and sedation. An xray after the procedure is usually obtained to confirm placement of the pacing electrode.
Main Menu
Pacer Catheter
Electical
Conduction Pathway
Right Atrium
Right ventricle

25. Educational Material
How long should you expect the temporary pacemaker to remain in place?
Temporary pacemakers are usually only left in place until the patient stabilizes enough by correcting the cause of the slow heartbeat or until they can be taken to the cath lab to have a permanent pacemaker placed.

26. Transvenous Pacemaker Management Protocol
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Return to Protocols

27. Transvenous Pacemaker Management Protocol

28. Transvenous Pacemaker Management Protocol
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Transvenous Pacemaker Management Protocol

29. Equipment for insertion
Generic procedure insertion tray
Chlorahexidine-based solution
9-volt battery
Local anesthetic, pain medication/sedation
Sterile drapes, towels, masks, goggles or face shields, gowns, gloves.
Suture with needle, syringes, needles
Dressing supplies
Guidewire

30. Equipment for insertion
Main Menu
Balloon-tipped
pacing catheter
(Located in CICU or
cath lab
Return

31. Equipment for insertion
Pulse generator
(Located in CICU, ICU or
Cath Lab)
Return

32. Equipment for insertion
Connecting cable
(Located in CICU
or Cath Lab)
Blue is ATRIAL
White is VENTRICULAR
Percutaneous
introducer needle
Introducer sheath with
dilator Return

33. Equipment
Blue is Atrial and is plugged into atrial port.

34. Equipment
White is ventricular and is plugged into ventricular port.

35. Equipment for Insertion
Alligator clips or wire with connecting pins
(Located in CICU or Cath Lab)
ECG monitor and
recorder
Return

36. Additional Equipment that may be needed
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Additional Equipment that may be needed
Emergency equipment
1.Crash cart
2. Intubation box
3. Drug box
Fluoroscopy
Lead aprons or sheets
12-lead ECG machine
Transcutaneous Ultasound

37. Assessment Assess patient’s cardiac rhythm
Determines need for invasive cardiac pacing.
Assess patient’s hemodynamic response to dysrhythmia.
Assessment determines the urgency of procedure.
Review current medications
Medications may be the cause of dysrhythmia
Antidysrhythmics may alter the pacing threshold.

38. Assessment
Review patient’s current laboratory studies including chemistry, electrolyte profile, arterial blood gasses, coagulation profile, platelet count and cardioactive medication levels.
Determines if inserting pacemaker was precipitated by metabolic disturbances or medication toxicity .

39. Assessment Assess presence and position of central venous access
Temporary transvenous pacing catheter is advanced through central venous circulation.
If access already established, must ensure proper placement before pacing catheter advanced through circulatory system.

40. Assessment Pre-procedure teaching to patient and family.
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Pre-procedure teaching to patient and family.
Obtain informed consent
In an emergency may not have time to obtain.

41. Procedure
Connect patient to bedside monitoring system and monitor ECG continuously.
Monitors intrinsic heart rate and rhythm to evaluate adequate rate and pacemaker function.
Assess pacemaker functioning and insert new battery into generator.
Attach connecting cable to pulse generator
Connect “positive” cable to “positive “ on generator and “negative” cable to “negative” on generator.

42. Procedure
Check placement of central venous access by x-ray before starting procedure.
Time-out procedure
Prepare insertion site by clipping hair close to skin in area surrounding insertion site.
All personnel performing and assisting procedure should don masks, caps, goggles, sterile gowns and gloves.
Gloves should be worn whenever the pacing electrodes are handled to prevent microshock.

43. Procedure Cleanse site with Chlorhexidine-based preparation
Drape site with sterile drapes
Administer local anesthetic to numb insertion site.
Make percutaneous puncture through vein selected for procedure (jugular, subclavian, antecubital or femoral)
Insert balloon-tipped catheter through introducer and advance pacing lead.

44. Procedure
Inflate balloon when tip of pacing lead is in vena cava. Transcutaneous ultrasound or Fluoroscopy of chest during insertion procedure may assist in obtaining proper position.
Advance pacing lead.
Verify transvenous pacing lead placement by:
Use V lead of bedside monitor system
Connect patient to limb leads
Use an alligator clip or wire with connector pins.

45. Procedure Advance pacing lead
Verify transvenous pacing lead placement by:
Use V lead of bedside monitor or 12-lead ECG
Connect patient to limb leads
Use alligator clip or wire with connector pins
Attach V lead of ECG to negative electrode connector pin of pacing lead wire
Set monitor system to record V lead continuously
Observe ECG for ST-segment elevation in V lead
Observe for left bundle-branch block pattern and left axis deviation.

46. Procedure
After electrodes properly positioned, deflate balloon and connect external electrode pins to pulse generator via connecting cable.
Positive and negative to respective terminals on generator.
Set pacemaker settings and initiate pacing.
See Quick Reference Guide for Nurses
Physician orders desired rate
Suture pacing lead in place to minimize risk of dislodgement.
Apply sterile, occlusive dressing over site.
Return

47. Procedure Obtain chest x-ray.
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Secure necessary equipment (hang generator on IV pole, strap to patient torso or hang from carrying device)
Obtain chest x-ray.
Pt needs to remain minimally active especially if lead is placed in extremity to avoid dislodgement of lead.

48. Patient Monitoring
Monitor vital signs and hemodynamic response to pacing as patient condition warrants.
Cardiac output should increase due to increasing heart rate or by overriding life-threatening dysrhythmias
Evaluate ECG for presence of paced rhythm or resolution of initiating dyshythmia.

49. Patient Monitoring Monitor patient’s comfort.
Administer analgesic or sedative as needed.
Evaluate response to interventions
Check and document sensitivity and threshold at least every 24 hours.
Threshold should be checked by physician in high-risk patients.
Ensures proper pacemaker functioning.
Prevents unnecessarily high levels of energy delivery to myocardium.

50. Patient Monitoring Change dressing according to policy
Use gloves to prevent microshock
Cleanse with Chlorhexidine-based preparation.
Apply dry, sterile dressing
Record date of dressing change
Monitor for other complications
Embolus
Thrombosis
Perforation of myocardium
Pneumothorax
Hemothorax
Phlebitis

51. Patient Monitioring Monitor electrolytes
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Monitor electrolytes
Imbalances may precipitate dysrhythmias
Ensure all connections are secure
For proper sensing, impulse conduction, and to minimize risk of microshock conduction to heart.
For questions or comments, please contact;
Donna Reeves RN (CICU)
or CICU supervisor/core

52. SOURCES Diepenbrock, N. H. (2004). Quick reference to critical
care (2nd ed.), (pp. 119 – 125). Philadelphia: Lippincott Williams & Wilkins.
Breuninger, C., Follin, S., et al. (Eds.). (2001).
Handbook of nursing procedures (pp. 603 – 604).
Springhouse, PA: Springhouse Corporation.
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