View source for Transvenous pacing

==Indications==
*Failure of transcutaneous pacing and chronotropes
**Sinus Arrest/[[Bradycardia]]
**[[AV Block]] - 3rd or 2nd degree
**Digoxin toxicity
**Overdrive pacing (e.g., in [[Torsades de Pointes]] AFTER return to sinus rhythm to prevent degeneration of rhythm)

==Contraindications==
*Asystolic cardiac arrest
*[[Hypothermia]]bradydysrhythmias

==Procedure==
#Site selection: Right IJ or left subclavian for most smooth anatomical course
#Equipment: 
#*External generator: Shows rate (bpm), output (mA) and sensitivity
#*Cordis Kit (7 Fr): Gold strip on kit at Harbor. Contains cordis introducer sheath, TV pacer catheter and pacer wire sheath
#**Sheath size (internal diameter) should match pacer wire size (external diameter). Otherwise you will get leakage!
#Similar to a central line, place single lumen catheter under ultrasound guidance.
#Pacing catheter
#*Test small balloon for leaks prior to insertion with 1.5mL of air while balloon rests in a container of saline
#*Connect the positive and negative electrodes to the external generator
#*Advance the catheter through the introducer sheath and into cordis hub to roughly 20 cm (catheter has marked bars indicating 10cm)
#External generator: Set HR 80 (or 10 - 20 bpm above patient's native rate), start at max current output (usually 20 mA), and sensitivity all the way down (paces no matter intrinsic rate)
#*Pearl - Digital generators have "emergency" button that goes to automatic settings
#Advancing Pacing Catheter: Inflate balloon and advance slowly.
#*Blind approach: Monitor shows pacer spikes followed by a widened QRS (LBBB appearance)
#*Ultrasound approach: Have assistant give a subcostal/parasternal long axis, which gives visualization image of when electrode contacts final resting position
#*Sensing approach: Use alligator clip to connect negative pacer electrode to any precordial lead. Look for ST elevation when RV endocardium engaged.
#*Fluoroscopy: If time permits, use this method in a patient that has prior pacemaker/ICD. Placement of TV pacer with out fluoro can disrupt prior electrode placements.
#Final resting position is when pacer wire is in RV apex
#*Take note of pacer wire depth in case it is accidentally moved
#*If you overshot your mark (ie IVC/Pulm artery), deflate balloon and pull back. DO NOT PULL INFLATED BALLOON BACKWARD THROUGH A VALVE.
#*Pearl - IVC pacing leads to coughing/hiccuping and ventilator alarms (ie high frequency)
#Deflate balloon (leave syringe attached) and secure catheter in place
#*Lock sheath onto cordis hub and then fully extend it & curl around while holding pacer wire in place. Sheath gives sterile amount of wire for any future adjustments if needed. 
#*Additional sutures can be placed to stabilize it
#Final Settings
#*Output: Determine threshold level by reducing electrical current settings until capture lost. Final current set to twice the threshold level for pt
#*Sensitivity: Adjust level (not too high or too low) so it allows intrinsic beats (unless you are overdrive pacing), but supplements it if needed. You do not want oversensing or undersensing.
#Placement confirmation
#*Good to obtain baseline CXR, which should show the catheter tip over the inferior border of the cardiac shadow
#*[[ECG]] shows paced QRS exhibiting a LBBB morphology, and a superior QRS axis

==Complications==
*Related to central venous access
**Infection, pneumothorax, air embolism, arterial puncture and venous thrombosis
*Related to pacing catheter:
**Valvular tear(s)/rupture(s)
**Myocardial Peforation (atria/ventricle/septum) - consider tamponade
*Ventricular Arrhythmias: VT or VF

==Links==
*University of Cincinnati
**[http://tamingthesru.com/transvenous-pacemaker-placement-part-1-the-walkthrough/ Part 1: Walkthrough]
**[https://tamingthesru.com/transvenous-pacemaker-part-2-a-procedural-slide-set/ Part 2: Procedural Slide Set]
**[https://tamingthesru.com/transvenous-pacemaker-insertion-part-3/ Part 3: Video]
*[http://www.youtube.com/watch?v=5BiQQYjw6no Drexel Video]
*[http://www.youtube.com/watch?v=chTwY6rpCIk Practical Pointers]
*[https://derangedphysiology.com/main/required-reading/cardiothoracic-intensive-care/Chapter%209.1.1/indications-contraindications-and-complications-temporary-pacing Deranged Physiology: Indications, contraindications and complications of temporary pacing]

==See Also==
*[[ACLS: Bradycardia]]
*[[Transcutaneous pacing]]

==References==
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[[Category:Cardiology]]
[[Category:Procedures]]
[[Category:Critical Care]]