Transvenous pacing: Difference between revisions
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#Site selection: Right IJ or left subclavian for most smooth anatomical course | #Site selection: Right IJ or left subclavian for most smooth anatomical course | ||
#Equipment: | #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. | #Similar to a central line, place single lumen catheter under ultrasound guidance. | ||
#Pacing catheter | #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, start at max current output (usually 20 mA), and sensitivity all the way down (paces no matter intrinsic rate) | #External generator: Set HR 80, 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 | #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 w/o fluoro can disrupt prior electrode placements. | ||
#Final resting position is when pacer wire is in RV apex | #Final resting position is when pacer wire is in RV apex | ||
# | #*Take note of pacer wire depth in case it's accidentally moved | ||
# | #*If you overshot your mark (ie IVC/Pulm artery), deflate balloon and pull back. YOU DO NOT WANT TO PULL INFLATED BALLOON 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 | #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 | #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, but supplements it if needed. You do not want oversensing or undersensing. | ||
#Placement confirmation | #Placement confirmation | ||
# | #*Good to obtain baseline CXR, which should show the catheter tip over the inferior border of the cardiac shadow | ||
# | #*EKG shows paced QRS exhibiting a LBBB morphology, and a superior QRS axis | ||
==Complications== | ==Complications== | ||
Revision as of 21:38, 22 February 2016
Indications
- Faiure of transcutaneous pacing + chronotropes
- Sinus Arrest/Bradycardia
- AV Block - 3rd or 2nd degree. May occur from MI, bacterial endocarditis, or Lyme dz
- Drug OD - Digoxin toxicity
- Overdrive pacing
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, 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 w/o 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's accidentally moved
- If you overshot your mark (ie IVC/Pulm artery), deflate balloon and pull back. YOU DO NOT WANT TO PULL INFLATED BALLOON 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, 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
- EKG shows paced QRS exhibiting a LBBB morphology, and a superior QRS axis
Complications
- Related to central venous access
- Infection, PTX, 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
- Drexel Video
- Practical Pointers