- Failure of transcutaneous pacing + chronotropes
- Asystolic cardiac arrest
- Site selection: Right IJ or left subclavian for most smooth anatomical course
- 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
- 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
- University of Cincinnati
- Drexel Video
- Practical Pointers