Temporary pacing (2)

Technique (for endocardial electrode placement)

1 If using fluoroscopy, move patient to X-ray suite or place lead shields around bed area. Place patient on ‘screening table’. Staff should wear lead aprons.

2 Use aseptic technique throughout. Insert 6Fr sheath in internal jugular or subclavian vein. Suture in position.

3 Connect pacing wire electrodes to pacing box (black = negative polarity = distal, red = positive polarity = proximal). Set pacemaker

to demand. Check box is working and battery charge adequate. Turn pacing rate to 30bpm above patient’s intrinsic rhythm. Set voltage to 4V.

4 Insert pacing wire through sheath into central vein. If using balloon catheter, insert to 15–20cm depth, then inflate balloon. Advance catheter, viewing ECG monitor for change in ECG morphology and capture of pacing rate. If using screening, direct wire toward the apex of the right ventricle. Approximate insertion depth from a neck vein is 35–40cm.

5 If pacing impulses not captured, (deflate balloon), withdraw wire to 15cm insertion depth, then repeat step 4.

6 Once pacing captured, decrease voltage by decrements to determine threshold at which pacing is no longer captured. Ideal position determined by a threshold ≤0.6V. If not achieved, re-position wire.

7 If possible, ask patient to cough to check that wire does not dislodge.

8 Set voltage at three times threshold and desired heart rate on ‘demand’ mode. Tape wire securely to patient to prevent dislodgement.

Technique (for external pacing)

1 Connect pacing wire gelled electrodes to pacemaker. Place black (= negative polarity) electrode on the anterior chest wall to the left of the lower sternum and red (= positive polarity) electrode to the corresponding position on the posterior hemithorax.

2 Connect ECG electrodes from ECG monitor to external pacemaker and another set of electrodes from pacemaker to patient

3 Set pacemaker to demand. Turn pacing rate to 30bpm above patient’s intrinsic rhythm. Set current to 70mA.

4 Start pacing. Increase current (by 5mA increments) until pacing rate captured on monitor.

5 If pacing rate not captured at current of 120–130mA, resite electrodes and repeat steps 3–4.

6 Once pacing captured, set current at 5–10mA above threshold.