What is the proper procedure for using a temporary external pacemaker (temporary transvenous pacing)

From the Guidelines

Temporary transvenous pacing should be used only as a last resort when chronotropic drugs are insufficient, and the treatment time should be as brief as possible. This approach is based on the most recent and highest quality study available, which emphasizes the potential complications associated with temporary pacing, including those related to the implantation procedure, securing the position of the implanted lead, and patient-related factors such as accidental extraction of the pacing lead 1.

Key Considerations for Temporary Transvenous Pacing

• The decision to use temporary transvenous pacing should be guided by specific clinical scenarios, such as high-degree AV block without escape rhythm or life-threatening bradyarrhythmias, as outlined in the 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy 1.
• Positive chronotropic drug infusion (e.g., isoproterenol, epinephrine) may be preferred for a limited time unless there is a contraindication, highlighting the importance of considering alternative treatments before resorting to temporary pacing.
• The procedure requires proficient central venous cannulation and manual dexterity for stable positioning of the catheter, underscoring the need for trained healthcare professionals to perform the procedure 1.

Setup and Monitoring

• Connect the pulse generator to the patient via pacing electrodes, which may be transvenous, epicardial, or transcutaneous.
• Set the pacing rate typically between 60-80 beats per minute, adjusting based on the patient's condition.
• Determine the appropriate pacing mode (VVI for ventricular pacing or DDD for dual-chamber pacing) according to the patient's specific cardiac needs.
• Establish the minimum output threshold and monitor the patient continuously for proper capture and potential complications.

Complications and Follow-Up

• Be aware of potential complications, including pacing system dysfunction, failure to capture or sense the R wave properly, and patient-related complications such as infection or thrombo-embolic events 1.
• Regular follow-up is crucial to avoid complications and determine suitability for implantation of a permanent pacemaker, emphasizing the ongoing responsibility of the physician who performs the procedure 1.

From the Research

Indications for Temporary External Pacemaker

• Temporary external pacemakers are indicated for severe bradydysrhythmia, especially when prompt intervention is required 2
• They are also used in critical care units for severe bradycardia or electrical storm 3
• Other indications include high-grade atrio-ventricular (AV) block, sinus arrest, overdrive suppression of VT, and pause-dependent VT 4
• Temporary cardiac pacing is utilized in acute situations and for critically ill patient populations requiring immediate therapy 5

Procedure and Management

• Implantation of a temporary pacemaker should be maintained for the shortest time possible to avoid potential complications 2
• The use of an active-fixation lead connected to an externalized pacemaker represents a valuable option to increase safety and patient comfort 3
• Externalized prolonged temporary pacing (EPTP) using active-fixation lead and an externalized pulse generator may be an alternative for transient pacing indications or concurrent illness that precludes permanent pacing 4
• Temporary transvenous pacing is traditionally an emergency procedure to stabilize patients suffering from hemodynamically unstable bradyarrhythmia 6

Complications and Safety

• Temporary pacemakers may be associated with serious adverse events such as infection, cardiac perforation, and lead dislodgment 2
• The use of prolonged temporary cardiac pacing may be associated with frequent and potentially severe complications, especially when indwelling for several days 3
• EPTP is a safe and useful method of prolonged temporary pacing for patients who require chronotropic support, but in whom immediate permanent pacemaker implantation is contraindicated 4
• Critical considerations in the management of patients being treated with a temporary pacemaker include assessment and management strategies to minimize complications 5