HOSPITAL NAME Department:

INSTITUTIONAL POLICY AND PROCEDURE (IPP) Manual:

Section:

TITLE/DESCRIPTION

POLICY NUMBER

TRANSVENOUS PACEMAKER INSERTION EFFECTIVE DATE

APPROVED BY

REVIEW DUE

REPLACES NUMBER

NO. OF PAGES

APPLIES TO

PURPOSE

To provide guidance for nurses assisting during the insertion of a transvenous pacemaker. DEFINITION

Transvenous pacemaker- this is an emergency procedure where the pacer wire is inserted via a large vein (eg subclavian) and threaded to the ventricle for stimulating the heart via electrical current and control the rate RESPONSIBILITY CROSS REFERENCES POLICY

Policy and Procedure for Transvenous Pacemaker Insertion PROCEDURE

ACTION 1. Check that patient has a patent IV, and that the defibrillator, emergency cart and appropriate medications are available. 2. Counsel patient and family and allow for ventilation and questions; obtain consent (time permitting) 3. Wash and dry insertion site; clip hair if necessary. 4. Obtain vital signs and ECG rhythm strip prior to insertion. Connect to 12 lead EKG and continuously monitor before, during and after. 5.Prepare according to central line insertion checklist. 6. Prep selected site IAW central line insertion checklist 7. Anesthetize the area locally 8.Prepare the external temporary generator: a. Insert new battery b. Turn the mA to 6 c. Turn rate control to ten beats above the patient’s rate. JCI Standards

RATIONALE 1. This is an emergency procedure. Venous access, emergent equipment and drugs have a high probability of use. 2. Time is needed for coping ; relieves anxiety; promotes cooperation. 3. Prepare site for dressing. 4. established baseline parameters. This will assist in monitoring for changes and complications. 5. Infection Control Manual 6.Reduce risk of infection. 7.Reduce pain from insertion. 8. The rate set above the patient’s rate will suppress the patient’s natural pacemaker.

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d. Turn sensitivity dial fully clockwise. 9. Connect the alligator clamp, one end to the VI EKG lead and the other to the distal or negative electrode wire of the pacemaker catheter. 10. Monitor patient while physician inserts pacing electrode.

9.This electrode serves as an exploratory intracavitary lead and resulting EKG waveform helps to ascertain electrode position. The EKG pattern is distinctive when the pacing electrode is in the vena cava, right atrium and right ventricle.

Confirming Position : The following EKG findings indicate electrode position: Location * Vena Cava * Right Atrium * Coronary Sinus * Right Ventricular * ( Out Flow Tract) * Right Ventricular

Lead V1: * Small Inverted p * Tall biphasic * Positive QRS with rabbit ears * Negative QRS

Lead II, III, AVF: * Same * Same * Positive or negative QRS * Left Axis pattern of injury (elevated ST)

* LBBB, Negative QRS

Porta Chest Note: Insertion of pacemaker during a cardiac arrest (asystole) requires connecting the pacing wire to the generator and setting the stimulation threshold to maximum or 20 Ma, and an arbitrary rate of 70 bpm. The electrode is then advanced blindly while one scans the EKG for evidence of ventricular capture. Post Insertion Procedure: ACTION 1. After contact between pacing electrode and the ventricular endocardium is established, assist the physician in connecting to pacemaker generator. Set according to physician’s orders.

Established a baseline. The output dial regulates the amount of electric current (mA) that is delivered to the myocardium to initiate depolarization. Ventricular pacing (stimulation threshold) should be established at less than 1 mA output whenever possible. The maintenance threshold is set at 1.5 to 2 times above the stimulation threshold to allow for increases in stimulation threshold without loss of ventricular capture.

Obtain a 12 Lead EKG For all Methods of Temporary Pacing A. Determine the stimulation threshold: a. Set pacing rate above patient’s intrinsic rate. JCI Standards

RATIONALE 1.The physician sets the parameters; must generate a written order for its use.

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b. Gradually decrease output (mA) from 20 mA until capture is lost. c. Gradually increase output (mA) until capture is established. This is the stimulation threshold. d. Set output (mA) at least 1.5 to 2 times higher than the stimulation threshold. This output setting is sometimes referred to as the maintenance threshold. B. Determine the sensitivity threshold: a. Set rate at least 10 beats per minute below patient’s intrinsic heart rate. Set sensitivity control to most sensitive setting (fully demand or lowest numerical setting). Sensing indicator light should flash with each intrinsic R wave. C. Set the pacemaker rate, output (mA) ,and sensitivity (demand or asynchronous), as prescribed or as determined by threshold testing. D. Assess rhythm for appropriate pacemaker function: a. Capture : is there a QRS complex for every ventricular pacing artifact? b. Rate: is the rate at or above the pacemaker if in the demand mode? c. Sensing: does the sensitivity light indicate every QRS complex is sensed?

Sensitivity threshold is the level at which intrinsic ventricular activity is recognized by sensing electrodes. For demand pacing, the sensitivity must be measure and set. Sensitivity threshold is set at maximum and is lowered only if pacer is sensing inappropriately. If set too high, it will result in sensing P or T as an R wave; if set too low, it results in asynchronous pacing (nonsensing).

Determined by patient’s response. A-V interval (similar to intrinsic PR interval) should be set for optional ventricular filling usually between 150 to 250 ms. ECG tracing should reflect appropriate response to pacemaker is functioning properly.

2. Ensure the pacing wire is secured as it exists the introducer; check all connections as well as battery and control settings at least q. 4 hrs. and document.

2. Prevent migration of wires; these connects are easily disconnected and may result in cardiac arrest. Protects setting from being inadvertently being altered.

3. Maintain site care per Infection Control Manual SOP on central lines.

3.This is a central line with potential for sepsis.

4. Keep the pulse generator dry and the controls protected from mishandling.

4. Moisture will cause pacemaker malfunction; improperly set controls can cause irritability resulting in dysrhythmias and cardiac arrest.

JCI Standards

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5. Protect the patient from electromicroshock and electromagnetic interference (EMI): a. Cover exposed wires with gloves or tape. b. Enclose pulse generator in rubber glove. c. Wear rubber when handling exposed wires. d. Avoid any nurse – patient contact with electrical apparatus. e. Check for ungrounded electrical equipment. f. Keep dressing over wires dry and intact when not in

5. Electromicroshock and EMI can cause the pulse generator to fail.

6. Monitor patient for complications. Restrict patient mobility depending on insertion site.

6. All invasive procedures have a percentage of complications that can be prevented by an astute nurse. 7. Proper documentation assists in the care of the patient and early recognition and prevention of complications.

7. Document location, type of pacing, pacing mode, stimulus threshold, sensitivity setting, pacing rate, and intervals, intrinsic rhythm, and per cent of pacing. Post sample tracings. FORMS EQUIPMENT

Transveuous : pacing catheter Pacemaker generator with battery and cable Introducer Kit Lidocaine (2) 5 cc syringe with 22 and 25 gauge needles Sterile gown, gloves, mask EKG machine Alligator clamps Emergency Crash Carts Defibrillator External Pacemaker REFERENCES

APPROVAL:

JCI Standards

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JCI Standards

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