TRANSVENOUS PACEMAKERS
 

Symptomatic bradycardia ( slow heart rate usually below 60 ) has been shown to be effectively treated with a pacemaker.  Usually upon arrival to the hospital, if the patient is symptomatic, a transvenous pacemaker will be placed in the patient via some type of access such as a venous sheath or a cordis.  There are different sites that these access devices can be placed which include the Internal Jugular area ( decreased chance of causing a pneumothorax ) , the left subclavian ( generally considered the most reliable site ), and the femoral area.

Prior to the procedure being done the RN should ensure that the physician talks at length with the patient ( if possible ) and family about the procedure about to be performed.

After the patient and family have had the procedure explained to them the RN should get the temporary pacemaker generator ready.  Always put a new battery in the pacemaker.

During the insertion procedure the RN should ensure that all personnel in the room have hat, mask, gown, and gloves.  The patient should have a sterile drape in place around the area that will be accessed and covering most of their body around that area.  Also during the procedure the RN should be monitoring the patient’s vital signs and LOC and keeping and close watch on the EKG monitor in able to the physician about any changes or problems.

During the procedure there should always be a crash cart and defibrillator at the bedside.  The RN should be standing by while the physician inserts the pacemaker.  When the pacing electrode is in place ( right ventricle ) then attach the pacing wire to the temporary generator.  To determine if the pacemaker is in the proper position turn the pacemaker rate above the patients own intrinsic rate.  Then gradually increase the mA to the point where the pacemaker captures ( stimulation threshold ).  After determining what mA level creates capture then increases the mA 1.5-2 times above the stimulation threshold.  There are practitioners that will find where the pacemaker captures by starting at 20 mA and going down until capture is lost and than going back up to the point of capture.

After determining the stimulation threshold the sensitivity threshold must be established.  This sensitivity threshold is the level at which the pacemaker best senses the patients own intrinsic beats.  Under sensing can cause the pacemaker to fire when it should not; and over sensing can cause the pacemaker to think that it is seeing intrinsic beats when there are none, and thus it does not fire.  The sensitivity threshold is very important.  The sensitivity light should blink for each R wave that the patient has.

After the pacemaker is in place be sure to note what the placement in cm is for the pacemaker line itself and then secure the line and place a sterile dressing over the insertion site of the access device.

The care of the patient after pacemaker placement should include checking the cables every 4 hours and checking the status of the battery every 4 hours.  This should be documented in the chart.  Some hospitals have the RN check the underlying ( the patient’s intrinsic rhythm ) every shift.  This can be done by holding down the pause button which then stops the pacemaker while the RN is holding the button down.  An RN should not do this if it is known that the patient does not have an intrinsic rhythm of their own.

There are other reasons for the use of  a temporary pacemaker.  They are sometimes placed during a PTCA ( percutaneous transluminal coronary angioplasty ) procedure prophylatically as there are sometimes bradysrhmias during this procedure.

Always be sure to know what your hospital policies are regarding any procedure such as this and the policies for your hospital regarding the care required in the care of patients with temporary pacemakers.  This website is for the purpose of introducing you to different concepts involved in the art of Critical Care Nursing.

.