Temporary transvenous pacemaker placement in the Emergency Department

Transvenous Pacemaker Placement: A Review for Emergency Clinicians

BACKGROUND

Transvenous pacemaker placement is an integral component of therapy for severe dysrhythmias and a core skill in emergency medicine.

OBJECTIVE

This narrative review provides a focused evaluation of transvenous pacemaker placement in the emergency department setting.

DISCUSSION

Temporary cardiac pacing can be a life-saving procedure. Indications for pacemaker placement include hemodynamic instability with symptomatic bradycardia secondary to atrioventricular block and sinus node dysfunction; overdrive pacing in unstable tachydysrhythmias, such as torsades de pointes; and failure of transcutaneous pacing. Optimal placement sites include the right internal jugular vein and left subclavian vein. Insertion first includes placement of a central venous catheter. The pacing wire with balloon is then advanced until electromechanical capture is obtained with the pacer in the right ventricle. Ultrasound can be used to guide and confirm lead placement using the subxiphoid or modified subxiphoid approach. The QRS segment will demonstrate ST segment elevation once the pacing wire tip contacts the endocardial wall. If mechanical capture is not achieved with initial placement of the transvenous pacer, the clinician must consider several potential issues and use an approach to evaluating the equipment and correcting any malfunction. Although life-saving in the appropriate patient, complications may occur from central venous access, right heart catheterization, and the pacing wire.

CONCLUSIONS

An understanding of transvenous pacemaker placement is essential for emergency clinicians.

Temporary-permanent pacemakers are associated with better clinical and safety outcomes compared to balloon-tipped temporary pacemakers

BACKGROUND

Balloon Tipped Temporary Pacemakers (BTTP) are the most used temporary pacemakers; however, they are associated with a risk of dislodgement and thromboembolism. Recently, Temporary Permanent Pacemakers (TPPM) have been increasingly used. Evidence of outcomes with TPPM compared to BTTP remains scarce.

METHODS

Retrospective, chart review study evaluating all patients who underwent temporary pacemaker placement between 2014 and 2022 (N = 126) in the cardiac catheterization laboratory (CCL) at a level 1 trauma center. Primary outcome of this study is to evaluate the safety profile of TPPM versus BTTP. Secondary objectives include patient ambulation and healthcare utilization in patients with temporary pacemakers.

RESULTS

Both groups had similar baseline characteristics distribution including gender, race, and age at temporary pacemaker insertion (p > .05). Subclavian vein was the most common site of access for the TPPM cohort (89.0%) versus the femoral vein in the BTTP group (65.1%). Ambulation was only possible in the TPPM group (55.6%, p < .001). Lead dislodgement, venous thromboembolism, local hematoma, and access site infections were less frequently encountered in the TPPM group (OR = 0.23 [95% CI (0.10-0.67), p < .001]). Within the subgroup of patients with TPPM, 36.6% of the patients were monitored outside the ICU setting. There was no significant difference in the pacemaker-related adverse events among patients with TPPM based on their in-hospital setting.

CONCLUSION

TPPM is associated with a more favorable safety profile compared to BTTP. They are also associated with earlier patient ambulation and reduced healthcare utilization.

An electrogram-guided transvenous temporary pacemaker implant simulator

INTRODUCTION

Transvenous temporary pacemaker (TvTP) implantation is a critical procedure often performed under time limitations, playing a crucial role in patient survival. However, the amount of training provided for resident cardiologists is variable, due to the availability of patients. Thus, the use of simulators for this cardiologic procedure could be used as training tools.

OBJECTIVE

The present study aimed to develop a simulator system for TvTP implantation based on electrograms, called ETTIS (Electrogram-guided Transvenous Temporary-pacemaker Implantation Simulator), and to evaluate its educational potential and cardiology residents' perceived learning efficacy as a training tool.

METHODOLOGY

The development of the ETTIS involved three stages: (1) Adaptation of an anatomical mannequin; (2) Design and manufacture of electronic circuits and software capable of identifying the catheter contact site within the heart chambers and reproducing electrograms in both surfaces (mode-on) and intracavitary (mode-off); (3) To evaluate its educational potential, a modified Likert questionnaire was administered to nine cardiology experts. Additionally, to evaluate the perceived learning efficacy, another modified Likert questionnaire was given to six cardiology residents both before and after training with the ETTIS. Descriptive statistics with measures of position and dispersion were employed, and the weighted Kappa test was used for agreement analysis.

RESULTS

A high rate of acceptance (over 90%) was found among experts who evaluated the ETTIS. The cardiology residents showed significant self-perceived learning gains, as evidenced by a lack of agreement between their responses to a questionnaire before and after training.

CONCLUSION

The ETTIS is a promising tool for medical training, displaying both educational potential and efficacy. It has been shown to be effective in learning a variety of skills, including cardiac catheterization and electrophysiology. Additionally, the ETTIS is highly engaging and allows cardiology residents to practice in a safe and controlled environment.

Transesophageal echocardiography (TEE)-guided transvenous pacing (TVP) in emergency department

BACKGROUND

Placement of a temporary pacemaker is a vital skill in the emergency setting in patients that present with life-threatening bradycardia. Transvenous pacing is the definitive method of stabilizing the arrhythmia compared to transcutaneous pacing, as it provides more comfort and better control of heart rate, until the insertion of a permanent pacemaker.

CASE REPORT

In this case report, we describe the steps using TEE to guide the insertion of transvenous pacer at the emergency department. Traditionally, the process of floating a transvenous pacer wire is performed "blindly" using landmarks and a monitoring ECG finding for capture, or under transthoracic echocardiography (TTE) ultrasound guidance. The blind procedure is associated with higher rate of failure and complications. While guidance using TTE is associated with higher success rates and fewer complications, inadequate imaging of the right side of the heart may limit the utility of this imaging modality. The use of transesophageal echocardiography (TEE) by emergency medicine and critical care physicians has gained traction in recent years due to its clear images and lack of interference with procedures being performed on the chest. In this article, we describe a protocol using TEE to guide the insertion of transvenous pacer through a case illustration.

Simulation-based Mastery Learning Improves Emergency Medicine Residents' Ability to Perform Temporary Transvenous Cardiac Pacing

INTRODUCTION

Temporary transvenous cardiac pacing (TVP) is a critical intervention that emergency physicians perform infrequently in clinical practice. Prior simulation studies revealed that emergency medicine (EM) residents and board-certified emergency physicians perform TVP poorly during checklist-based assessments. Our objective in this report was to describe the design and implementation of a simulation-based mastery learning (SBML) curriculum and evaluate its impact on EM residents' ability to perform TVP.

METHODS

An expert panel of emergency physicians and cardiologists set a minimum passing standard (MPS) for a previously developed 30-item TVP checklist using the Mastery Angoff approach. Emergency medicine residents were assessed using this checklist and a high-fidelity TVP task trainer. Residents who did not meet the MPS during baseline testing viewed a procedure video and completed a 30-minute individual deliberate practice session before retesting. Residents who did not meet the MPS during initial post-testing completed additional deliberate practice and assessment until meeting or exceeding the MPS.

RESULTS

The expert panel set an MPS of correctly performing 28 (93.3%) checklist items. Fifty-seven EM residents participated. Mean checklist scores improved from 13.4 (95% CI 11.8-15.0) during baseline testing to 27.5 (95% CI 26.9-28.1) during initial post-testing (P < 0.01). No residents met the MPS at baseline testing. The 21 (36.8%) residents who did not meet the MPS during initial post-testing all met or exceeded the MPS after completing one additional 30-minute deliberate practice session.

CONCLUSION

Emergency medicine residents demonstrated significantly improved TVP performance with reduced variability in checklist scores after completing a simulation-based mastery learning curriculum.

Application of the improved simple bedside method for emergency temporary pacemaker implantation suitable for primary hospitals

The purpose of the research was to evaluate the safety and effectiveness of the X-ray-free improved simple bedside method for emergency temporary pacemaker implantation as well as the practicability of the method in primary hospitals. Patients [including those suffering from sick sinus syndrome and third-degree and advanced atrioventricular blockage (AVB)] who needed emergency temporary pacemaker implantation from July 2017 to August 2020 in Hunan Provincial People’s Hospital were selected. They were stochastically divided into a research group (95 cases) treated with the improved simple bedside method and a control group (95 cases) with X-ray guidance. The ordinary bipolar electrodes were used in both groups. On this condition, the operation duration, the first-attempt success rate of electrodes, pacing threshold, success rate of the operation, the rate of electrode displacement, and complications in the two groups were separately calculated. The comparison results of the research group with the control group are shown as follows: operation time [(18 ± 5.91) min vs. (43 ± 2.99) min, P < 0.05], the first-attempt success rate of the electrode (97% vs. 98%, P > 0.05), pacing threshold [(0.97 ± 0.35) vs. (0.97 ± 0.32) V, P > 0.05], success rate of the operation (98.9% vs. 100%, P > 0.05), the rate of electrode displacement (8.4% vs. 7.3%, P > 0.05) and complications (3.2% vs. 2.1%, P > 0.05). The emergency temporary pacemaker implantation based on the improved simple bedside method is as safe and effective as the surgical method under X-ray guidance, and the operation is simpler and easier to learn and requires a shorter operating time, therefore, it is more suitable for use in emergency and primary hospitals.

Development of a Rigorously Designed Procedural Checklist for Assessment of Emergency Medicine Resident Performance of Temporary Transvenous Cardiac Pacing

OBJECTIVES

Temporary transvenous cardiac pacing (TVP) is a potentially lifesaving intervention included in the list of essential core procedures for emergency medicine (EM) training; however, opportunities to perform TVP during residency cannot be guaranteed. EM graduates report feeling subjectively underprepared for this procedure, but objective performance data are lacking. Checklist-based simulated assessment is an increasing focus of competency-based medical education, particularly for invasive procedures like TVP. The objectives of this paper were as follows: first, to enlist a multidisciplinary team of experts to create an assessment tool for TVP using best practices in checklist development; second, to determine the reliability of checklist scoring; and third, to assess EM residents' baseline ability to perform TVP using a dedicated task trainer.

METHODS

This study was conducted at a single 4-year EM residency. A panel of emergency physicians and cardiologists designed a TVP checklist using a modified Delphi approach. After consensus was achieved on a final checklist, EM residents were assessed using a dedicated TVP task trainer. Inter-rater reliability was determined using Cohen's kappa coefficient. Resident performance was determined by number of correctly performed checklist items.

RESULTS

The expert panel achieved consensus on a 30-item checklist after three rounds of revisions. The Cohen's kappa coefficient for the overall checklist score was 0.87, with individual checklist items ranging from 0.63 to 1.00. In total, 58 residents were assessed with a mean score of 13.5 of 30 checklist items. Scores increased with each year of training.

CONCLUSIONS

This study details the rigorous development of a TVP checklist designed by a multidisciplinary team of experts. Checklist scores demonstrated strong inter-rater reliability. The overall poor performance of this cohort suggests the current approach to TVP training does not provide sufficient preparation for EM residents. Competency-based techniques, such as simulation-based mastery learning, should be explored.

Impact of bedrest on cardiovascular events and complications associated with temporary pacemakers in patients waiting for permanent pacemaker implantation

BACKGROUND

Patients with a temporary pacemaker (TPM) for bradycardias are required to maintain bedrest until permanent pacemakers (PPMs) are implanted because of the development of Adams-Stokes syndrome, worsening heart failure, or complications associated with TPMs is anticipated. However, bedrest may be detrimental in patients because it leads to disuse syndrome. This study examined whether bedrest could decrease the incidence of cardiovascular events or complications associated with TPMs in patients waiting for PPM implantation.

METHODS

We conducted a retrospective cohort study on 88 patients who had emergency hospitalization for the treatment of bradycardias, and a TPM was inserted during the waiting period before PPM implantation. We divided patients into two groups according to whether they underwent bedrest (Bedrest Group) or not (Ambulation Group) during the period that patients were supported with TPM. We evaluated whether bedrest was a predictor of adverse events using a logistic regression analysis.

RESULTS

Adverse events occurred in 31 patients (35%). In the univariate analysis, there was no significant difference in the incidence of adverse events between the Bedrest and Ambulation Groups (39% vs. 29%). In the logistic regression analysis, bedrest was not a predictor of adverse events (odds ratio, 1.40; 95% confidence interval, 0.53-3.68, P = .497).

CONCLUSIONS

In patients with TPMs for bradyarrhythmias during the waiting period for PPM implantations, bedrest might not prevent adverse events, such as cardiovascular events and complications associated with TPMs.

Temporary transvenous cardiac pacing: a survey on current practice

BACKGROUND

Temporary transvenous cardiac pacing (TTCP) is a standard procedure in current practice, despite limited coverage in consensus guidelines. However, many authors reported several complications associated with TTCP, especially development of infections of cardiac implantable electronic devices (CIED). The aim of this survey was to provide a country-wide picture of current practice regarding TTCP.

METHODS

Data were collected using an online survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing.

RESULTS

We collected data from 102 physicians, working in 81 Italian hospitals from 17/21 regions. Our data evidenced that different strategies are adopted in case of acute bradycardia with a tendency to limit TTCP mainly to advanced atrioventricular block. However, some centers reported a greater use in elective procedures. TTCP is usually performed by electrophysiologists or interventional cardiologists and, differently from previous reports, mainly by a femoral approach and with nonfloating catheters. We found high inhomogeneity regarding prevention of infections and thromboembolic complications and in post-TTCP management, associated with different TTCP volumes and a strategy for management of acute bradyarrhythmias.

CONCLUSION

This survey evidenced a high inhomogeneity in the approaches adopted by Italian cardiologists for TTCP. Further studies are needed to explore if these divergences are associated with different long-term outcomes, especially incidence of CIED-related infections.

Perfecting temporary pacemakers in a developing country

INTRODUCTION

Transvenous pacemakers are used to temporarily pace heart in emergent situations. This study was conducted to analyze the current success rate of temporary pacemaker insertion in our institution and discover causes for failure to improve the technique.

METHODOLOGY

A retrospective cohort study was conducted of 263 patients from 2006 to 2016 who underwent TPM insertion at Aga Khan University Hospital, Karachi.

RESULTS

The success rate for the procedure was 97.7%, with one mortality caused by the pacemaker. No significant risk factor was found for the failure of TPM.

CONCLUSION

There was no significant effect of anatomical site or technique on the failure of TPM insertion. However, with better training and higher experience of the residents, the complications and rate of failures can be reduced.

An Inexpensive Conceptual Training Model for Transvenous Pacemaker Placement

INTRODUCTION

Emergent transvenous (TV) pacemaker placement can be life-saving, but it has associated complications. Emergency medicine (EM) educators must be able to teach this infrequent procedure to trainees.

METHODS

We constructed a conceptually-focused, inexpensive training model made from polyvinyl chloride pipes and connectors, vinyl tubing, and a submersible pump. Cost of the model was $51. We tested the model with a group of 15 EM residents. We then asked participants to complete a survey reporting confidence with the procedure before and after the session. Confidence was compared using a Wilcoxon matched-pairs test.

RESULTS

Confidence improved after the session, with a median confidence before the session of 2 (minimally confident; interquartile range [IQR] 1-3) and a median confidence after the session of 4 (very confident; IQR 3-4, p=0.001). All residents agreed that the model helped them to understand the process of placing a TV pacemaker.

CONCLUSION

Our TV pacemaker placement model was inexpensive and allowed for practice of a complex emergency procedure with direct visualization. It improved trainee confidence.

Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency Department

Placement of a transvenous pacer is an important procedure mainly used to treat hemodynamically unstable brady-arrhythmias. In the Emergency Department (ED), wire placement into the right ventricle is typically performed blindly, or in some cases, under transthoracic ultrasound guidance. This case report describes a patient with extensive cardiac history who presented after a witnessed arrest, and after return of spontaneous circulation, sustained an unstable bradycardia requiring emergent transvenous pacer placement while in the ED. A temporary pacer wire was placed transvenously without successful capture. Transesophageal echocardiography was then utilized to guide and adjust the pacer wire placement helping to successfully achieve capture. To our knowledge, this is the first report to describe transesophageal echocardiogram-assisted placement of a transvenous pacer wire while in the ED.

Temporary transvenous pacing guided by the combined use of ultrasound and intracavitary electrocardiography: a feasible and safe technique

Temporary transvenous pacing is a crucial procedure in emergency and critical care medicine. While fluoroscopy guidance is considered the gold-standard to place the temporary pacing electrode catheter (EC), its use is usually limited by equipment availability and time. By contrast, ultrasound (US) guidance is a useful alternative, since it is widely available at the bedside, does not emit ionizing radiation and provides optimal times to active pacing with fewer complications. However, many times, in spite of visualizing the EC in the right ventricle using US, the pacing capture and sensing are not optimal, and thus, having an easily applicable method for best assessing this issue is desirable, especially if it could be combined with US without difficulties. With the purpose of illustrating the points made previously, the combined US-intracavitary electrocardiography technique is described in detail in this paper.

Transvenous pacemaker placement: left lateral decubitus position and wireless digital radiography

A patient presented with symptomatic third degree atrioventricular block requiring emergency transvenous pacemaker placement. During the procedure, wireless digital radiographs tracked the position of the pacemaker electrode, which repeatedly missed the target right ventricle. The patient was then rolled to left lateral decubitus position and the electrode was advanced into the right ventricle, achieving electrical capture, hemodynamic stability, and symptom resolution. We review the published literature on transvenous pacemaker placement and identify two innovations: left lateral decubitus position to facilitate catheter placement and wireless digital radiography for procedure guidance.

Implant of permanent pacemaker during acute coronary syndrome: Mortality and associated factors in the ARIAM registry

BACKGROUND

Patients with acute coronary syndrome complicated with high degree atrioventricular block still have a high mortality. A low percentage of these patients need a permanent pacemaker (PPM) but mortality and associated factors with the PPM implant in acute coronary syndrome patients are not known. We assess whether PPM implant is an independent variable in the mortality of acute coronary syndrome patients. Also, we explored the variables that remain independently associated with PPM implantation.

METHODS

This was an observational study on the Spanish ARIAM register. The inclusion period was from January 2001 to December 2011. This registry included all Andalusian acute coronary syndrome patients. Follow-up for global mortality was until November 2013.

RESULTS

We selected 27,608 cases. In 62 patients a PPM was implanted (0.024%). The mean age in PPM patients was 70.71±11.214 years versus 64.46±12.985 years in patients with no PPM. PPM implant was associated independently with age (odds ratio (OR) 1.031, 95% confidence interval (CI) 1.007-1.055), with left ventricular branch block (OR 6.622, 95% CI 2.439-18.181), with any arrhythmia at intensive care unit admission (OR 2.754, 95% CI 1.506-5.025) and with heart failure (OR 3.344, 95% CI 1.78-8.333). PPM implant was independently associated with mortality (OR 11.436, 95% CI 1.576-83.009). In propensity score analysis PPM implant was still associated with mortality (OR 5.79, 95% CI 3.27-25.63).

CONCLUSION

PPM implant is associated with mortality in the acute coronary syndrome population in the ARIAM registry. Advanced age, heart failure, arrhythmias and left ventricular branch block at intensive care unit admission were found associated factors with PPM implant in acute coronary syndrome patient.

Outcomes of emergency department placement of transvenous pacemakers

PURPOSE

Placement of TVPs is a core EM procedure. Despite this, there is no specific outcome data on this procedure in the ED setting. This study examines the success of Emergency Physician (EP) attempted TVPs as well as their hospital courses and survivals.

METHODS

The charts of patients undergoing TVP placement in the ED of an urban community hospital were prospectively collected by a department billing abstractor and then underwent a structured review. All patients had a TVP placed by a board eligible or board certified EP or by a PGY2 EM resident under the direct supervision of an attending EP. All TVPs were placed utilizing a 5 Fr balloon tipped bi-polar pacer without fluoroscopic visualization.

RESULTS

Over a 36 month period, 43 patients met the study criteria. The mean age was 76.6 (+/- 1.49) years with 27 females (62.7%). Successful pacemaker capture was achieved in 41(95.4%) of TVP attempts. All of the patients were transferred from the ED with vital signs, 41 (95.4%) to a critical care unit and 2 (4.6%) to the electrophysiology laboratory. A total of 26 (60%) patients received permanent pacemakers. Four patients (9.3%) expired during their hospital stay. The remaining patients were discharged to the following: 31 (72%) to home, 5 (11.6%) to a subacute rehabilitation facility, 3 (7%) to a nursing home.

CONCLUSION

EP placed TVPs have a high rate of successful capture and patients undergoing this procedure have a good prognosis.

Insertion and Management of Temporary Pacemakers

Temporary pacemakers are used in a variety of critical care settings. These life-saving devices are reviewed in 2 major categories in this review: first, the insertion and management of epicardial pacemakers after and during cardiac surgery; and second, the insertion of transvenous temporary pacemakers for the emergent treatment of bradyarrhythmias. Temporary epicardial pacemakers are used routinely in patients recovering from cardiac surgery. Borrowing from advances in cardiac resynchronization therapy there are many theoretical and untested benefits to pacing the postoperative cardiac surgery patient. Temporary transvenous pacing is traditionally an emergency procedure to stabilize patients suffering from hemodynamically unstable bradyarrhythmia. We review the traditional and expanding use of transvenous pacemakers inside and outside the operating room.

Emergent transvenous cardiac pacing using ultrasound guidance: a prospective study versus the standard fluoroscopy-guided procedure

AIMS

To compare time to active pacing and complication rates associated with temporary transvenous pacemaker (TTVPM) insertion between a fully echo-guided approach of vein access and lead placement, and standard placement of TTVPM under fluoroscopic guidance.

METHODS AND RESULTS

We performed a prospective single-center observational study enrolling all consecutive patients from 1 January 2008 to 31 December 2012 needing emergent TTVPM placement. According to personal experience and clinical setting, the operators could choose between a fully echo-guided approach of TTVPM placement through the jugular vein and a standard fluoro-guided approach through the femoral vein. Safety and efficacy endpoints were pre-specified, registered, and compared. A total of 113 patients were treated using the echo-guided approach, and 90 via the fluoro-guided approach. The two groups differed with regard to clinical setting at presentation: an acute coronary syndrome was more frequent in the fluoro-guided approach group (39.7% vs. 16.8%, p<0.001), whereas asystole was more frequent in the echo-guided approach group (9.7 vs. 0%). Median time from decision to active pacing was significantly shorter in the echo-guided approach group (22 vs. 43 minutes, p<0.01). The overall complication rates were significantly lower in the echo-guided approach group (15.0% vs. 28.8%, p 0.02), because of lower rates of infections (2.7% vs. 11.1%, p 0.02) and puncture-related hematomas (0 vs. 3.3%, p=0.08). There were no deaths related to TTVPM, but one heart perforation requiring emergent pericardiocentesis occurred in the fluoro-guided approach group. One pneumothorax treated conservatively occurred in the echo-guided approach group, while no differences were observed with regard to sustained tachyarrhythmias (1.8% vs. 2.2%) or malfunctions requiring reposition of the catheter (8.8 vs. 8.9%). Overall, complications delaying permanent pacemaker implant for >48 hours were observed less often in the echo-guided approach group (6.8 vs. 20.7%, p = 0.03).

CONCLUSION

Echo-guided insertion of TTVPM through the jugular vein is a feasible and safe alternative to fluoroscopic guidance and may reduce complications and time to active pacing in patients who are not candidates for emergent cardiac catheterization.

Relationship between seasonal weather changes, risk of dehydration, and incidence of severe bradyarrhythmias requiring urgent temporary transvenous cardiac pacing in an elderly population

There is little information on any seasonal variations or meteorological factors associated with symptomatic bradyarrhythmias requiring cardiac pacing. The aim of this single-center study was to investigate the seasonal distribution of the incidence of severe, life-threatening bradyarrhythmias requiring urgent temporary transvenous cardiac pacing in an elderly population. Consecutive patients who underwent urgent temporary transvenous cardiac pacing between 2007 and 2012 were enrolled. The baseline characteristics of the patients and some meteorological parameters, including the calculation the daily heat index (HI), were recorded. During the study period, 79 consecutive patients (mean age 82 ± 8 years, 41% male) underwent urgent temporary transvenous cardiac pacing, mainly for third-degree atrioventricular block (79%). The incidence of bradyarrhythmias was significantly higher in summer than in the other seasons (P < 0.001). Moreover, the highest incidence was observed in months with HI > 90 °F for >3 h per day for at least 10 days (P < 0.001). A direct correlation was found between the average monthly temperature and the monthly number of patients undergoing temporary cardiac pacing (r = 0.54, P < 0.001). Compared with other patients, those observed during the hottest months were significantly older and more frequently affected by chronic disabling neurological diseases (all P < 0.05). In addition, they more frequently showed biochemical indices of dehydration, renal function impairment and hyperkalemia (all P < 0.05). This study showed an increased incidence of severe bradyarrhythmias in an elderly population during the hottest months of the year. In these months, in subjects characterized by increased susceptibility to dehydration, the risk of developing bradyarrhythmias was increased significantly.

Use of echocardiography to identify appropriate placement of a central venous catheter wire in the vena cava prior to cannulation

Ultrasound guidance is now the standard of care when placing a central venous catheter (CVC), resulting in decreased complications and increased first-pass success rates. However, even with ultrasound guidance being used for the initial venipuncture, misplacement of a CVC in either an unwanted vein or in an artery still occurs. Here, we discuss a simple technique to assist in the adequate placement of the CVC in the vena cava using bedside echocardiography.

Temporary Endocavitary Pacemakers and their Use and Misuse: the Least is Better

Temporary pacemakers are classically indicated for severe bradydysrhythmia, especially when the clinical settings require prompt intervention. Implantation of a temporary pacemaker is not a benign procedure since it may be associated with serious adverse events such as infection, cardiac perforation, and lead dislodgment. Accordingly, we recommend, when the clinical condition allows, to proceed directly with permanent pacemaker implantation without prior use of a temporary pacemaker. However, if a temporary pacemaker is required, it should be maintained for the shortest time possible. This policy allows avoiding or decreasing the potential complications associated with temporary pacemaker implantation.

Assessing the accreditation council for graduate medical education requirement for temporary cardiac pacing procedural competency through simulation

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) guidelines recommend that residents perform 6 cardiac pacing attempts during residency training, while making no distinction between transcutaneous pacing (TCP) or transvenous pacing (TVP). This study seeks to enhance and validate emergency medicine residency curricula by assessing and measuring the minimum number of performances for TCP and TVP through simulation for procedural competency.

METHODS

In 2009-2010, 36 residents were invited to the simulation laboratory to participate in individual procedural training sessions. The residents each rotated through the 2 following partial-task training stations staffed by faculty members: (1) TVP and (2) TCP. Using the process of deliberate practice, the procedures were repeated until the faculty members had determined procedural competency defined as 2 completions without error via a preset checklist.

RESULTS

Residents required a mean (SD) of 3.11 (0.56) attempts and a median of 3 attempts to successfully perform TCP and a mean (SD) of 5.25 (0.94) attempts and a median of 6 attempts to successfully perform TVP. Learners required a mean (SD) total number of 8.39 (1.09) attempts and a median of 9 attempts to achieve competency at cardiac pacing. No resident required more than 5 attempts to achieve competency in TCP; no resident required more than 6 attempts to achieve competency in TVP.

CONCLUSIONS

When measuring TVP alone, the number of attempts to achieve competency are comparable with that of the ACGME guidelines. When accounting for both TCP and TVP, the number of attempts required to achieve competency is greater than those delineated by the ACGME guidelines. The results of this trial warrant continuation and reproduction on a larger scale to revisit the ACGME guidelines.

Waiting for a pacemaker: is it dangerous?

AIMS

To determine waiting period-related morbidity, mortality, and adverse events in acute patients waiting for a permanent pacemaker (PPM).

METHODS AND RESULTS

A retrospective chart review of all PPM implantations in Region Zealand, Denmark, in 2009 was conducted. Patients were excluded if they were discharged from the hospital during the waiting period or referred from the outpatient department. Adverse events were tracked. Four hundred and eighty-seven PPM implantations were identified. Of these, 259 patients (53.2%) required acute PPM implantation and waited a mean of 5.1 days from PPM indication to implantation. A lack of implantation capacity was responsible for 4.5 of the waiting days. Twenty-nine patients (11.2%) developed infection while waiting, primarily urinary tract infections. Thirteen patients (5.0%) suffered non-sustained ventricular tachycardia, and eight patients (3.1%) suffered clinical cardiac arrest followed by successful resuscitation. Three patients (1.2%) died during the waiting period before successful implantation. Forty-eight patients (18.5%) received the sympathomimetic beta-adrenergic agent, isoprenaline, and seven patients (13.7%) had malignant arrhythmias or cardiac arrest, reaching statistical significance (P < 0.05). Twenty-eight patients (10.8%) had a temporary transvenous-pacing catheter applied acutely.

CONCLUSIONS

The patients awaited acute PPM implantations for a mean of 4.5 days because of capacity problems. Overall, 83 patients (32.0%) experienced at least one adverse event during the waiting period. The present study indicates that a waiting period is dangerous as it is associated with an increased risk of adverse events. Acute PPMs should be implanted with a 24-h pacemaker implantation service capacity.

[Efficacy and safety of non-permanent transvenous pacemaker implantation in an intensive care unit]

OBJECTIVE

To analyze the clinical indications for use, morbidity and mortality associated with a non-permanent transvenous pacemaker.

DESIGN

Prospective and observational study.

SETTING

Cardiac intensive care unit.

METHOD

One hundred and eighty-two patients with non-permanent pacemakers implanted consecutively over a period of four years.

DATA COLLECTED

Main variables of interest were demographic data, clinical indications, access route, length of stay and complications.

RESULTS

A total of 63% were men, with a median age of 78 ± 9.5 years and with symptomatic third-degree atrioventricular block in 76.9% of the cases. Femoral vein access was preferred in 92.3% of the cases. Complications appeared in 40.11% of the patients, the most frequent being hematoma at the site of vascular access (13.19%). Restlessness was associated to the need for repositioning the pacemaker due to a shift in the electrode (p=0.059) and to hematoma (p=0.07). Subclavian or jugular vein lead insertion (p=0.012; OR=0.16; 95%CI, 0.04-0.66), restlessness during admission to ICU (p=0.006; OR=3.2; 95%CI, 1.4-7.3), and the presence of cardiovascular risk factors (p=0.042; OR=5; 95%CI, 1.06-14.2) were identified by multivariate analysis as being predictors of complications. Length of stay in ICU was significantly longer when lead insertion was carried out by specialized staff (p=0.0001), and in the presence of complications (p=0.05).

CONCLUSIONS

Predictfurors of complications were restlessness, cardiovascular risk factors, and insertion through the jugular or subclavian vein. Complications prolonged ICU stay and were not related to the professionals involved.