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. 2002 Jan 12;324(7329):112.

Problems with temporary cardiac pacing

Ultrasonography can aid central venous cannulation

Paul Jefferson 1,2, Vincent Perkins 1,2
PMCID: PMC1122001  PMID: 11786463

Editor—Murphy in his editorial highlights problems with temporary cardiac pacing where the service is provided by doctors in training with inadequate supervision.1 An essential component of temporary pacing is obtaining central venous access. The failure rate for this intervention remains notable. Murphy suggests involving anaesthetists or intensivists to help resolve this problem.

There are other ways to address this important issue rather than increasing the workload of another department. The first would be to increase the involvement of consultant physicians from the current level of only 14%. Failure rates for central venous cannulation are related to the experience of the operator, with failure rates almost double in inexperienced hands.2

The second is to move from a landmark guided technique for central venous cannulation to an ultrasound guided technique. A meta-analysis comparing ultrasound guidance with a landmark technique for central venous cannulation suggested that ultrasound guidance significantly reduced the rates of failures and complications and the need for multiple attempts at placement.3 The benefits may be more obvious in patients with difficult central venous access.4

References

  • 1.Murphy JJ. Problems with temporary cardiac pacing. BMJ. 2001;323:527. doi: 10.1136/bmj.323.7312.527. . (9 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med. 1986;146:259–261. doi: 10.1001/archinte.146.2.259. [DOI] [PubMed] [Google Scholar]
  • 3.Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature. Crit Care Med. 1996;24:2053–2058. doi: 10.1097/00003246-199612000-00020. [DOI] [PubMed] [Google Scholar]
  • 4.Hatfield A, Bodenham A. Portable ultrasound for difficult central venous access. BJA. 1999;82:822–826. doi: 10.1093/bja/82.6.822. [DOI] [PubMed] [Google Scholar]
BMJ. 2002 Jan 12;324(7329):112.

Better training in general medicine is required

Tristan Richardson 1

Editor—Temporary transvenous cardiac pacing is a life saving procedure and an important skill for emergency physicians to have.1-1 It is often a poorly taught procedure with potentially life threatening complications. It should not be embarked on without due care, attention, and training. When possible, waiting and observing more stable patients overnight until the permanent pacemaker list is much more desirable. But potentially deskilling the frontline may have equally disastrous consequences, as would transferring potentially unstable patients to other centres.

If trainees in general medicine are not to expected to perform temporary pacing, then should the same be said for chest drains, central lines, and lumbar punctures? When specialty medicine does cover 24 hours patients will expect specialists performing their particular skill, but further deskilling general medical trainees in the current climate may do more harm than good. What we need is better training in general medicine or an overhaul of acute medicine.

References

BMJ. 2002 Jan 12;324(7329):112.

Training is essential

Sophie Risebero 1

Editor—I was surprised to read in the editorial by Murphy that one of his proposed solutions to the problems with temporary cardiac pacing was to ask anaesthetists to step in to address a deficiency in general medical training.2-1 Central venous cannulation is an oft performed and sometimes life saving procedure, and lack of competence in this technique among physicians in training suggests that training needs to be changed.

With recent changes in training in anaesthetic and intensive care medicine there is an increasing number of preregistration training posts in anaesthesia. A growing number of senior house officer posts in intensive care medicine is also available to trainees from all medical backgrounds where competency based training in a wide range of procedures, including placement of central lines, is offered. Failing this almost all acute hospitals have some form of critical care unit where trainees and senior physicians are likely to be welcomed in order to attain and maintain competency in such procedures. Taking advantage of such opportunities is surely a better way to address training issues while encouraging the development of even closer cooperation between the two specialties.

References

BMJ. 2002 Jan 12;324(7329):112.

Formal training in core procedure is lacking for specialist registrars in general internal medicine

Liam Cormican 1,2, Emma Baker 1,2

Editor—Murphy draws attention to the deficiencies in the training of general physicians (non-cardiology) in temporary cardiac pacing.3-1 The Joint Committee for Higher Medical Training of the Royal College of Physicians has stated that training in procedure is mandatory for accreditation in general (internal) medicine by including it as one of the “core/essential” procedures of the curriculum for specialist registrars in this specialty. In the absence of formal training, acquisition and maintenance of competence at temporary cardiac pacing requires opportunity to perform the procedure. We therefore used a questionnaire to determine specialist registrars' experience in this technique.

Twenty specialist registrars seeking dual accreditation in a chosen specialty and general internal medicine who participated regularly in the general medical on call rotas (18 specialist registrars) or the intensive care (two) of a 1000 bed teaching hospital answered a series of questions about their experience in temporary cardiac pacing.

The number of temporary pacemaker wire insertions performed by the registrars varied greatly. Four had inserted between 21 and 50 temporary wires, the chosen specialty of two of them being intensive care medicine. Fifteen had inserted fewer than 10 temporary pacing wires (supervised and unsupervised) during their professional career, seven had inserted fewer than five, and one had not inserted any.

Although most of these specialist registrars had some experience of temporary cardiac pacing, few were currently performing the procedure often enough to maintain competence. Only three of the group had inserted a temporary pacing wire within the previous 6 months. Seven had performed the procedure within the previous 12 months, six between 1 and 2 years previously, and three more than 2 years previously, with one specialist registrar not having inserted a temporary wire in the previous 5 years. Ten of the group thought that they would like to have a more experienced member of staff to help them in case of difficulty.

Specialist registrars seeking accreditation in general internal medicine are currently the most senior doctors in house to provide temporary cardiac pacing. Furthermore, they are expected to provide guidance and training in this procedure to more junior medical colleagues and subsequently assume overall responsibility as general medical consultants on call. Our study shows that most specialist registrars do not perform temporary cardiac pacing often enough to maintain or even achieve competence in this procedure. Formal training in this procedure therefore will be necessary if it is to remain as a core/essential procedure required of practitioners of general internal medicine.

References

BMJ. 2002 Jan 12;324(7329):112.

Novices can reliably and safely perform temporary pacing from femoral route

Nigel Clarke 1,2, Patrick Davey 1,2, David Sprigings 1,2, John Birkhead 1,2

Editor—A need for urgent temporary pacing remains in district general hospitals.4-1 External cardiac pacing is useful but is not always reliable and can be quite painful. Transferring patients to a specialist centre with recurrent syncope or significant hypotension, regardless of the use of isoprenaline infusions and external pacing is not acceptable.

What is required is a straightforward and reliable technique of transvenous temporary pacing that can be performed by a senior house officer, specialist registrar, or consultant with no or little recent experience. The two possibilities are balloon flotation catheters inserted through the subclavian or jugular vein and semirigid pacing wires through the femoral vein. Balloon flotation catheters work well and can be inserted by a novice with the aid of a simple instruction diagram, assuming that central access is achieved.4-2 Traversing the tricuspid valve can, however, be difficult in the presence of severe tricuspid regurgitation.

The ideal solution for urgent transvenous temporary pacing by a novice is the femoral route and a standard wire. The anatomical landmarks are well defined, and access is reliably achieved. External compression on the femoral vein allows haemostasis if bleeding complicates thrombolysis. The temporary wire readily crosses the tricuspid valve to take up a stable position, even in the presence of severe tricuspid reflux. Little manipulation is required within the heart because the wire follows a natural curve. This minimises procedure time and the incidence of ventricular arrhythmias. If there are concerns regarding incidence of infection the wire can be renewed with a new wire from the subclavian or jugular as a planned exercise allowing the possibility for teaching.

We conducted a feasibility study over a period of eight months to assess the ease with which senior house officers who had no or very little pacing experience could undertake femoral route pacing when instructed by a specialist registrar in cardiology (group A, 17 patients). A different senior house officer was invited to perform the procedure each time after a brief explanation. All achieved access without complication and a suitable pacing wire position under the guidance of the specialist registrar. This group was compared with the remainder undergoing temporary pacing, performed by more experienced senior house officers alone or with supervision by their non-cardiology consultant (group B, 13 patients). Most in group B used jugular or subclavian access. Ethics approval was not sought because the study was a retrospective comparison of two groups undergoing a clinically indicated procedure by equally accepted techniques.

In group A, 1 of the 17 patients (6%) required repositioning and 10 (59%) were placed under six minutes compared with 3 (23%) and 6 (46%) of the 13 patients in group B, respectively. Temporary pacing via the femoral vein is reliable, safe, and quickly learnt by novices.

References

  • 4-1.Murphy JJ. Problems with temporary cardiac pacing. BMJ. 2001;323:527. doi: 10.1136/bmj.323.7312.527. . (9 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-2.Fergusson JD, Banning AP, Bashir Y. Randomised trial of temporary cardiac pacing with semirigid and balloon-floatation catheters. Lancet. 1997;349:1883. doi: 10.1016/S0140-6736(97)24026-2. [DOI] [PubMed] [Google Scholar]

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