Transvenous pacemaker placement
Sterilize the field. Don full sterile personal protective equipment per universal precautions, appropriately drape the area, and cover ultrasound transducer with a sterile covering.
Establish a right internal jugular or left subclavian vein introducer sheath (see Introducer Sheath Placement).
Slide compressed sterile sleeve onto pacing catheter.
Check the balloon for integrity and then advance the catheter into the introducer hub.
Instruct an assistant to make the following non-sterile connections: Attach the connecting cable to the pacing generator.
Advance the catheter so that the tip lies within the superior vena cava and beyond the introducer sheath (20 cm is sufficient).
Inflate the balloon with 1.5mL of air. Close the stopcock to keep the balloon inflated.
Advance the pacing catheter quickly and smoothly. Follow using cardiac ultrasound. Always deflate the balloon prior to withdrawing the catheter to avoid valve damage, and inflate when advancing.
When the pacing catheter is in the right ventricle, deflate the balloon. Remove the syringe.
Extend the sterile sleeve to that it fully covers the pacing catheter. Attach to the introducer hub. If your sheath and sleeve have valves, close them by turning clockwise to keep the wire and sleeve in place.
Set the rate to 80 beats/minute (or 10 beats/min faster than underlying ventricular rhythm, whichever is higher) and the output to 5 mA. Turn the pacer on.
Assess for electrical capture by looking for a QRS complex to follow each pacer spike on the ECG monitor. Assess for mechanical capture by checking for a palpable pulse that equals the pacemaker rate. Reposition the catheter if needed.
Once capture is obtained, turn the output down to the minimum level that maintains capture.
Apply a large sterile barrier dressing.
Assess pacemaker function again (assess electrical capture with ECG, observing LBBB morphology, and assess mechanical capture with pulse).
Order appropriate chest X-ray to confirm proper placement (apex of right ventricle).