Technique for endocardial electrode placement

1. If using fluoroscopy, move patient to X-ray suite or place lead shields around bed area. Place patient on 'screening table'. Staff should wear lead aprons.

2. Use aseptic technique throughout. Insert 6Fr sheath in internal jugular or subclavian vein. Suture in position.

3. Connect pacing wire electrodes to pacing box (black = negative polarity = distal, red = positive polarity = proximal). Set pacemakerto demand. Check box is working and battery charge adequate. Turn pacing rate to >30bpm above patient's intrinsic rhythm. Set voltage to 4V.

4. Insert pacing wire through sheath into central vein. If using balloon catheter, insert to 15-20cm depth then inflate balloon. Advance catheter, viewing ECG monitor for change in ECG morphology and capture of pacing rate. If using screening, direct wire toward the apex of the right ventricle. Approximate insertion depth from a neck veinis 35-40cm.

5. If pacing impulses not captured, (deflate balloon), withdraw wire to 15cm insertion depth then repeat step 4.

6. Once pacing captured, decrease voltage by decrements to determine threshold at which pacing is no longer captured. Ideal position determined by a threshold <0.6V. If not achieved, re-position wire.

7. If possible, ask patient to cough to check that wire does not dislodge.

8. Set voltage at 3 x threshold and set desired heart rate on 'demand' mode. Tape wire securely to patient to prevent dislodgement.

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