ClinicalArticle

Mastering Temporary
Invasive Cardiac Pacing

nvasive electrical pacing is used

to initiate myocardial contractions
when intrinsic stimulation is insufficient, the native impulses are not
being conducted, or the heart rate is
too slow to maintain an adequate
cardiac output.1,2 Several pacing
options are available. Selection of a
particular method depends on both
the patients current condition and
his or her projected future needs.
Among patients with cardiac disease,
noninvasive (transcutaneous), semiinvasive (esophageal), temporary
invasive, and implanted (permanent)
pacemakers are often indicated.1,2 In
this article, however, we focus on
those invasive but temporary pacemaker systems that critical care
nurses often find confusing.
Temporary invasive pacing of
the myocardium is used for a variety
of emergent and elective conditions1
(Table 1). Pacing electrodes are routinely inserted during certain cardiac

Devorah Overbay, RN, MSN, CCRN

Laura Criddle, RN, MS, CCRN, CCNS

Table 1 Indications for temporary invasive cardiac pacing

Sick sinus syndrome

Heart blocks

Drug-refractory dysrhythmia

Cardiovascular surgery

Symptomatic sinus arrest

Suppression of ventricular ectopy resulting from
bradycardia
Atrial fibrillation
Bradycardia/tachycardia syndrome
Symptomatic sinus bradycardia
Type I (occasionally) and type II second-degree
atrioventricular block
Acute bifascicular or trifascicular block
Complete atrioventricular block
Cardiac arrest with ventricular asystole
Overdrive ventricular pacing to suppress or prevent
ventricular ectopic activity
Overdrive atrial pacing to break supraventricular
tachycardia or atrial flutter
Prophylactic use during anesthesia and surgery in
patients with a history of acute coronary syndrome or
cardiac dysrhythmias
Treatment for complete heart block developed during or
after surgery
Cardiac output augmentation postoperatively

surgical procedures such as bypass

grafting and valve repair or replacement.2 Another common indication
for insertion of a temporary pacemaker is recent myocardial infarction.3 Although treatment with

Authors
Devorah Overbay is a clinical transplant coordinator at Oregon Health & Science University in Portland, Ore. She is a former critical care and cardiovascular clinical nurse specialist.
Laura Criddle is a doctoral student at Oregon Health and Science University.
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-blocking agents is considered an

important intervention after recent
myocardial infarction, the agents
slow the heart rate markedly.4 In
addition, serious bradydysrhythmias often occur in patients with
recent myocardial infarction even
without drug therapy.5 These low
heart rates interfere with successful
recovery. Temporary pacing after
myocardial infarction can be a lifesaving intervention, allowing patients
to enjoy the benefits of -blocker
therapy while simultaneously maintaining an adequate heart rate and
cardiac output.

CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 25

Although the generators used with temporary pacemakers can be

intimidating, familiarity with this equipment
is essential for critical
care nurses.1 In the following material, we
review relevant cardiac
anatomy and physiology, discuss various
pacemaker components, and describe the
nursing care of patients
being paced with transvenous or epicardial
electrodes.

Sinus
Node

Atrioventricular
Node

Cardiac Anatomy
and Physiology

Bundle of His

Purkinje
Fibers

Microscopically,
myocardial tissue is difFigure 1 Cardiac conduction system.
ferentiated by the functions of its various cell
types. Working myocarthroughout the entire circulatory
dial cells contract, providing pumpsystem.3
ing forces; clusters of specialized
pacemaker cells initiate electrical
Many intrinsic and extrinsic facimpulses; and the Purkinje fibers
tors influence the genesis and the
provide rapid conduction of these
propagation of cardiac impulses.
3
impulses. The sinoatrial node,
Dysrhythmias may arise from abnormal initiation or conduction of
located high in the right atrium, is
impulses or from both.3 Bradydysthe cluster of cells that initiates
normal cardiac stimulation and
rhythmias can result from electrolyte
serves as the primary pacemaker.
imbalances, the toxic effects of drugs,
These signals then travel across the
inherent abnormalities in the conducatrium to the atrioventricular node,
tion system, ischemia, or myocardial
located close to the septal leaflet of
damage.2 By sustaining a rate suffithe tricuspid valve. Conducting
cient to allow filling and emptying of
fibers from the atrioventricular
the hearts chambers, artificial
node converge in the bundle of His,
mechanical pacemakers can be a lifeallowing rapid transmission of
saving adjunct for maintaining an
impulses to the Purkinje fibers of
adequate cardiac output.
the ventricles (Figure 1). The result
of this highly coordinated impulse
Components of Pacing
propagation is a cardiac contraction
The mechanics of pacing
that efficiently pumps blood
involves several fundamental com-

26 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004

ponents. The first of these

is the battery-powered generator that initiates electrical stimulation. Three basic
types of pulse generators
are available:
1. single-chamber atrial
pacers,
2. single-chamber ventricular pacers, and
3. atrioventricular
sequential pacers, which
pace both atrial and ventricular chambers.
Single-chamber atrial
pacers are adequate for
enhancing heart rate in
patients with an intact cardiac conduction system.
Ventricular pacers are
designed for patients with
normal contractility who
require an increase in heart
rate. Atrioventricular
sequential pacers provide
synchronization between the atria
and the ventricles for optimal cardiac output.
The pacing generator is connected
to 1 to 4 pacing wires and may or
may not require a connecting cable
between the wires and the generator. The last element of pacing is the
patients own cardiac tissue. Failure
to pace may be due to a malfunction
or disruption of mechanical components. Failure may also be due to
poor myocardial function associated
with electrolyte disturbances, myocardial scarring, or any factors that
affect impulse conduction or cardiac
contractility.

Pacemaker Concepts
The four basic concepts of pacemaker functioning are connection,
output, capture, and sensitivity.

Connection
The connection between the pacemaker generator and the heart is
made through either unipolar or bipolar electrode wires.1 In a unipolar
system, only the negative electrode
is in direct contact with the heart. In
a bipolar system, both negative and
positive electrodes lie within the
heart. Pacemakers can be either
unipolar or bipolar. Distinguishing
between the negative and positive
electrodes is important so that the
wires are connected appropriately to
the pulse generator.6
The 2 types of invasive temporary
pacing are epicardial and transvenous.3 The transvenous category
also includes devices that combine a
specialized pulmonary artery catheter
with a pacemaker.1 Transvenous pacing involves a pulse generator, which
is externally connected to 2 electrode
wires, threaded through a large vein
(generally the subclavian or internal
jugular) into either the right atrium
or the right ventricle.1 These wires
directly contact the endocardium
within the heart (Figure 2).
Pulmonary artery catheters are
the newest form of invasive temporary pacing. In specialized pulmonary
artery catheters, dedicated atrial and
ventricular ports provide sites for the
introduction of electrode wires while
still allowing routine thermodilution
hemodynamic monitoring.1 Unfortunately, inflating the balloon to measure pulmonary artery wedge pressure
may cause the electrodes to migrate
out of their pacing position. Consequently, simultaneous pacing and
determinations of wedge pressures
are infrequently done.
The second method of temporary invasive pacing involves directly
stimulating the epicardium (Figure 3).

To pulse generator

Figure 2 Temporary transvenous pacemaker.

This type of pacing is initiated after

cardiac surgery.1,2 Postoperatively,
electrodes are lightly sutured to the
epicardium before the thorax is
closed. These pacing wires are pulled
through the skin and secured to the
external chest wall, ready for attach-

ment to a temporary pacing generator as needed.3 A patient may have a

single set or a double set of electrodes,
but each set of electrodes includes 2
wires that protrude from a stab incision in the chest wall. When dual-wire
sets are used, one set or pair paces the

To pulse generator

Figure 3 Temporary epicardial pacemaker.

CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 27

ventricles and the other is attached

to the atria.
In each pair of wires, one lead is
positive and the other (commonly
the shorter of the 2 wires) is negative;
however, practice varies between
institutions. Ventricular pacing wires
exit through the left side of the sternum; atrial pairs are placed on the
right side.1 Having identifying labels
on the wires is helpful. If no labels
are present, ascertaining which wire
is which (and marking the wires
accordingly) can save precious time
later in emergency situations.
Distinguishing ventricular wires
from atrial wires, and positive electrodes from negative electrodes, is

considerably easier in patients with

transvenous or pulmonary artery
catheter pacemakers. Pacing wires are
threaded directly into the chambers of
the right atrium and right ventricle by
using the appropriate prelabeled ports.
On the top of the generator of
each temporary atrioventricular
sequential pacemaker are connectors
labeled Atrial +/-, and Ventricular +/(Figure 4). Single-chamber pacemakers
have only 2 connector ports, positive
and negative; the wires must be connected and secured to the correct port.

Output
Once the wires from the patient
are connected to the generator, the
amount of
electrical output must be
Pacing wire ports on top
selected. The
sole function
of the generator is to supply sufficient
energy to the
heart muscle
to stimulate a
contraction.
Setting the
output has 3
components:
rate, amount,
and chamber.
The rate
determines
the number of
stimulations
to be delivered per
minute. The
amount conBattery compartment on bottom
trols the level
of energy proFigure 4 Pulse generator for a dual-chamber pacemaker.
vided, and the
chamber

28 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004

defines the location in the heart to

which the energy is delivered.
Sometimes, the most obvious
step in setting up a pacemaker is
also the step most forgotten: ensuring that a fresh battery is in the generator.1 Most institutions have a
policy that requires checking a batterys energy level, or replacing the
battery, before attaching the generator for each new patient. Table 2 is a
quick guide to pacemaker setup.
Each patients physician is responsible for providing initial direction
regarding rate, output amount, and
chambers to be paced.1 To facilitate
this step, some institutions have
developed preprinted temporary
pacemaker orders. Other critical
care units have temporary pacing
policies in place to provide nurses
with guidelines for initial settings.
Rate The original rate setting

depends on both the patients condition and the reason for pacing.1
Rates for a surgical patient can start
as high as 90 to 110 beats/min. In
medical patients, therapy is generally started at 70 to 90 beats/min.
In patients who have had cardiac
arrest, the initial rate is 80
beats/min. Pacing rates for overdrive suppression of tachydysrhythmias may greatly exceed these
values.1 The heart rate on a patients
rhythm strip should never be lower
than the patients set pacemaker
rate.3
Amount The output amount is the

level of energy delivered by the

pulse generator to the heart to initiate depolarization. Output is measured in milliamperes.1 The usual
starting point is 10 mA in nonurgent situations. Output is then

Table 2 Quick guide to pacemaker setup

1. Locate the pacemaker generator.

2. Ensure that the battery is fresh.
3. Identify each wire set as atrial or ventricular.
One or both types may be present. Epicardial ventricular wires exit from the left
side of the chest; atrial wires, from the right.
4. Identify the positive and negative leads for each pair of wires.
Negative leads are generally shorter.
5. Attach the wires to the appropriate sites.
6. Turn the pulse generator on.
7. Set the rate according to the physicians preference and the physiological needs of the
patient.
For example:
Surgical patients: 90-110 beats/min
Medical patients: 70-90 beats/min
Cardiac arrest: 80 beats/min
8. Set the milliamperage. General adult guidelines:
Nonurgent: 10 mA
Emergent: 15-20 mA
Increase milliamperage until capture is obtained.
9. Set the sensitivity. General adult guidelines:
Start at 2-5 mV.
If failure to sense occurs, turn the sensitivity DOWN.
If the pacer is sensing beats not actually present, turn the sensitivity UP.
10. Observe the patient closely for response.
11. Secure the wires and all connections, label wires, and place the pacemaker in
a safe location.

slowly increased until capture is

obtained and the pacing threshold
is defined.1 This level is not constant; it fluctuates over time as an
endothelial sheath forms around
the tips of the electrodes. Therefore,
to prevent loss of capture, the output is set 112 to 3 times higher than
the identified pacing threshold.1 In
emergent circumstances, starting
with a high output (15-20 mA) is
recommended. Threshold testing is
performed to fine-tune the settings.
Chamber The atrial chamber, the
ventricular chamber, or both chambers of the heart can be paced.
Pulse generators for dual-chamber
pacemakers have separate atrial
and ventricular output controls.1 If
both the atrium and the ventricle
are paced, a separate output setting
is required for each chamber. The

settings for the 2 chambers may be

different or identical. The chamber to
be paced is selected by programming
the generator.1

Vs

Vs

Vs

Vp

Capture
Electrical capture, the ability of
the electrical impulse to initiate a
cardiac response, is detected by examining an electrocardiogram. Capture
is both an electrical and a mechanical
event. Electrical capture is indicated
by a pacer spike followed by a corresponding P wave or QRS complex,
depending on which chamber is
being paced (Figures 5 and 6). If the
atrium is paced, the spike appears
before the P wave.7 If the ventricle is
paced, the spike occurs before the
QRS complex.1
Because the pacemaker causes the
heart to depolarize in an artificial
fashion, the path of depolarization is
abnormal, resulting in widened P
waves and QRS complexes.3 A pacer
spike without a corresponding P wave
or QRS complex indicates failure to
capture1 (Figure 7). For a list of potential causes of loss of capture, see
Table 3.
If loss of capture occurs, the
patient is assessed first and then connections and settings are checked to

Vs

Vp

Vp

Figure 5 Normal electrical capture, ventricular pacer. Normal ventricular electrical

capture is demonstrated by a pacer spike (Vp) followed by a corresponding,
widened QRS complex.
Abbreviations: Vp, ventricular pacing; Vs, ventricular stimulation (intrinsic).
Rhythm strip courtesy of Medtronic, Inc, Minneapolis, Minn.

CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 29

Ap

Ap

As

As

Ap

Figure 6 Normal electrical capture, atrial pacer. Normal atrial electrical capture is
demonstrated by a pacer spike (Ap) followed by a corresponding P wave.
Abbreviations: Ap, atrial pacing; As, atrial stimulation (intrinsic).
Rhythm strip courtesy of Medtronic, Inc, Minneapolis, Minn.

Figure 7 Failure to capture, dual-chamber pacemaker. Failure to capture occurs when

a pacer spike is present but is not followed by a corresponding waveform (P wave or
QRS complex). Arrow indicates electrical stimulus without ventricular capture.
Rhythm strip courtesy of Medtronic, Inc, Minneapolis, Minn.

detect disconnections, broken wires,

or other mechanical issues. If the
patients condition is stable, thresh-

old testing is done. If hemodynamic

compromise exists, the milliamperage is quickly increased until capture

Table 3 Factors that influence capture and sensing*

Fluid status changes
Pericardial effusion
Electrolyte or metabolic abnormalities
Medications
Tissue inflammation, fibrosis, or necrosis
Generator battery failure
Low pulse generator voltage
High pulse generator amperage
Development of endothelial sheaths
Disconnection, dislodgment, or fracture of leads
*X denotes an influence; no entry indicates no influence.

30 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004

Capture
X
X
X
X
X
X
X
X
X

Sensing
X
X

X
X
X
X
X

occurs. Turning the patient onto his

or her left side may also improve
capture by increasing contact between
the electrode and myocardial tissue.6
Electrical capture alone is inadequate. Adequacy of mechanical capture is assessed by feeling for a pulse
or checking blood pressure.7 Mechanical capture exists when the pacer
spike and its corresponding QRS
complex are followed by a cardiac
contraction.2
Sensitivity
Sensitivity is the component of
pacing that often confounds even
experienced clinicians. Nonetheless,
sensing merely refers to the ability of
the generator to detect and recognize
the impulses the myocardial tissue is
generating on its own.1 Intrinsic cardiac activity is usually more organized
and global than are paced beats.
Intrinsic activity stimulates better
contractions, and more effective forward flow of blood, from the chambers of the heart, especially when the
atria and ventricles are intrinsically
beating synchronously. When atrial
beats are unsynchronized or absent,
as in atrial fibrillation, atrioventricular block, or sinus arrest, cardiac
output decreases because less blood
than usual is ejected from the atria
during ventricular diastole. This concept is important because almost 30%
of normal cardiac output is due to
the atrial kick, or atrial systole, that
occurs during ventricular filling when
the 2 chambers perform in sync.3
These physiological principles
can be directly applied to the use of
mechanical pacemakers. Whenever
possible, intrinsic beats should be
allowed to occur naturally, providing a more global and organized
contraction. However, intrinsic

beats must be supplemented when

the rate is insufficient or conduction
of the beats does not generate ventricular contractions. For maximum
effectiveness, paced beats and
intrinsic beats must be synchronized. To synchronize the beats, the
generator first analyzes the intrinsic
rhythm and then stimulates the
heart only as needed.
Adjusting the sensing level sets
the pacer to look for intrinsic beats.
Pacemaker generators can be programed to deliver an impulse to the
ventricle each time an atrial beat is
sensed, or they can be set to stimulate
only when no intrinsic beat has been
detected during a predetermined
interval. For example, in a patient with
an intrinsic rate of 30 beats/min, the
generator may be set to pace both
chambers at 80 beats/min. The pacemaker will have no way of determining what the intrinsic rhythm is, or
when to stimulate in synchrony,
unless the sensitivity is adequately
adjusted to provide pacing only on
demand.
The sensitivity setting is measured in millivolts3 and is initially set
at about 2 to 5 mV. Failure to sense

occurs when the generator does not

recognize the hearts intrinsic
impulses1 (Figure 8). The most common cause of failure to sense is displacement of the electrode2 (Table
3). Repositioning the patient on his
or her left side may improve contact
between the electrode and the myocardium. If the response is still inadequate, then the sensitivity must be
increased.3 This increase is accomplished by turning down the millivoltage, allowing the generator to
detect beats that occur at lower millivolt levels. Conversely, if the pacemaker is detecting beats that are not
actually occurring (inappropriate
sensing), then the sensitivity threshold must be increased to block out
artifact. This increase is accomplished
by turning up the millivoltage.1

Care of Patients With Pacemakers

Once the wires are inserted into
the pacemaker box, the generator is
turned on, settings are adjusted, and
pacing should begin. However, if the
device is set to pace only when a
patients heart rate is lower than a
certain value, no pacing will occur
until the designated limit is reached.

Figure 8 Failure to sense, single-chamber atrial pacemaker. Failure to sense occurs

when the generator does not detect intrinsic beats and initiates an inappropriate
impulse that may or may not capture. Arrow indicates an atrial beat not sensed by
the pulse generator, which is followed by a pacer spike.
Rhythm strip courtesy of Medtronic, Inc, Minneapolis, Minn.

Electrical safety practices are especially important in caring for patients

with pacemakers. To prevent microshocks, nurses should always wear
gloves when handling electrodes and
should cover unused transthoracic
wires with the fingertip of a disposable glove.1 Microshocks are associated with ventricular dysrhythmias.
The pulse generator must be placed
in a location where it will not be
dropped on the floor. Lengthy cables
attached to the pacemaker need careful attention so that wires are not
inadvertently dislodged.
Routine nursing care of patients
with temporary pacemakers consists
of regular cardiovascular assessment
to evaluate pulses, level of consciousness, heart rhythm, pacer activity,
and hemodynamic response. Daily
management also includes an assessment of the insertion site. Depending
on the type of connection, the site will
be either a transthoracic or a central
venous catheter insertion site. The
wires must be secure and not at risk
for dislodgement.2 Nurses should
check to see if the wires are intact
and should note the number and
location. Care for a transvenous
wire site is the same as care for a
central vascular access site; dressing
are changed as prescribed by institutional protocol.7 Usually, the site is
cleaned with povidone-iodine or
another antimicrobial agent, and a
sterile occlusive dressing is applied,
with changes every 48 to 72 hours.7
In the first 48 hours after cardiac
surgery, epicardial wires usually are
under the initial dressing of the
chest tube or midsternal incision.
Once these bulky dressings are
removed, care of the epicardial site
should be performed daily whether
the site is left open to air or covered

CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 31

with a light dressing.7 The area is

cleaned with isotonic sodium chloride solution and assessed for redness or drainage. The wires must be
taped securely to the skin to prevent
accidental dislodgement.
Capture and sensitivity threshold testing should be performed
every 12 to 24 hours to determine
the best settings for the generator
(Table 4). As time passes, both
transvenous and epicardial wires
acquire endothelial sheaths around
their tips and thus require more milliamperes to capture and fewer millivolts to sense.7 The ability to
capture and sense is also influenced
by patients fluid volume status and
changes in cardiac tissue. Therefore,
thresholds must be tested regularly
to ensure proper pacing and prevent
loss of capture or inappropriate
stimulation. Chambers are tested
one at a time; atrial and ventricular
chambers should not be tested
simultaneously.7 Threshold testing
is generally contraindicated when
patients are being paced more than
90% of the time because of the risk
of losing capture while the patients
are dependent on generator-initiated
beats.7

Summary
Competent management of
patients with an invasive temporary
pacemaker is an important skill for
nurses who provide care for critically
ill patients with cardiac disease.
Such management requires familiarity with normal cardiovascular
anatomy and physiology, conduction
system defects, and rhythm interpretation. With an understanding of
the basic concepts of rate, output,
chambers, sensitivity, and capture,
pacing can be done with ease. Care

32 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004

Table 4 Threshold testing procedure6

Test atrial and ventricular chambers separately.
Capture
Do not test capture if the patient is being paced 90% or more of the time.
1. Turn the pacemaker rate up 10 beats/min higher the patients intrinsic rate.
2. Decrease the milliamperage until loss of capture occurs, and then slowly increase it
until depolarization occurs after every pacer spike. The milliamperage setting at
which depolarization occurs with every spike is the threshold for capture.
3. Set the milliamperage to 112 to 3 times the determined threshold.
4. Reset the pacer to the prescribed rate.
Sensitivity
Do not test sensitivity if the patient is being paced 90% or more of the time.
1. Set the heart rate at 10 beats/min lower than the patients intrinsic rate.
2. Reduce the output to 0.1 mA to prevent competitive pacing.
3. Increase the millivoltage until the sense indicator stops flashing and the pace
indicator starts flashing.
4. Slowly decrease the millivoltage until the sense indicator flashes continuously. This
value is the sensing threshold.
5. Set the millivoltage at half the sensitivity threshold value.
6. Reset pacer to prescribed rate.

of patients with a temporary invasive

pacemaker requires monitoring cardiac tissue and hemodynamic status,
observing for changes that would
indicate the need for modifications
in the pacemaker settings. Nursing
interventions include physical assessment, care of the insertion site, routine
threshold testing, and management of
the pulse generator.
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Critical Care Nursing. St Louis, Mo: Mosby;
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A, Ayres S, Holbrook P, Shoemaker W, eds.
Textbook of Critical Care. 4th ed. Philadelphia, Pa: WB Saunders Co; 2000:1061-1078.
3. Woods S, Sole M. Dysrhythmia interpretation.
In: Sole M, Lamborn M, Hartshorn J, eds.
Introduction to Critical Care Nursing. Philadelphia, Pa: WB Saunders Co; 2001:41-81.
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Shoemaker W, eds. Textbook of Critical Care.
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