Response

Abstract

Listen

Translate article

We thank Drs Baker and Wilson for their thoughtful comments on our work1Metkus T.S. Schulman S.P. Marine J.E. Eid S.M. Complications and outcomes of temporary transvenous pacing: an analysis of > 360,000 patients from the National Inpatient Sample.Chest. 2019; 155: 749-757Google Scholar and regarding the larger issue of providing optimal training for temporary pacemaker insertion to maximize educational value and patient outcomes. They highlight that trainees in the South West of England are placing fewer temporary transvenous pacemakers (TTPs), contrasting that fact with our report that the overall rate of TTP placement remains constant.1Metkus T.S. Schulman S.P. Marine J.E. Eid S.M. Complications and outcomes of temporary transvenous pacing: an analysis of > 360,000 patients from the National Inpatient Sample.Chest. 2019; 155: 749-757Google Scholar We note that our report comprises a national estimate of all TTP placements, irrespective of trainee involvement. However, our experience as medical educators mirrors their data suggesting that trainees are less confident in their ability to perform the procedure. Drs Baker and Wilson query whether changes in trainee experience could be a cause of the complication rates we observed, including the association of teaching hospital status with tamponade. Finally, they highlight the importance of strategies to optimally train clinicians in performing the procedure safely. Conceptually, placement of the transvenous pacemaker includes performing venous access with placement of the appropriate sheath, insertion of the balloon flotation catheter, and ensuring adequate placement of the pacemaker with appropriate capture.2Francis G.S. Williams S.V. Achord J.L. et al.Clinical competence in insertion of a temporary transvenous ventricular pacemaker. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology.Circulation. 1994; 89: 1913-1916Google Scholar Clinician inexperience has been associated with increased complications of central line placement3McGee D.C. Gould M.K. Preventing complications of central venous catheterization.N Engl J Med. 2003; 348: 1123-1133Google Scholar and pulmonary artery catheterization4Evans D.C. Doraiswamy V.A. Prosciak M.P. et al.Complications associated with pulmonary artery catheters: a comprehensive clinical review.Scand J Surg. 2009; 98: 199-208Google Scholar; this association is likely true for TTPs as well, extrapolating from other venous access procedures. A task force on clinical competence for TTP insertion highlights the cognitive and technical skills that the procedure requires and emphasizes that basic mastery of right heart catheterization is a requisite for TTP insertion.2Francis G.S. Williams S.V. Achord J.L. et al.Clinical competence in insertion of a temporary transvenous ventricular pacemaker. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology.Circulation. 1994; 89: 1913-1916Google Scholar The task force also notes that a minimum of 10 to 25 procedures may be required for training, although this number may vary at the individual level. In our experience, even trainees proficient in venous access and right heart catheterization can be unfamiliar with the different equipment, imaging findings, and knowledge of intracardiac electrograms that placing a TTP requires. These aspects of the procedure could be nicely amenable to didactic and simulation training, which has been described in the education of emergency medicine trainees.5Ahn J. Kharasch M. Aronwald R. et al.Assessing the accreditation council for graduate medical education requirement for temporary cardiac pacing procedural competency through simulation.Simul Healthc. 2013; 8: 78-83Google Scholar We also emphasize the importance of a reliable institutional pathway for expert consultation to supervise, teach, and perform TTP placement as necessary for patients presenting acutely. Ultimately, the combination of novel educational methods such as simulation coupled with educator and institutional commitment to teaching proper placement of TTP will best serve our patients. Experiences of Temporary Transvenous Pacing in the South West of England vs the US National Inpatient SampleCHESTVol. 155Issue 6PreviewWe read with interest the previous analysis in CHEST (April 2019) by Metkus et al1 of the outcomes and complications associated with temporary transvenous pacing. The authors should be congratulated on providing observational data on such a large dataset of 360,223 patients in the United States. Previously, many studies have been performed on much smaller datasets or in single centers.2,3 Full-Text PDF Complications and Outcomes of Temporary Transvenous Pacing: An Analysis of > 360,000 Patients From the National Inpatient SampleCHESTVol. 155Issue 4PreviewThe incidence of complications and the outcomes of temporary transvenous pacemaker (TTP) placement in the modern era are not well established. Full-Text PDF