Temporary cardiac pacing in district general hospitals--sustainable resource or training liability?

Abstract

Temporary transvenous cardiac pacing is a potentially life-saving procedure for patients in whom there is an actual or a high risk of bradyarrhythmias or asystole in the emergency setting. In North America or Western Europe, provision of a temporary pacing service is normally within specialist cardiac centres, but in the UK, general physicians in District General Hospitals are typically on-call for such duties. Historically, this is the domain of the Medical Specialist Registrar. However, in the face of a fall in the number of temporary pacing procedures required, and less onerous rotas for junior doctors, critical problems with the current system now exist. The complication rates of temporary cardiac pacing remain high. The first component of temporary pacing—obtaining central venous access—may result in local trauma or pneumothorax. Failure to gain venous access itself is a recognized problem, with up to 17% of subclavian approaches and 8% of internal jugular vein approaches being unsuccessful.1 The second component—positioning of the temporary wire—may be associated with arrhythmias or cardiac perforation. However, perhaps the most feared complication is that of iatrogenic infection. In one series, 20% of patients developed microbiologically-confirmed septicaemia when the pacing wire was left in situ for > 48 h.1 This itself is a source of significant morbidity. Additionally, it often delays definitive treatment in the form of permanent pacemaker insertion when the patient is transferred to a …