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Discussion

Adjusting a temporary pacer

As a new grad in a CVICU setting I've gotten very different perspectives from different nurses regarding troubleshooting, pausing, or in any way touching a temporary pacemaker. My preceptor is one that will pause it to check the underlying rhythm at least once a shift. She'll also adjust the sensitivity if it begins to malfunction (pacemaker spikes all over the QRS complex, etc). The other night however, I was with another nurse who had an issue with the pacemaker throwing spikes into the middle of the complex (innappropriately pacing or whatever the term is for it) and wouldn't touch the thing. I believe the mode was DDD and the sensitivity was on async, this pt was an AVR and CABGx2 on POD1. I felt like maybe this pt's underlying rhythm was kicking in and we probably needed to pause it to see what was going on or change the sensitity, just as I had seen my preceptor do before. We ended up getting advice from the supervisor and leaving it alone since he was perfectly stable and waited til the surgeon came in that morning. The surgeon turned it off and pt was accelerated junctional rhythm so he just left it that way and everything was fine. Is that how things would have gone in your unit or do nurses make adjustments to the settings, pause, etc? I feel like I should be given a formal class or something about this thing. Thanks for your responses

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I would have increased the sensitivity and see if that helped. Or at least called the cardiologist. Can't you go into v tach if the pacer fires during repolarization?? Kind of like an r on t ???

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Pacing is probably the thing that terrified me most as a new CTICU nurse. Once you've turned it down once and seen asystole underneath, you're not real keen to do it again! But I went and did a 6 week pacing course and it was one of the most valuable things I ever did in terms of nursing education.

Of course you should be able to add sensitivity - there's really no risk in INCREASING sensitivity in a patient such as you described. If they are at risk of pacing spikes landing on a T wave, you bet it's worth adjusting.

In CTICU I would check and document outputs and sensitivities every shift.

A pt w/ an underlying rhythm should not be left in async for the R on T risk.

Never fear pausing the device to check rhythm and the associated hemodynamics.

I've seen several unnecessary codes from innapropriate pacing/failed sensing.

Turn sensitivity on and make sure the device is sensing native complexes. If accerelated junx w/ a good BP, turn the device off.

We have some nurses that will pause to check underlying rhythm and some that will absolutely not d/t fear of pacer dependency and/or unstable hemodymancis. I personally pause- our pacer units have a pause that lasts no more than 10 seconds, then it returns to the pacer settings. This enables us to get EKG's of the underlying without causing undue delay in pacing when pt is dependent. Of course if they are that dependent on the pacer-say asystole or HB and it is known you'd be foolish to pause pacing simply to check the underlying rhythm as a nurse-leave that for the MD.

It is always appropriate to adjust the sensitivity to gain good capture. Our policy is to check thresholds and document every shift ,and set the MA's to 2.5 times higher than the threshold with a minimum of no less than 10ma. If your pt has epicardial wires for days, epithelial tissue will surround the contacting ends and the ma and sensitivity needs will increase over time.

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It is always appropriate to adjust the sensitivity to gain good capture. Our policy is to check thresholds and document every shift ,and set the MA's to 2.5 times higher than the threshold with a minimum of no less than 10ma. If your pt has epicardial wires for days, epithelial tissue will surround the contacting ends and the ma and sensitivity needs will increase over time.

Sensitivity does not affect capture, and it's measured in millivolts, not mA. Perhaps you're thinking of output? Sensitivity allows the pulse generator to inhibit pacing if a native beat is competing.

It's definitely OK to change sensitivity and output as needed, because you're not changing the actual settings; you're making the settings work the way they're supposed to.

I do check the underlying rhythm, unless I know that there is something deadly underlying. If the patient is able to take the pacer being off for a minute without decompensating, I might take a moment to check the blood pressure and cardiac index with the native rhythm.

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