Temporary emergency pacing—an orphan in district hospitals

Abstract

This editorial discusses a report on the 1 year experience with temporary pacing, especially in the emergency setting, in several Norwegian district hospitals. The vast majority of the patients received transvenous temporary pacing, and the majority of leads were placed by noncardiologists. The procedure times were long and complications were frequent. The organization of emergency pacing is discussed, and we suggest that unless qualified physicians can establish transvenous pacing, the patients who need that should be transferred with transcutaneous pacing as back-up during transport to a hospital with more available competence. Ideally, those who need pacing immediately, including those who need permanent pacing, should be offered permanent implantation on a 24 hours/7 days per week base.

Key words::

• pacemaker
• bradycardia
• quality assessment
• emergency medicine

In the present issue, Bjørnstad and coworkers from Norway describe the problems with establishing emergency pacing for bradyarrhythmias outside the university hospitals (1). Physicians from internal medicine without daily routine in cardiac pacing were usually responsible for such activities beyond daytime. Often, they were assisted by an anesthesiologist who could place an introducer into a jugular vein, but frequently, it was a once-in-a-year experience for all involved. The number of unsuccessful procedures as well as the complication rates were high. The authors are to be complimented for reporting the gloomy state of this art. There is little reason to believe that conditions are much better in the other Nordic countries.

When acute temporary pacing is considered, one must evaluate the potential hazards of the bradyarrhythmia and scrutinize the possibilities for avoiding pacing. If the patient is hemodynamically stable, a “monitor, wait and see”-strategy may be appropriate. Can drugs that reduce heart rate or conduction be withheld? Can atropine or beta-adrenergic agents stabilize the patient?

In 1959, Furman and Schwedel first reported successful temporary transvenous pacing (2). That was in two patients with AV-block and atrial still stand, respectively. Later on, the main indication has been conduction disturbances in acute myocardial infarction. Fortunately, the general impression is that modern drug treatment and acute revascularization have reduced the need for temporary emergency pacing (3). In the present Norwegian study, only 50 implantations were performed over 1 year, for a population of close to one million. As a consequence of this low number, more than one half of the physicians involved performed no more than one implantation during the year of study.

In daytime, temporary pacing may be performed by able cardiologists on a variety of indications: to obtain diagnostic invasive electrograms, burst pace arrhythmias, programmed stimulation for diagnostic purpose, and occasionally, prophylactic pacing during certain invasive procedures. Under such conditions, complication rates are very low. The same probably holds true when emergency pacing is needed during revascularization procedures for myocardial infarction. Experience secures quality. In Norway, the 24 hours/7 days temporary pacing service is covered by interns with back-up from a specialist in internal medicine, among which cardiologists contribute. District hospitals thus do not always have a cardiologist on call. This may explain the low number of yearly procedures per physician, the long average procedure time and the high rate of complications reported by Bjørnstad and coworkers. Transcutaneous pacing was used to a very limited extent in this study, at variance from a recent Danish study where in general, transvenous pacing was established when there was a cardiologist present, whereas transcutaneous pacing was used in the remaining 39% of hospitals (4) before transferal to a larger hospital.

There is a long list of possible complications to transvenous pacing. Bleeding, pneumothorax, venous thrombosis, pulmonary embolism, and perforation with subsequent cardiac tamponade all occur. When pacing is established, the patient often becomes dependent of cardiac stimulation, and lead dislodgment may be serious, and perhaps worse than were the previous short syncopal attacks that indicated pacing. To this should be added the risk of infection. In the present study, 60% of those temporarily paced finally had a permanent pacemaker implanted.

Transcutaneous pacing was introduced by Zoll in 1952 (5). Madsen and coworkers describe use of this method in 1988 (6) and conclude that transcutaneous pacing is effective (92% success in emergency cases) and safely can be used if inserting a transvenous catheter is impossible, or until one can be inserted. However, transcutaneous pacing is uncomfortable or really painful, and the patients usually need heavy sedation. Pacing is not reliable and often difficult to monitor. Therefore, common use is limited to the time until transvenous pacing can be established. In Denmark, distances between hospitals are shorter and transportation to another hospital for transvenous pacing was quite common, in contrast to the Norwegian study where it never occurred.

In Norway, internal medicine comprises eight subspecialties, among which cardiology is the largest one, both with respect to number of physicians and patients, and receives the largest number of emergency admissions. The general medical department is responsible for the 24 hours/7 days’ medical service, and in local and regional hospitals, there is not always a cardiologist available on call. Further, outside the university hospitals few cardiologists frequently perform invasive procedures. Both the American and the European recommendations state that 25 temporary pacemakers should have been implanted during basic training for cardiology (7), at competence level III, that is, “able to independently perform the technique or procedure unaided” (8).

The optimal solution is to have an able cardiologist on call for pacing procedures. The challenge then is to maintain the competence of the cardiologist when the number of procedure is limited. The department that is responsible for the cardiology service must also be responsible for maintenance of the cardiologists’ competence and cooperate with a larger center for practical updating. If there is no cardiologist on call, there are two options; either to use the specialist of internal medicine or the trainee doctor on duty, in cooperation with an anesthesiologist, or to use external pacing and transport the patient to a more competent hospital, as it is currently done in Denmark. The latter approach was found feasible by Vukov and Johnson (9). In a recent British survey, the self-assessed competence of noncardiology registrars was recorded. The outcome was far from satisfactory (10), in line with the Norwegian experience.

In the present study, 60% of the patients who received temporary pacing, later on had a permanent pacing system implanted. Often the patients had to wait for several days until pacemaker implantation. During the waiting period, frequent and severe complications occur, as recently demonstrated in a Danish study (11). An infection in the permanent pacing system may become a disaster, and treatment costs are high. A temporary pacing wire increases the risk of future infections and should be avoided unless essential (12).

Local traditions and competence as well as geographical considerations may justify different strategies, but it is obvious that we need a system that is better than that reported from South-Eastern Norway. A first step could be to transport patients who need immediate cardiac pacing, to a center that can offer permanent pacemaker implantation within 24 hours. The transport logistics have already been established for acute coronary syndromes. The consequence of the recent Danish study (11) is that the ultimate goal may be to offer a 24-hour pacemaker implantation service capacity for patients in need of acute long-term pacing, as already implemented in some parts of Denmark. At present, lack of skilled pacemaker implanters restricts this ambition. However, the Nordic societies for cardiology should present these challenges to hospital leaders and health authorities.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.