How to place transvenous pacer

Equipment

• Essential: External pacemaker/generator, transvenous pacing catheter and compatible introducer sheath (e.g., 7 Fr Cordis kit), sterile central line kit, ultrasound machine
• Optional: Fluoroscopy (if available), alligator clip for ECG lead sensing

Positioning and Landmarks

• Position: Patient supine; head turned slightly away from the insertion site
• Landmarks/US: Use ultrasound guidance to obtain central venous access via right internal jugular (preferred) or left subclavian approach for a more direct route to the right ventricle ^1^4

Analgesia/Sedation

Option	When	Key note
Intravenous fentanyl	Prior to central line insertion	Provides modest sedation while preserving hemodynamics
Ketamine (low-dose)	In unstable patients needing procedural comfort	Maintains cardiovascular stability and spontaneous ventilation

Steps

1. Site Selection & Preparation: Choose the right internal jugular (or left subclavian) for a direct approach; prepare the sterile field and use ultrasound for venous access.
2. Central Venous Access: Insert a single lumen catheter using standard central line technique under ultrasound guidance to serve as the introducer sheath ^1.
3. Equipment Check: Test the pacing catheter’s balloon by inflating with 1.5 mL of air to ensure no leaks.
4. Pacer Connection & Initial Settings: Connect the catheter electrodes to the external pacemaker. Set the generator in asynchronous mode (e.g., rate around 80 bpm, max current output [~20 mA], low sensitivity so that pacing is not inhibited by intrinsic activity) ^2.
5. Catheter Advancement: With the balloon inflated, advance the pacing catheter through the introducer, using the marked measurement lines (typically advance to ~15–20 cm) while monitoring for pacer capture via ECG (look for paced QRS with LBBB morphology) and, if available, bedside ultrasound visualization of RV contraction ^1^3.
6. Capture Confirmation & Adjustment: Once electrical (and ideally mechanical) capture is observed, deflate the balloon and secure the catheter at the noted depth.
7. Final Generator Settings: Reduce current to identify the capture threshold then set output to twice the threshold. Adjust sensitivity as needed to allow intrinsic beats while supplementing the rhythm ^2.
8. Post-procedure Confirmation: Obtain a chest X-ray to confirm the tip is positioned near the RV apex and adjust as necessary.

Post-procedure

• Confirm: Verify electrical and mechanical capture via ECG, pulse oximetry, and/or bedside ultrasound.
• Aftercare: Secure the catheter with sutures and tape; ensure sterile dressing over access site.
• Re-check: Monitor for complications; repeat imaging if there is any concern for displacement or perforation.