Radiologic assessment of transvenous pacemaker placement during CPR

During an 18-month period we prospectively studied 36 emergency department patients who had a transvenous pacing catheter placed without fluoroscopic or ECG guidance during closed-chest massage. Transvenous pacing was instituted at a mean elapsed time of 35 minutes (range, ten to 80 minute) after the onset of cardiac arrest, including prehospital and ED care times. Catheter tip position was assessed using postresuscitation or postmortem chest radiographs. Pacing catheters were fixed in the position of electrical capture prior to radiographs; when capture was never achieved, the catheter was fixed at 35 cm from the point of insertion. Position of the catheter tip on radiographs was as follows: right ventricle, ten of 36 patients; right atrium, 18 of 36; and other location, eight of 36. Ectopic catheter tip positions included inferior vena cava (four), pulmonary artery (one), hepatic vein (two), and internal jugular vein (one). Catheter tip position within the right ventricle correlated with a significantly higher incidence of electrical capture when compared with other catheter tip locations (P less than .004). There was a significantly higher incidence of successful placement into the right ventricle when an internal jugular, rather than a subclavian venous, access route was used (P less than .004). Only one of 36 patients was resuscitated successfully; none lived to be discharged from the hospital. Misplacement of the catheter tip may contribute to the poor success rate of transvenous pacing during CPR. The internal jugular vein may be the access site of choice when transvenous pacing is attempted during chest compressions.(ABSTRACT TRUNCATED AT 250 WORDS)