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  1. Bradyarrhythmias occur commonly in the intensive care unit (ICU), and most events do not necessitate temporary pacing.

  2. Transient bradycardia often occurs in the setting of enhanced vagal tone or other reversible causes.

  3. Temporary pacing should be considered when symptoms or hemodynamic compromise develops secondary to the bradyarrhythmia.

  4. Transvenous temporary pacing in the ICU setting generally requires intracardiac electrogram (EGM) guidance.

  5. Reliable temporary pacing requires adequate sensing and pacing thresholds, stable position of the lead, and secure connections of the pacing system.

  6. Permanently implanted pacemakers and implantable cardioverter-defibrillators (ICDs) generally function well in the standard programmed settings, and apparent “anomalous behavior” may be the result of acute rhythm change or electrolyte abnormalities, rather than device malfunction.


Bradyarrhythmias occur commonly in the ICU, and most events do not necessitate temporary pacing. Transient bradycardia often occurs in the setting of enhanced vagal tone due to tracheal irritation, suction, or intubation; abdominal distention; or severe vomiting. Reversible causes such as severe electrolyte or acid-base imbalances should be corrected first whenever possible, as this may obviate the need for pacing or enhance the likelihood that a temporary lead will function appropriately when placed. Isolated sinus pauses, transient extended pauses in atrial fibrillation (AF), and nocturnal bradycardia in patients with obstructive sleep apnea are all common, and generally do not require temporary pacing. Pacing is considered when patients are having symptoms or have developed hemodynamic compromise thought to be secondary to a bradyarrhythmia, or if a rhythm is detected that is associated with a high risk of subsequent malignant bradyarrhythmia (Table 103–1). Recognizing circumstances that portend risk, for example, anterior wall or inferior wall myocardial infarction (MI), or preexisting infra-Hisian conduction disease, will help identify patients at high risk for need of temporary pacing.

Table 103–1Indications for temporary cardiac pacing (based on ACC/AHA guidelines).

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