This review examined means of reducing complications when inserting temporary cardiac pacing wires. The author concluded that right internal jugular veins are the best access route, and that the use of antibiotics, ultrasound probes and alternative procedures should be considered. Given the non-randomised nature of the data and several methodological issues, the reliability of these conclusions is unclear.

To review the evidence on temporary cardiac pacing wires, and to determine the best routes of venous access and means of reducing complications.

MEDLINE, EMBASE, the Cochrane Library and the Internet were searched; some search terms were reported. Unpublished data, including abstracts to conferences and meetings, were also sought. The author also searched for papers reported in languages other than English.

The inclusion criteria for study designs were not stated clearly. None of the included studies were randomised.

Studies of temporary cardiac pacing wires were eligible for inclusion. The included studies examined cardiac pacing wires inserted via the subclavical vein, internal jugular vein, femoral vein and antecubital fossa vein.

Studies of patients undergoing placement of temporary cardiac pacing wires appeared to be eligible for inclusion. The included studies involved patients with the following indications for wire insertion: third degree heart block or other bradycardias, failure of permanent pacemaker, sick sinus syndrome and sinus pauses.

The primary outcomes included in the review were the occurrence and nature of complications, and whether the cardiac pacing wires were administered by a specialist or generalist.

The author did not state how the papers were selected for the review, or how many reviewers performed the selection.

The author did not report that they assessed validity.

The author did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

The studies were combined in a narrative.

Differences between the studies were discussed in the narrative synthesis in terms of route of venous access, complications and specialist compared with generalist administration.

Fifteen studies with a total of 3,817 patients were included in the review. A retrospective study performed by the author was also reported but was not discussed in this abstract.

Complications occurred in between 10% and 59.9% of procedures (mean 26.5%).

The most frequent complications were: failure to secure venous access (mean 15%, range: 6 to 40), failure to place the lead correctly (mean 10%, range: 5 to 25), sepsis (mean 9%, range: 2 to 18), puncture of arteries (mean 4%, range: 0 to 6), lung or myocardium puncture (mean 2%, range: 0 to 4) and life-threatening arrythmias (mean 1%, range: 0 to 2).

There was no relationship between study date and reported complication rate. From the graph it appears that there is a trend toward a positive relationship between age and complication rate, although no formal statistical analyses were presented.

Two studies were of both generalist and specialist clinical practitioners, nine were of generalists only, and three were of specialists only. From the graph it appears that complications were lower for specialists than generalists, although no statistical analysis was presented. One study reported 9 complications from 30 procedures (30%) for generalists, compared with 20 complications from 87 procedures (23%) for specialists.

The complication rates in the largest study were highest for antecubital fossa lines (17.2%) compared with those for right internal jugular routes (8.1%).

Internal jugular veins are the preferred route for access, followed by subclavian and femoral veins; the right side should be used when possible. The use of antibiotics and ultrasound probes should be considered for all wire insertions in order to reduce the risk of complications. Alternatives to wire insertion should be seriously considered, particularly in elderly patients.

The review question was clear, although the inclusion criteria were not explicitly stated. The search was adequate and attempts were made to locate unpublished studies and studies published in languages other than English, thereby reducing the possibility that relevant studies were not included in the review. The author did not report assessing validity or using measures to minimise bias and error in the selection of studies and extraction of data for the review, therefore the possibility of reviewer bias or error cannot be assessed. The decision to employ a narrative synthesis was appropriate. There were little data on the individual studies included in the review, which means that it is difficult to assess the review's generalisability. Since the validity of the included studies was not assessed and appropriate review methodology was not reported, it is not possible to determine the reliability of the author's conclusions.

Practice: The author stated that the setting up of an on-call rota of experienced doctors should be considered in order to reduce complication rates. In addition, he made the following recommendations in relation to the clinical procedure: the need for a wire should be considered in the light of all possible alternatives; the most experienced available clinician should perform the procedure; the right internal jugular vein should be used if possible; an ultrasound machine should be used if available; vigilant asepsis should be employed.

Research: The author did not state any implications for further research.

This record is a structured abstract written by CRD reviewers. The original has met a set of quality criteria. Since September 1996 abstracts have been sent to authors for comment. Additional factual information is incorporated into the record. Noted as [A:....].