safety margin for transcutaneous pacing

Insert the transcutaneous pacing wire. Add 2 mA or set the output 10% higher than the threshold of initial electrical capture as a safety margin. 2020 Jan - Feb. 58:119-24. Augmentation of cardiac output by external cardiac pacing: pacemaker-induced CPR. For more information, please refer to our Privacy Policy. The current was gradually increased to 110 mA, and the heart began to contract in unison with the pacer shocks. All rights reserved. versed) Avoid placing the pads over an AICD or transdermal drug patches There is little data on optimal placement however, try to place the pads as close as possible to the PMI (point of maximal impulse) [1,2] For pacing readiness in the setting of AMI as follows: New left, right, or alternating bundle branch block or bifascicular block, Bradycardia with symptomatic ventricular escape rhythms. 309(19):1166-8. endstream endobj 128 0 obj <>stream External noninvasive temporary cardiac pacing: clinical trials. Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Ettin D, Cook T. Using ultrasound to determine external pacer capture. Pacing Clin Electrophysiol. Transcutaneous pacing is noninvasive and can be performed by ECC providers at the bedside. As the mA output is increased, complete capture is achieved. Craig, Karen RN, BS. Ramin Assadi, MD Assistant Professor of Medicine, Division of Interventional Cardiology, University of California, Los Angeles, David Geffen School of Medicine Utility and safety of temporary pacing using active fixation leads and externalized re-usable permanent pacemakers after lead extraction. This rate can be adjusted up or down (based on patient clinical response) once pacing is established. Content posted on this site is NOT medical advice and should not be used to treat patients or yourself. The patient's blood pressure improves slightly to 84/47 (confirmed by auscultation). Contact us through social media or use the Contact form under the About Us menu. Most patients cannot tolerate currents of 50 milliamps and higher without sedation. The pacing electrode pads of an external pacing unit and locations in which each pad should be placed. Source: Reprinted from How to provide transcutaneous pacing, Nursing2005, K Craig, October 2005. Ho JD, Heegaard WG, Brunette DD. We respect your privacy and will never share your email. Transcutaneous Pacing (TCP) is a temporary means of pacing a patient's heart during an emergency and stabilizing the patient until a more permanent means of pacing is achieved. The information on this website should not be used to establish standard care or standards of practice for the purposes of legal procedures. Payne JE, Morgan JL, Weachter RR, Alpert MA. hbbd```b``&@$ZzD`O`)d+0H2L@D".H(S0$N``$@ k https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvOTg5MzktcGVyaXByb2NlZHVyZQ==. [Full Text]. 2014 Jun. J Emerg Med. Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine These heart contractions did not correspond with the surrounding thoracic muscle contractions generated by the pacer. In the ICU the patient remains dangerously hypotensive in spite of dobutamine and levophed drips. Available at https://www.medscape.com/viewarticle/957561. Kawata H, Pretorius V, Phan H, et al. x]$Gq\;gX0 {Yc|!$` optuuSY=wo*###;"?Y-W7~O>?O{/{zyj[ov~w{maot?)`]-7q7awk_-a5L@|yx\ s?9^kXuhs~8s\_}7C}q#N>:^?}8xa=\=sxbsx!_ ?baCzU>a~}es7o1M!4XFRn~>Rp"X Z'pqo !|)!Xry{(It_9T%v'8\AT$DN)s:i|hF}$M]GHW#0^,_2|X%#E3jn'cnC.yI'u?wB:,_pH,(5X8f# xOoxIY=dbm^DGOFwvNf On arrival at the hospital the patient is transitioned to transvenous pacing. Patient discomfort, burns (these are rare due to the large pads and lower outputs of today's TC pacing devices), Failure to recognize an underlying treatable ventricular fibrillation due to obscuration of the ECG by pacer spikes. 1995;33:769. Transcutaneous cardiac pacing in a patient with third-degree heart block. Figure Cautions for using TCP Watch for a change in your patient's underlying rhythm. 2020 Sep. 43(9):1004-11. [QxMD MEDLINE Link]. Note that pacing temporary wires at unnecessarily high outputs may lead to premature carbonisation of the leads and degradation of wire function. Oversensing is inappropriate inhibition of the pacemaker due to detection of signals other than R waves (e.g. 37(6):781-90. 84(3 Pt 1):395-400. Metkus TS, Schulman SP, Marine JE, Eid SM. Transcutaneous pacing can be painful and may fail to produce effective mechanical capture. Sovari A, Zarghamravanbakhsh P, Shehata M. Temporary cardiac pacing. At ACLS Medical Training, we pride ourselves on the quality, research, and transparency we put into our content. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. However, if the threshold is > 10 mA, the margin of safety is set to a lesser value, so as not to accelerate fibrosis at the lead/myocardium interface. Cardiac output is defined as the amount of blood the heart pumps out per minute and is the product of stroke volume and heart rate. 2023 Springer Nature Switzerland AG. 49(5):678-81. The transcutaneous pacer is set for 70 PPM at 50 mA. [QxMD MEDLINE Link]. [Internet]. This will pause the TCP spikes for a few seconds so you can identify the underlying rhythm. High degree AV block with wide complex escape rhythm. We guarantee the ACLS Medical Training provider card will be accepted worldwide and offer a 100% money back guarantee. 1988 Dec. 11(12):2160-7. Without abrading the skin, carefully shave excessive body hair, which can elevate the pacing threshold and increase burning and discomfort. Trigano AJ, Azoulay A, Rochdi M, Campillo A. Electromagnetic interference of external pacemakers by walkie-talkies and digital cellular phones: experimental study. Alternatively, the positive electrode can be placed anteriorly on the right upper part of the chest (see the image below). Because of this, patients who are conscious and hemodynamically stable should be sedated with a drug, such as midazolam, before initiation of pacing (see Procedural Sedation). Ventricular fibrillation would necessitate a different treatmentthe definitive therapy is immediate defibrillation. 1988 Mar. 117(21):e350-408. [QxMD MEDLINE Link]. Abraham G Kocheril, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Cardiology, Central Society for Clinical and Translational Research, Heart Failure Society of America, Cardiac Electrophysiology Society, American College of Physicians, American Heart Association, American Medical Association, Illinois State Medical SocietyDisclosure: Nothing to disclose. 4. Simply email us through the contact us link displayed on every page of this website any time within 60 days of purchase. Avoid using your patient's carotid pulse to confirm mechanical capture because electrical stimulation can cause jerky muscle contractions that you might confuse with carotid pulsations. [1], Shortly after cardiac pacing was initiated, the patients systolic blood pressure dropped to 50 mmHg. 2019;155(4):74957. You can see another example where an echo was used to verify capture here. Treat underlying cause. Safety and efficacy of noninvasive cardiac pacing. Medtronic Academy [Internet]. Document your patient's initial cardiac rhythm (including rhythm strip and 12-lead ECG if possible), the signs and symptoms that indicated his need for pacing therapy, the pacer settings (rate, current output, pacing mode), a cardiac rhythm strip showing electrical capture, the patient's pulse and BP, his pain intensity rating, analgesia or sedation provided, and his response. Thomas James, Director of Customer Experience. When using external transcutaneous pacing, the conduction can fade with time; the pacer can stop working. Equipment used in transcutaneous cardiac pacing includes the following: Although some pacing units provide only pacing, most defibrillators provide both cardiac pacing and rhythm monitoring. [QxMD MEDLINE Link]. Clip excessive body hair if necessary (shaving could cause tiny nicks in the skin, causing pain and irritation). First human demonstration of cardiac stimulation with transcutaneous ultrasound energy delivery: implications for wireless pacing with implantable devices. Holger JS, Minnigan HJ, Lamon RP, Gornick CC. 9% normal saline is run wide open with an additional IV line established in the left lower extremity. 52(1):111-6. -q-1gj+T!LcLm3cQrZH'm Successful transcutaneous pacing in 2 severely hypothermic patients. Zoll PM, Zoll RH, Falk RH, Clinton JE, Eitel DR, Antman EM. Provided by the Springer Nature SharedIt content-sharing initiative, Over 10 million scientific documents at your fingertips, Not logged in Treat those bradycardias associated with hypotension, pulmonary edema, or evidence of decreased cerebral perfusion that is unresponsive to initial first line measure, Initiate TCP while searching for correctable causes and concomitantly administering other therapies (i.e. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. When considering institution of transcutaneous pacing, always think about alternate causes for acute dysrhythmia, e.g. 14(2):137-42. [Full Text]. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Project the cash flows ten years into the future, and repeat steps one and two for all those years. Christian Schroder How to determine paccing threshold? To record a clear electrocardiographic rhythm, the recording electrode should be placed as far as possible from the pacing pads (see Positioning). Current is applied until electrical capture (characterized by a wide QRS complex since the SA node-AV node conducting pathway is bypassed, with tall, broad T-waves on the EKG) occurs. Monitor your patient's heart rate and rhythm to assess ventricular response to pacing. The utility of ultrasound to determine ventricular capture in external cardiac pacing. SVT with Aberrancy or Ventricular Tachycardia? This blog post has been written, fact checked, and peer-reviewed by our team of medical professionals and subject matter experts. Transcutaneous Cardiac Pacing. Resuscitation. 50(9):877-83. 1983 Nov 10. Key to the case management is the determination that the symptoms or signs due to the decreased heart rate. Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty ProfessorsDisclosure: Nothing to disclose. hb```"uVxa !&00a` 30*31(5Xp-`Jb&[3O M2UrPf!,+4h=_A&- _6 Normal action potential of myocyte and main ion channels that play major roles in different phases of action potential. The problem of false capture (also known as echo distortion) is under-recognized and under-reported in the medical literature. Abraham G Kocheril, MD, FACC, FACP, FHRS Professor of Medicine, University of Illinois College of Medicine Medication Summary The goal of pharmacotherapy is to provide sedation and pain medication to relieve the discomfort, such as burning sensation of the skin and/or skeletal muscle contractions that. J Endovasc Ther. ACLS Medical Training does not provide medical advice, diagnosis, or treatment. 2002;25(2):2604. Am J Emerg Med 2016; 34:2090. Holger J S, Lamon R P, and Minnigan H J et al. Transcutaneous Cardiac Pacing. Consider sedation for conscious patients unless they are unstable or deteriorating rapidly and pacing should not be delayed, turn on pacer and set the demand rate to approx. D Conduct a problem-focused history and physical examination; search for and treat possible contributing factors. J Cardiovasc Electrophysiol. [cited 2019 July 22]. Complications and outcomes of temporary transvenous pacing. Ann Emerg Med. Take the free cash flow of the first year and multiply it by the expected growth rate. In this chapter we discuss the implications of a slow heart rate and the treatment options available including how to place these temporary pacing devices and trouble-shooting to achieve the best clinical outcome. Transcutaneous pacing requires only pacing pads, EKG leads, . [Some need treatment and some dont eg a well conditioned athelete]. Optimal placement for pads varies by manufacturer, but is generally anterior-posterior or anterior-lateral, with the former being most common. Position the electrodes on clean, dry skin and set the pacing current output as shown in the photos. Influence of the shape of the pacing pulse on ventricular excitation threshold and the function of skeletal muscles in the operating field during non-invasive transcutaneous cardiac pacing under general anaesthesia. Sherbino J, Verbeek PR, MacDonald RD, Sawadsky BV, McDonald AC, Morrison LJ. Both electrical and mechanical capture must occur to benefit the patient. 2018 Aug. 36(8):1523.e5-.e6. Cardiol J. Sign up with your email address to receive updates and new posts. Ventricular fibrillation would necessitate a different treatmentthe definitive therapy is immediate defibrillation. Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA, Department of Surgery, Oregon Health & Science University, Portland, OR, USA, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA, Allshouse, K.J., Musialowski, R.S. There are many reasons why medical professionals often fail to achieve true electrical and mechanical capture. Pulses are difficult to palpate due to excessive muscular response. Europace. Transcutaneous pacing (TCP) is a difficult skill that is often performed incorrectly. 1985 May. Simons GR. A preliminary report. 9. 2013 Aug. 15(8):1205-9. Part of Springer Nature. Trigano JA, Remond JM, Mourot F, Birkui P, Levy S. Left ventricular pressure measurement during noninvasive transcutaneous cardiac pacing. University of Ottawa Heart Institute: Temporary Cardiac Pacing. If the patient has adequate perfusion, observe and monitor (Step 4 above), If the patient has poor perfusion, proceed to Step 5 (above), Atropine 0.5 mg IV to a total dose of 3 mg. [You can repeat the dose every 3 to 5 minutes up to the 3 mg maximum], Dopamine 2 to 20 mcg/kg per minute (chronotropic or heart rate dose), Hemodynamically unstable bradycardia (eg, hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, acute heart failure [AHF] hypotension), Unstable clinical condition likely due to the bradycardia. Cardiac Pacing and Resynchronization Clinical Practice Guidelines (ESC/EHRA, 2021), https://www.medscape.com/viewarticle/957561, Society for Cardiovascular Magnetic Resonance, Central Society for Clinical and Translational Research, Society for Cardiovascular Angiography and Interventions. If you do not have ventricular capture ensure the pacing box is turned on and that all connections are correct. When bradycardia is the cause of symptoms, the rate is generally less than 50/min. Temporary Transvenous and Transcutaneous Pacemakers. Patients requiring a permanent system should only undergo temporary pacing for syncope at rest, haemodynamic compromise, or bradycardia-induced ventricular tachyarrhythmias. Reuse of OpenAnesthesia content for commercial purposes of any kind is prohibited. Webster J G, and Tompkins W J et al. It can be difficult to assess whether myocardial capture has been achieved; the surface electrogram and telemetry are frequently obscured by a large-amplitude pacing artifact, and palpation of the pulse can be . Permanent-temporary pacemakers in the management of patients with conduction abnormalities after transcatheter aortic valve replacement. 2023 ACLS Medical Training, All Rights Reserved. 2018 Jun. Transcutaneous temporary pacing is mostly used as a "bridging" modality in emergency circumstances. Your message has been successfully sent to your colleague. Next, perform the Primary Assessment, including the following: Decision Point: Adequate Perfusion? The size of the electrode pads usually ranges from 8-15 cm, and the pacing electrodes can be applied by medical personnel. Feldman MD, Zoll PM, Aroesty JM, Gervino EV, Pasternak RC, McKay RG. Cardiac intensive care. 2. 5th ed. Algorithms for loss of capture for transcutaneous and transvenous pacemakers have been developed. Skeletal muscle contraction occurs at current levels as low as 10 milliamps, and does NOT suggest electrical or mechanical capture. This rate can be adjusted up or down (based on patient clinical response) once pacing is established. Wolters Kluwer Health, Inc. and/or its subsidiaries. Schwartz B, Vermeulen MJ, Idestrup C, Datta P. Clinical variables associated with mortality in out-of-hospital patients with hemodynamically significant bradycardia. CrossRef If capture is maintained but the patient remains symptomatic of inadequate tissue . Malden: Blackwell Publishing; 2005. Consider this excerpt from the Journal of Emergency Medicine where Douglas Ettin, M.D. [QxMD MEDLINE Link]. Am J Med. 3 months ago Get new journal Tables of Contents sent right to your email inbox, Take the lead on safety with temporary cardiac pacing, Monitoring temporary pacemaker connections, Articles in PubMed by Karen Craig, RN, BS, Articles in Google Scholar by Karen Craig, RN, BS, Other articles in this journal by Karen Craig, RN, BS, Privacy Policy (Updated December 15, 2022). Crit Care Nurse. Bektas F, Soyuncu S. The efficacy of transcutaneous cardiac pacing in ED. Learn how temporary noninvasive cardiac pacing can protect your patient until normal conduction is restored or he receives a transvenous pacemaker. Philadelphia: Elsevier; 2019. p. 45660. Step 4: Set the current milliamperes output 2 mA above the dose at which consistent capture is observed (safety margin). When using external transcutaneous pacing, the conduction can fade with time; the pacer can stop working. What is the safety margin for a transcutaneous pacemaker? More examples of transcutaneous pacing (TCP) with capture. J Emerg Med. 1999 Apr. 2007. Once the TPW has been positioned check stability by asking the patient to take deep Acad Emerg Med. Oesophageal and transcutaneous pacing may depolarise large areas of the myocardium simultaneously, but the effect is usually similar to ventricular pacing. Advance the plastic sheath over the pacing wire until it straightens out and covers the J-shaped end of the pacing wire. to perform CPR) during pacing. endstream endobj 125 0 obj <>/Lang(en-US)/MarkInfo<>/Metadata 6 0 R/OCProperties<>/OCGs[]>>/Pages 122 0 R/StructTreeRoot 11 0 R/Type/Catalog/ViewerPreferences 149 0 R>> endobj 126 0 obj <>/MediaBox[0 0 612 792]/Parent 122 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 127 0 obj <>stream Jaworska K, Prochaczek F, Galecka J. In contrast, true electrical capture will show wide QRS complexes with tall, broad T-waves. 2001 Mar. 2021 Aug 29. 2003;21:227. Our editorial team follows strict sourcing guidelines and relies on academic research institutions, government agencies, medical associations, and peer-reviewed medical literature in the field of resuscitation and emergency medical care. Those units can usually deliver a current as high as 200 mA for as long as 40 ms. In addition to synchronized TCP, there is an option for asynchronous TCP in cases of VF, VT, complete heart block. METHOD OF INSERTION AND/OR USE place pads in AP position (black on anterior chest, red on posterior chest) connect ECG leads set pacemaker to demand turn pacing rate to > 30bpm above patients intrinsic rhythm set mA to 70 start pacing and increase mA until pacing rate captured on monitor Available from: http://www.medtronicacademy.com/. On arrival, the patient is found lying in bed unresponsive to painful stimuli. Maintain electrical safety. If you log out, you will be required to enter your username and password the next time you visit. [QxMD MEDLINE Link]. If either stroke volume or heart rate falls, there may be dire consequences in blood flow to the body, producing severe symptoms for the patient. 1999;17:10071009. :Use of ultrasound to determine ventricular capture in transcutaneous pacing. threshold to provide a safety margin. The anterior electrode should have negative polarity and should be placed either over the cardiac apex or at the position of lead V3. EMS is dispatched to a private residence for 70-year-old female who is believed to be unconscious. 3rd ed. Video courtesy of Therese Canares, MD; Marleny Franco, MD; and Jonathan Valente, MD (Rhode Island Hospital, Brown University). 2007 Apr. Three common causes of bradycardia in the emergency department include drugs (specifically overdoses) hyperkalemia, and myocardial ischemia: While most textbooks may quote overdrive pacing for refractory tachyarrhythmias, practically speaking, most of these will get simply get cardioverted, TCP is only a bridge until a transvenous pacemaker can be placed, There are a few instances where TCP may be preferable over TVP, Patients who may respond to respond to therapy (eg. Am J Emerg Med. He may require TCP until his conduction system recovers or until he receives a transvenous pacemaker. hmk9^4zp$ 4-xYplcovcfFoLR(+JE$H 0^(ea,- SN#!3BB'>fWih)C5/&8j/m]%p f]f/inwWz6k=k6`j^?`Yt>OM3mVu3Fugv1W ]\,RkGF2f.]7Ye,Z(;~|uj8i)K+}Rk'I#,Qt&JB" H%MR[Bh. Medscape Medical News. Ottawa: University of Ottawa. % If time allows, obtain informed consent. The patients skin is pale and clammy. Please try again soon. In skilled hands, the semifloating transvenous catheter is successfully placed under electrocardiographic (ECG) guidance in 80% of patients.1 The technique can be performed in less than 20 minutes in 72% of patients and in less than 5 minutes in 30% ( Videos 15.1 - 15.3 ). The margin of safety formula can also be applied to different departments within a single company to define how risky they may be. Transcutaneous pacing electrodes (self adhesive gel pads frequently also used as defibrillator pads) are usually positioned in an anteroposterior configuration (see Fig. Ettin D and Cook T.:Using ultrasound to determine external pacer capture. Recognition of the type of AV block is a secondary goal. your express consent. Also, complete or third-degree AV block is the degree of block most likely to cause cardiovascular collapse and require immediate pacing. Stop advancing the pacing wire when 4 to 5 cm remains outside the cannula. Periodically check the area where the electrodes are placed for skin burns or tissue damage. [QxMD MEDLINE Link]. Increasing energy can assist mitigating that risk. [PMID:8558949], 2. Share cases and questions with Physicians on Medscape consult. Complete AV block is generally the most important and clinically significant degree of block. [Guideline] Epstein AE, DiMarco JP, Ellenbogen KA, et al. Additional treatments This work by www.downeastem.org is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. [21]. Transcutaneous pacing with external pacemakers is indicated as a temporizing measure for treatment of symptomatic bradycardias, including sinus bradycardias and atrioventricular (AV) nodal blocks; it may also be used prophylactically in patients with these rhythms who are maintaining a stable blood pressure. Hemodynamic responses to noninvasive external cardiac pacing. [QxMD MEDLINE Link]. Try to avoid abrading the skin when shaving excess hair, to remove a foreign body, to clean the skin, and to review and address the above-mentioned factors that may increase the pacing threshold. You need to have some way to tell that the heart is being paced and generating a blood pressure; have a pulse oximeter or arterial line waveform for confirmation of the monitors electrical activity. Please review our refund policy. Medscape Education. Am J Emerg Med. N Engl J Med. 73(1):96-102. Sedation and analgesia can be considered when consulting a Base Hospital Physician to tailor the management plan to the patient. Pacing spikes are visible with what appear to be large, corresponding QRS complexes. Europace. Pacing Clin Electrophysiol. Brooks M. ESC Updates guidance on cardiac pacing, resynchronization therapy. HV[O0~cwB61i])I\u;N6v#TUssTlBj5X\y|BW-f%a{|@Gc"HQahxZt;cFb)Qk$B)mA:'h}Lq, `'Q #564!R.M!CHR`!m:nj+\Pl,V|im}NBH'!9 3I6@* KpW2CU(%ph)m0fEYjbBO45P;pH+!KLT[Vv,D]'tl!gdVK\Y{}X [QxMD MEDLINE Link]. stream Use of this blog and its associated media does not constitute the establishment of a physician-patient relationship. Finally, do not be fooled by the monitor into believing that the appearance of QRS complexes means that the patients heart has been captured and is delivering a sustainable blood pressure! Sinus node disease rarely requires temporary pacing. Sodeck GH, Domanovits H, Meron G, et al. Use an instrument (SpO2, Doppler, capnography, or echo) to help confirm mechanical capture whenever possible. Step 3: Set the demand rate to approximately 60/min. However, paramedics are still concerned about the patients hypotension. [QxMD MEDLINE Link]. Pacing thresholds may change without warning and capture can readily be lost. This intervention can be used to over-ride a malignant tachydysrhythmia or compensate for symptomatic bradycardia. 2015 Nov. [cited 2019 July 22]. Please confirm that you would like to log out of Medscape. Im SH, Han MH, Kim SH, Kwon BJ. During transcutaneous pacing procedure, upon electrical and mechanical capture, it is recommended to increase the milliamps (mA) 10% higher than the threshold of initial electrical capture as a safety margin (usually 5-10 mA). (eds) Interventional Critical Care. Q Correspondence to Karen Craig is president of EMS Educational Services, Inc., in Cheltenham, Pa. Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. It is important to educate the patient about the procedure and especially about potential discomfort related to skin tingling and burning and associated skeletal muscle contractions.