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AICD and Pacemaker Update. Kathryn Gray CRNA. Terminology:. Excitability: The ability of a cell to respond to a stimulus by depolarizing and propagating an action potential Depolarization : Occurs when there is a decrease in the polarity across a cell membrane.

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Aicd and pacemaker update

AICD and Pacemaker Update

Kathryn Gray CRNA


Terminology
Terminology:

Excitability: The ability of a cell to respond to a stimulus by depolarizing and propagating an action potential

Depolarization: Occurs when there is a decrease in the polarity across a cell membrane.

Hyperpolarization: Occurs when there is an increase in the polarity across a cell membrane.

Conductivity: The ability of a cell to transmit action potentials to adjacent cells.

Rhythmicity: The ability of cells to generate automatic action potentials.





Lets get nerdy
Lets get nerdy…

This equation is used to define the electrical gradient across a membrane based on ion concentrations

This can be applied to cardiac myocytes which helps to explain the ion potentials during AP propagation and RMP.


Paging dr nernst
Paging Dr. Nernst

Nernst Equation Em= (-RT/zF) X log [K]i/[K]o

Em is the equilibrium potential of the ion based on transmembrane concentrations.

R-universal gas constant (8.314472 JXK -1)

T- absolute temperature (273.15 degrees kelvin)

[K]i- potassium concentration on the inside of the cell

[K]o-potassium concentration on the outside of the cell.

z- the number of electric charges carried by a single potassium ion

F- the Faraday constant (9.6485309 X104 cmol-1)


Lets get really nerdy
Lets get really nerdy…

The Goldman-Hodgkin-Katz equation accounts for the ionic potentials of multiple ions across a cell membrane.

EMF= 61.5 X log([Na]iPNa+[K]iPK+[Cl]oPCl)

([Na]oPNa+[K]oPK+[CliPCl)


The sinoatrial node
The Sinoatrial Node

The SA node is made up of specialized cardiac muscle cells which do not have contractile abilities.

The SA node is the primary pacemaker in the cardiac conduction system.

It’s intrinsic rate is faster than the other latent pacemakers in the heart and thus overrides them.

It’s automaticity and intrinsic rate is dependant upon *calcium leak channels in the sarcoplasmic reticulum.




Ectopic pacemakers
Ectopic Pacemakers

This is a portion of the heart with a more rapid rate than the sinus node.

Also occurs when transmission from the SA node to A-V node is blocked (A-V block).

During sudden onset of A-V block, sinus node impulses do not get through, and next fastest area of discharge becomes pacemaker of heart beat.

Delay in pickup of the heart beat is called “Stokes-Adams” syndrome. The new pacemaker is in A-V node or penetrating part of A-V bundle.


Av node
AV node

The AV node contains highly specialized tissue that slows impulse conduction considerably thereby allowing sufficient time for complete atrial depolarization and contraction prior to ventricular depolarization and contraction.


Purkinje fibers
Purkinje Fibers

Located in the inner ventricular walls of the heart, just beneath the endocardium.

The Purkinje fibers have the fastest conduction speed of any fibers in the heart.


The ventricles
The ventricles

Normal ventricular RMP is -80 to -90mV

Action potential is accelerated once threshold is reached by the opening of fast Na channels and slow Ca channels.






Innervation of the heart
Innervation of the heart

Releases norepinephrine at sympathetic ending

Causes increased sinus node firing rate

Increases rate of conduction impulse

Increases force of contraction in atria and ventricles

Parasympathetic (vagal) nerves,

Release acetylcholine at their endings

innervate S-A node and A-V junctional fibers

Causes hyperpolarization because of increased K+ permeability in response to acetylcholine

Muscarinic Acetylcholine Receptors, when stimulated cause decreased heart rate

Sympathetic

Parasympathetic




Causes of cardiac dysfunction
Causes of cardiac dysfunction

Temperature extremes

pH imbalances

Hypo or Hypercalcemia

Malnutrition, cachexia

Hypoxia/Ischemia

Hypo or hyperkalemia

Autonomic imbalances

Hypo or hypercarbia

Magnesium deficiency

Drug toxicity and adverse drug reactions

Stress and catecholamine release

CAD

HTN

Dilated myopathy

Morbid obesity

Advanced age

CHF

Chronic lung disease and subsequent corpulmonale

Endocrine imbalance

Hypertropicmyopathy

Sick sinus syndrome

Increased ICP

Renal disease

Physiologic Imbalances

Associated Co-motbidities


Types of conduction disruptions
Types of conduction disruptions

  • - Atrial Fibrillation

  • - Atrial Flutter

  • - 1st degree heart block

  • - 2nd degree heart block

  • - 3rd degree heart block

  • - Ventricular fibrillation

  • - Ventricular tachycardia

  • - Re-entry arrhythmias







This is a schematic of how each pacemaker will affect the EKG depending on the intrinsic beat and pacemaker mode


Rate responsive pacemakers
Rate Responsive Pacemakers EKG depending on the intrinsic beat and pacemaker mode

  • Rate-Responsive Direct metabolic sensors:

    • 1. Mixed Venous O2 saturation

    • 2. Central venous pH

  • In-Direct metabolic sensors:

    • 1. Ventilation rate

    • 2. Mixed Venous Temperature

  • Non-Metabolic Physiological sensors

    • 1. QT interval

    • 2. Ventricular Depolarization Gradient

    • 3. Stroke Volume

    • 4. Mean Arterial Blood Pressure

  • Direct Activity sensors

    • 1. Motion detection


Pacemaker effects on co
Pacemaker effects on CO EKG depending on the intrinsic beat and pacemaker mode


Anesthesia and in situ pacemakers
Anesthesia and in situ pacemakers EKG depending on the intrinsic beat and pacemaker mode

Electromagnetic interference is always a problem when taking a person into the OR for a surgical procedure.

Increase in Pacemaker threshold with some drugs in the OR setting.

Physiologic alterations can change pacemaker function.


Questions you need to ask before going into the or
Questions you need to ask before going into the OR EKG depending on the intrinsic beat and pacemaker mode

What is the device?

What brand and model?

Does your hospital have a programmer for this make and model?

What is the magnet mode?

Why does the patient have a pacemaker?

What rhythm does the patient have when the pacemaker is shut off?

When was the last time it was interrogated?

How long has it been since the battery has been changed?


Aicd s
AICD’s EKG depending on the intrinsic beat and pacemaker mode


Indications for aicd insertion
Indications for AICD insertion EKG depending on the intrinsic beat and pacemaker mode


It depends
IT DEPENDS!! EKG depending on the intrinsic beat and pacemaker mode

  • What do you do when your patient has an existing pacemaker or AICD?


Anesthesia for patients with aicd s
Anesthesia for patients with AICD’s EKG depending on the intrinsic beat and pacemaker mode

Questions to ask the patient:

Why do they have an AICD?

How long have they had it?

Who is the manufacturer?

When was the last time it was interrogated?

When was the last time they received an AICD shock?

How often do they get shocked?


Danger in the o r

Danger in the O.R. EKG depending on the intrinsic beat and pacemaker mode


Electrocautery
Electrocautery EKG depending on the intrinsic beat and pacemaker mode

Bipolar vsUnipolar

Why do we need a grounding pad?

Why are we afraid of bovie with pacemakers and AICD’s?


Electromagnetic interference in the o r
Electromagnetic interference in the O.R EKG depending on the intrinsic beat and pacemaker mode.

Electrocautery

MRI

ESWL

Defibrillation

Motor evoked potentials

Nerve stimulators


Oversensing
Oversensing EKG depending on the intrinsic beat and pacemaker mode

  • Cause

    • Insulation breach

    • Bipolar impedance


Pacemaker oversensing
Pacemaker EKG depending on the intrinsic beat and pacemaker modeoversensing


Pacemaker undersensing
Pacemaker EKG depending on the intrinsic beat and pacemaker modeundersensing


Failure to capture
Failure to capture EKG depending on the intrinsic beat and pacemaker mode


Innapropriate aicd shock
Innapropriate EKG depending on the intrinsic beat and pacemaker mode AICD shock


The magic magnet
The Magic Magnet EKG depending on the intrinsic beat and pacemaker mode

The magnet IS NOT

magical!!!

Don’t be lured in to a false sense of security of “I’ll just put a magnet on it” to fix any problems.


Magnet mode
Magnet Mode EKG depending on the intrinsic beat and pacemaker mode

What happens when a magnet is applied over a pacemaker?

  • The pacemaker mode temporarily switches to VOO in single chamber devices and DOO in dual chamber devices.

    • Asynchronous pacing delivers output regardless of intrinsic activity

    • Pacing rate will be 85 bpm for pacemaker battery levels above ERI (elective replacement indicator) and 65 bpm for battery levels below ERI*

    • When the magnet is removed, the previously programmed mode returns*

  • Use when:

    • Checking pacemaker battery level

    • EMI is present (surgery, TENS, etc.)

    • Device troubleshooting (breaking a PMT, assessing capture, etc.)


Magnet mode1
Magnet Mode EKG depending on the intrinsic beat and pacemaker mode

  • What happens when a magnet is placed over an AICD?

  • If the patient is not pacemaker dependant….

  • If the patient is pacemaker dependant…


So what are the recommendations
So what are the recommendations? EKG depending on the intrinsic beat and pacemaker mode

De-fasciculation prior to succinylcholine is recommended if the patient has a RR pacemaker

Question the use of Nitrous if the pacemaker is new

Inhalation agents and propofol do not affect pacing thresholds.

What other monitors do I need?

YOU DO NOT ALWAYS NEED TO TURN OFF THE AICD OR PACEMAKER!


R ecommendations
R EKG depending on the intrinsic beat and pacemaker modeecommendations

Atropine should be close at hand if the patient should have severe bradycardia.

A patient with an AICD or pacemaker should NEVER be sent home without the device being interrogated by a representative of the device’s company if a magnet has been used.

What about ACLS with AICD’s and pacemakers?


Recommendations
Recommendations: EKG depending on the intrinsic beat and pacemaker mode

  • Perioperative management of these patients should be individualized.

  • The best type of anesthesia for the patient with an AICD or pacemaker depends on the type of surgery and the patient’s co-morbidities

  • Bipolar is better

  • If using monopolar cautery, place pad close to incision site and keep bursts to less than 5 seconds.

  • Cardioversion will reset the device

  • If below the umbilicus the risk of EMI is very low with a pacemaker.

  • Surgery below the umbilicus in the patient with an AICD may still create risk of innapropriate shock.


R ecommendations1
R EKG depending on the intrinsic beat and pacemaker modeecommendations

  • All volatile anesthetics depress cardiac contractility by decreasing calcium into cells during depolarization

  • NEVER TURN OFF A PACEMAKER OR AICD WITHOUT HAVING THE PATIENT HOOKED UP TO EXTERNAL PACING/DEFIBRILLATION PADS!!!!

  • Important phone numbers

    • Biotronik 800.547.0394

    • Boston Scientific 651.582.4000

    • SorinEla 800.352.6466

    • Medtronic 800.328.2518

    • St. Jude Medical 800.722.3774


Preoperative recommendations
Preoperative Recommendations: EKG depending on the intrinsic beat and pacemaker mode

  • All patients with pacemakers undergoing elective surgery should have had a device check as part of routine care within the past 12 months that identifies the required elements specified below.

  • • All patients with ICDs undergoing elective surgery should have had a device check as part of routine care within the past 6 months.


Emergency recommendations
Emergency recommendations EKG depending on the intrinsic beat and pacemaker mode

  • Identify the type of device

  • Determine if the patient is pacing

  • Pacemaker dependent

    — Yes: pacemaker (not ICD)

    — Yes: ICD and pacemaker

    — No: pacemaker (not ICD)

    — No: ICD and pacemaker

  • What if I need a central line?


Procedure specific recommendations
Procedure specific recommendations EKG depending on the intrinsic beat and pacemaker mode

  • MonopolarelectrosurgeryCIED evaluated within 1 month from procedure

  • External cardioversionCIED evaluated prior to discharge or transfer from cardiac telemetry

  • Radiofrequency ablation CIED evaluated# prior to discharge or transfer from cardiac telemetry

  • Electroconvulsive therapy CIED evaluated# within 1 month from procedure unless fulfilling Table 9 criteria

  • Nerve conduction studies (EMG) No additional CIED evaluation beyond routine

  • Ocular procedures No additional CIED evaluation beyond routine

  • Therapeutic radiation CIED evaluated prior to discharge or transfer from cardiac telemetry; remote monitoring optimal;

  • some instances may indicate interrogation after each treatment (see text)

  • TUNA/TURP No additional CIED evaluation beyond routine

  • Hysteroscopic ablation No additional CIED evaluation beyond routine

  • Lithotripsy CIED evaluated# within 1 month from procedure unless fulfilling Table 9 criteria

  • Endoscopy No additional CIED evaluation beyond routine

  • Xray/CT scans/mammography No additional CIED evaluation beyond routine

  • #This evaluation is intended to reveal electrical reset. Therefore, an interrogation alone is needed. This can be accomplished in person or by remote


P acemaker and aicd policy
P EKG depending on the intrinsic beat and pacemaker modeacemaker and AICD policy

Each facility should have a pacemaker and AICD policy. You should find and become familiar with yours.

When dealing with patients who have pacemakers or AICD’s, please use these policies to guide you since these are what you will be measured by if there are any problems.


References
References: EKG depending on the intrinsic beat and pacemaker mode

Atlee, J.L. (1996). Arrhythmias and pacemakers: Practical management for anesthesia and critical care medicine.Philadelphia,Pennsylvania:W.B. Saunders.

Björn, C.K., Roden, D.M. (2008). Genetic framework for improving arrhythmia therapy. Nature, 451, 929-936.

Burns, E. (2013). Pacemaker malfunction. Retrieved on August 12th, 2013 from www.lifeinthefastlane.com

Byong, J.,Mashahiro, O., shien-Fong, L.,Peng-Sheng, C. (2009). The Calcium and Voltage Clocks in Sinoatrial Node Automaticit. Korean circulation journal. June; 39(6): 217–222.

Charney, W. (1999). Handbook of modern hospital safety. Philadelphia, Pennsylvania: Elsevier-Mosby.

Crossley, G. et al. (2011). The heart rhythm society, american society of anesthesiologist expert consensus statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: Heart Rhythm Society.

Ellenbogen, K.A., Kay, G.N., Wilkoff, B.L. (2000). Clinical cardiac pacing and defibrillaiton.Philadelphia,Pennsylvania: W.B.Saunders.

Estafanous,F.G., Barash, P.G., Reves, J.G. (2001). Cardiac anesthesia principals and clinical practice(2nd ed.). Philadelphia,Pennsylvania: Lippincot-Williams and Wilkins.

Faust, R.J. et al.(2002). Anesthesiology review (3rd ed.). Philadelphia, Pennsylvania: Reed-Elsevier.

Greenburg, M.L. (2008). Catheter ablation. Retrieved October 16th, 2009 from www.emedicine.medscape.com.

Guyton, A.C.,Hall, A.C.(2006).Textbook of medical physiology (11th ed.). Philadelphia, Pennsylvania: Elsevier-Saunders.

Hines, R.L., Marschall, K.E. (2008). Stoelting’s anesthesia and co-existing diseases (5th ed.). Philadelphia, Pennsylvania: Elsevier-Saunders.

Klabunde, R.E. (2009). Cardiovacular physiology concepts. Ohio University. Retrieved on September 26th, 2009 www.cvphysiology.com.

Kanagaratnam, P., Koa-Wing, M., Wallace, D.T., Goldenburg, A.S., Peters, N.S., Davies, D.W. (2007). Experience of roboticcatheter ablation in humans using a novel remotely steerable catheter sheath. Journal of interventional cardiac electrophysiology. s10840-007-9184-z.


References1
References: EKG depending on the intrinsic beat and pacemaker mode

Kumar, P. (2007). AICD defibrillators. Retrieved September 26th, 2009 from www.heartonline.org

McChance, K.L., Huether, S.E. (2006). Pathophysiology: The biologic basis for disease in adults and children (5th ed.). Philadelphia, Pennsylvania: Elsevier-Mosby.

McCrossin, C., (2012). Pacemakers and ICDs. Retrieved on August 12th, 2013 from .docstoc.com

Morgan, G.E., Mikhail, M.S., Murray, M.J. (2006). Clnical anesthesiology (4th ed.). New York, New York: Lange.

Nagelhout, J.J., Zaglaniczny, K.L. (2005). Nurse anesthesia (3rd ed.). St. Louis, Missouri: Elsevier-Saunders.

Roizen, M.F., Fleisher, L.A. (1997). Essence of anesthesia. Philadelphia,Pennsylvania: W.B.Saunders. Philadelphia,Pennsylvania:Elsevier-Saunders.

Rooke, A.G. Pacemakers. University of Washington. Retrieved September 26th, 2009 from www.vaanes.org.

Seok, C. (2008). Fiber optic sensorized tools for cardiology aplications. Retreived October 16th, 2009 from www.bdml.stanford.edu

Sweesy, M.W. (2009). Fundamental electrical relationships:Ohm’slaw,sStrength duration curve & factors affecting thresholds.Cardio Rhythm 2009, Hong Kong, China. Retrieved October 3rd from www.cardiorhythm.com.

Peters, N.S., (2000). Catheter ablation for cardiac arrhythmias: ablation is the safe and curative treatment of choice. British Medical Journal. RetrievedOctober 16th, 2009 from http://findarticles.com/p/articles/mi_m0999/is_7263_321/ai_66238403/?tag=content;col1

Tempelhof, M.W. (2007). Pacemakers: The basics. Retrieved September 26th, 2009 from www.askdrwiki.com.

Trankina, M.F. (2002). Peripoerative pacemaker-ICD management.American Society of Anesthesiologists.Whats new in…., vol.66 pp 1-2.

TyRx (2009). AgisRx: Site specific delivery-global impact. Retrieved on September 27th, 2009 from www.tyrx.com.

Wallace, A. (2008). Pacemakers for anesthesiologists made incredibly simple. Retrieved September 27th, 2009 from www.cardiacengineering.com.

Williams, C. (2007). Cardaic electrophysiology for the anesthetist.Powerpoint presentation retrieved on September 26th, 2009 from www.medtronicconnect.com.


Questions

Questions? EKG depending on the intrinsic beat and pacemaker mode

Thank You!!!


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