Anaesthetic management of a patient with a pacemaker
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ANAESTHETIC MANAGEMENT OF A PATIENT WITH A PACEMAKER. Dr. Vandana Talwar Senior Specialist & Associate Professor VMMC and Safdarjang Hospital, New Delhi. www.anaesthesia.co.in [email protected]

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Anaesthetic management of a patient with a pacemaker
ANAESTHETIC MANAGEMENT OF A PATIENT WITH A PACEMAKER

Dr. Vandana Talwar

Senior Specialist & Associate Professor

VMMC and Safdarjang Hospital,

New Delhi

www.anaesthesia.co.in

[email protected]


Artificial pacemakers are electronic devices that stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


COMPONENTS OF PACING SYSTEM stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


Pacing lead stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

Pulse generator Electrodes

(heart muscles)


PULSE GENERATOR stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Power source (thin metal box) stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

    • Lithium iodine battery

      • 4-10 years

      • Low rate of self discharge

  • Electrical circuits

    • Pacing circuit

    • Sensing circuit

  • Implanted / External


PACING LEAD stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Flexible insulated metal wire or lead stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Ni, Co, Cr, Mb, Fe

  • Unipolar

    • Negative electrode (cathode) – RA / RV

    • Positive electrode (anode) – pulse generator

    • Works if anode is in contact with the body

  • Bipolar

    • ‘pos’ and ‘neg’ are in the paced chamber

    • Coaxial


THRESHOLD stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

R-WAVE SENSITIVITY


THRESHOLD stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Lowest amount of energy that will stimulate the heart and produce a paced impulse

    • Acute threshold

    • Chronic threshold

  • Lower the threshold – longer the life


R-wave sensitivity stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Voltage (mv) required to activate the generator’s sensing circuit to inhibit / trigger the pacing circuit

  • Permanent non-programmable PM – 2mv


INDICATIONS FOR PERMANENT PACING (ACC/AHA) stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


Acquired AV block stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Third degree and advanced second degree block

    Symptomatic bradycardia

    Drugs  sympt bradycardia

    Asystole > 3 sec or escape rate < 40 beats / min

    Acute MI

    Postoperative AV block

    After catheter ablation of AV junction


  • Chronic bifascicular and trifascicular block stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

    Intermittent 3° AV block

    Type II 2° AV block

  • Sinus node dysfunction

    Symptomatic bradycardia

    Symptomatic chronotropic incompetence

  • Hypersensitive carotid sinus syndrome and neurocardiogenic syncope


PACEMAKER CODE (NASPE / BPEG) stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


First position stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias : chamber being paced

Second position : chamber being sensed

A : Atrium

V : Ventricle

D : Dual

O : Neither, PM switched off / asynchronous mode


Third position stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias : mode of sensing

I : Inhibition

T : Triggering

D : Dual

O : Neither


Inhibition stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Most common

  • Sensed event will inhibit the PM

  • If no sensed event  impulse

  • Eliminates competition

  • Energy sparing

  • Diathermy  inhibition


Fourth position stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

Programmable

Rate adaptive function – designed to raise or lower the pacing rate to help meet the body’s need during physical activity or rest

Fifth position

Antitachycardia function


TYPES OF PACEMAKERS stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


SINGLE CHAMBER VENTRICULAR PACING – VVI stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Most widely used stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • At flutter/AF and heart block or long ventricular pauses

  • Not recommended

    • Sinus node disease (chronic AF)

    • AV block

  • Pacemaker syndrome

    • Loss of AV synchrony


DUAL CHAMBER PACING - DDD stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • AV block stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Sinus node disease

  • Carotid sinus syncope

    • 2 pacing leads

      • RA appendage

      • RV apex

    • Atrial event will inhibit or trigger a ventricular response


  • Advantages stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

    • Maintains AV synchrony

    • Preserves atrial contribution to preload (áCO – 34%)

  • Disadvantages

    • Pacemaker mediated reentrant tachycardia


ASYNCHRONOUS / SYNCHRONOUS MODE stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


Asynchronous / non-sensing mode (AOO, VOO, DOO) stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Fixed rate pacing

  • Rarely used

    Advantages

  • Not inhibited by diathermy

  • Useful to cover surgery

    Disadvantages

  • Competition – R on T vent arrhythmias

  • Wastes energy


Synchronous / sensing mode stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Demand pacing

  • No competition

  • 2 circuits

    • Impulse formation

    • Sensing circuit

  • Inhibited / triggered

  • Diathermy interpreted as cardiac activity


TEMPORARY CARDIAC PACING stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Temporary bradyarrhythmia (MI, cardiac surgery) stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Before permanent pacing for a life threatening bradyarrythmia

  • Elective replacement of permanent PM

  • During surgical procedures


TRANSVENOUS / ENDOCARDIAL PACING stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Leads introduced subclavian / jugular / femoral stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • RA / RV under fluoroscopy

  • Bipolar

  • Pacing leads are more rigid (J shaped)


TRANSCUTANEOUS stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

(EXTERNAL PACING)


  • Rapid, safe, easy to initiate stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Large self adhesive surface patch electrodes (8cm)

  • Advantages

    • Before transvenous / permanent

  • Disadvantages

    • High threshold

    • Severe chest pain


PREOPERATIVE EVALUATION stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


History stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • CAD – 50%

  • HT – 20%

  • DM – 10%

  • Drug history (digoxin, antiarrythmics)

  • Indication for PM implantation

  • Return of pre PM symptoms (vertigo, syncope)


PACEMAKER EVALUATION stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • When was it implanted and last checked stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Factory preset rate

  • Battery status (10% reduction in rate)

  • What type of generator (I-Card)

    Pacing mode, stimulation threshold, sensing function

  • S/S cerebral hypoperfusion when exercising muscles around generator


EXAMINATION stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Pulse stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

    Regular (70-72/min)

    Irregular (competition)

  • BP

  • Bruits

  • Signs of CCF

  • Location of generator

  • Consciousness level


INVESTIGATIONS stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • CBC, coagulation screening, uninalysis stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Well penetrated X-ray chest

    • Radio opaque marker : model of PM

    • Integrity and position of leads

  • 12-lead baseline ECG (one to one capture)

  • S.electrolytes

    • K+ - 3.5 – 5meq/L

    • K+ imbalance : loss of pacing / V. Tach


INTERPRETATION OF ECG stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


No / intermittent pacing spikes : stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmiasown rhythm

Check PM function

  • Asynchronous mode

  • Carotid massage / valsalva

  • Magnet / programmer

    Pacing spikes before every beat : PM dependent

  • Inhibit device to check innate rythm


PREOPERATIVE PROPHYLACTIC stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

PM INSERTION


  • Third degree AV block stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Second degree AV block

    • Symptomatic

    • Ventricular escape rate < 40 beats /min

  • Asymptomatic second degree / first degree AV block

    • S/S of SSS

    • Relief of symptoms with temporary pacing

  • Any type of BBB with

    • Second / third degree heart block

    • Syncope


GA / REGIONAL stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Based on underlying disease stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Regional – more reasonable choice

  • GA

    • Not contraindicated

    • Inhalational anesth do not alter threshold


MONITORING stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Dictated by the surgery stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Pulse and BP

  • Pulse oximeter

  • Oesophageal stethoscope

  • ECG-V5 and II (interference)

  • PAC - caution (could dislodge if endocardial lead is < 4wks old

  • CVP - caution


Electromagnetic Interference stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


Sources stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Conducted (direct contact)

    • Electrocautery, diathermy

    • Defibrillation

    • TENS

  • Radiated

    • MRI, PET

    • Radiation therapy

      Increased EMI

      Unipolar leads ( sensing)

      Dual chamber PM


HOW DOES EMI AFFECT PACING stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

(RF 300-500 KHZ)


  • Inhibition stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

    • Interpreted as cardiac activity

  • Asynchronous pacing

    • EMI recognized

  • VF / AF

  • Increased pacing threshold

  • Irreversible loss of battery output

  • Reprogramming(DDD VVI / VOO)  haemodynamic compromise


PRECAUTIONS for EMI stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Bipolar cautery – preferable stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Use minimum current

  • Do not use within 15cm of pulse generator

  • Limit to 1 sec bursts every 10secs

  • Ground plate

    • Close to operative site

    • Good skin contact (thigh)

    • Away from pulse generator


OTHER FACTORS AFFECTING PACING THRESHOLD stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • K stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias+ balance

    • Acute   V.Tachycardia

    • Acute   loss of pacing (hyperventilation, diuresis)

  • MI

    • Loss of PM capture

  • Myopotential inhibition (unipolar pacing)

    • Exercise

    • Shivering

    • Muscle fasciculations (Scoline)

  • Hypoxia / Hypercapnia


Precautions and Preparation in OT stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Temporary reprogramming to asynchronous/ triggered ( stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmiasavoid if prone to VT and VF)

  • Programmer / External converter magnet

    Magnet : VT

    Reprogramming of PM

  • Emergency drugs (atropine, isoproterenol)

  • Temporary pacing

  • Defibrillator


PM INHIBITED stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • No intrinsic and no PM rhythm stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

  • Cease cautery

  • High powered magnet over generator

  • Atropine / Isoproterenol / Inotropes

  • Temporary pacing

  • Repeated precordial thumps

  • CPR


EXTERNAL DEFIBRILLATION stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • High energy current stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias thermal burns

  • Use lowest defibrillator current

  • Ant-post paddles

    • Ant - far away from pulse generator

  • If Ant paddles must be used

    • Place perpendicular to leads

    • Atleast 10-15 cm from the generator


POSTOPERATIVE EVALUATION stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias


  • Evaluation of PM function stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

    • Early postop period

    • 24h-48h later

  • Demand / magnet rates vary from preop

  •  capture threshold

    • Permanent damage

    • Reprogramming


Thank You stimulate the heart with electrical impulses to maintain or restore a normal heart beat in patients with arrhythmias

www.anaesthesia.co.in

[email protected]


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